Chris Lindop – GE Healthcare IHE Radiology Planning/Technical Committee Co-Chair

1. IHE XDS-I: Planning for an Image Enabled EHR Chris Lindop – GE Healthcare IHE Radiology Planning/Technical Committee Co-Chair

2. Non-imaging data Patient data Clinical data Laboratory results Surgery reports Prescriptions, meds Letters or notes Integrate with imaging data and processes Focus: Image-enabled EHR • Imaging data • Patient data • Images and evidence • Radiology • Cardiology • Nuclear Medicine • Integrate with non-imaging data and processes

3. Business need: share in the Care settingRadiology Reports and Images • Between Care Providers: • Radiologists • Radiologists and Technologists • Radiologists and Surgeons • Radiologists and Clinicians • Between Care Providers and Patients • Within an enterprise • Cross-enterprise in a healthcare region • Cross-healthcare regions

4. Using images Neurologist: reviewing stroke patient transfer to ward Nurse: preparing GI ward round for Dr. X GP: seeing a post-MI patient after hospital discharge Patient: be prepared for an obstetric visit Producing images/ evidence Cardiologist: during catheter intervention Radiologist: starting an abdomen CT Physician: counseling at diabetes outpatient clinic Oncologist: planning radiotherapy Technologist: fulfilling an imaging order Potential use cases of an image-enabled EHR Information need may include current or longitudinal evidence

5. IHE - Connecting standards to care • Care providers and IT professionals work with vendors to coordinate the implementation of standards to meet their needs • Care providers identify the key interoperability problems they face • Drive industry to develop and make available standards-based solutions • Implementers follow common guidelines in purchasing and integrating systems that deliver these solutions

6. IHE Participants and Relationships • Participants include: • Users - Clinicians, Staff, Administrators, CIOs, Governments • RSNA, HIMSS, etc • Vendors - Information Systems and Equipment • e.g., imaging, Clinical Information Systems, Consultants • Maintains formal liaison with Standards Development Organizations (SDOs): • HL7, DICOM, ISO (Liaison D) • ISO TC215 (including ANSI) approved IHE Process and Profiles to be published as technical reports

7. Radiology IT Infrastructure Laboratory Cardiology Patient Care Coordination Pathology IHE Europe Austria France Germany Netherlands Radiation Oncology Patient Care Devices Eye Care Italy Norway Spain UK Sweden Public Health, Quality and Research IHE Asia-Pacific Australia Malaysia New Zealand Professional Societies / Sponsors ACC ACCE ACEP ACP GMSIHIMSS Contributing & ParticipatingVendors COCIR EAR-ECR DRG SIRM BIR EuroRec RSNA SFRSFIL ESC JAHISJIRAJRS METI-MLHW MEDIS-DCJAMI IHE Organizational Structure IHE International Board Global Development Regional Deployment IHE North America IHE Asia USA China Japan Canada Korea Taiwan 8

8. IHE: A Framework for Interoperability • A common framework for harmonizing and implementing multiple standards • Application-to-application • System-to-system • Setting-to-setting • Enables seamless health information movement within and between enterprises, regions, nations • Promotes unbiased selection and coordinated use of established healthcare and IT standards to address specific clinical needs

9. An Integration Profile : • A Set of Actors • Exchanging Transactions Use casesProcess Flows Actors Transactions • For each transaction: • Std referenced • Options specified • Mapping required IHE Technical FrameworksImplementation Guide for each Integration Profile

10. Product IHE IntegrationStatement IHEConnect-a-thon IHEDemonstration Product With IHE Easy to Integrate Products Standards IHEIntegration Profiles B IHEIntegration Profile A RFP Proven Standards Adoption Process IHE Connect-a-thonResults IHETechnicalFramework User Site • IHE Integration Profiles at the heart of IHE : • Detailed selection of standards and options each solving a specific integration problem • A growing set of effective provider/software-developer agreed solutions • Vendors can implement with ROI • Providers can deploy with stability • Process started in 1998; continuously improved

11. Radiology Profiles Users Guides Radiology Departmental Workflow Mammography Workflow Workflow Patient Info. Reconciliation Charge Posting Scheduled Workflow Presentation of Grouped Procedures Teaching Files & Clinical Export Reporting Workflow Mammo-graphy Acquisition Workflow Import Reconcil-iation Workflow Post-Processing Workflow Presentation & Content NMImage Mammo-graphy Image Radiation Exposure Monitoring Image Fusion EvidenceDocument Consistent Presentation of Images KeyImageNotes Simple Image & Numeric Reports Card Option Infrastructure Portable Data for Imaging Cross-Enterprise Document Sharing for Imaging Audit Trail & Node Authentication – Radiology Access to Radiology Information Trial Implementation ITI Profile(radiology option

12. IHE Integration Profiles for Health Info NetsWhat is available and has been added in 2007 Medical Summary (Meds, Allergies, Pbs) Basic Patients Privacy Consents Emergency Referrals Format of the Document Content and associated coded vocabulary Establish Consents & Enable Access Control PHR Extracts/Updates Format of the Document Content and associated coded vocabulary Patient Demographics Query ECG Report Document Format of the Document Content and associated coded vocabulary Lab Results Document Content Format of the Document Content and associated coded vocabulary Cross-Enterprise User Assertion Scanned Documents Patient Identifier Cross-referencing Format of the Document Content and associated coded vocabulary Imaging Information (Images & Reports) Format of the Document Content Provides Trusted Identity Map patient identifiers across independent identification domains Format of the Document Content and associated coded vocabulary Document Digital Signature Attesting “true-copy and origin Cross-Enterprise Document Sharing Audit Trail & Node Authentication Request Formfor Data Capture Registration, distribution and access across health enterprises of clinical documents forming a longitudinal record Centralized privacy audit trail and node to node authentication to create a secured domain. External form with custom import/export scripting Notification of Document Availability Cross-Enterprise Document Pt-Pt Reliable Interchange Consistent Time Notification of a remote provider/ health enterprise Coordinate time across networked systems Cross-Enterprise Document Media Interchange Cross-Community Access Security & Privacy Clinical and PHR Content Patient ID Mgmt Health Data Exchange Other Final Text Approved Trial Implementation-2007 –Final Txt 2008

13. Categories of Healthcare Communication Services HIEs and RHIOs Hospitals Patient and Provider ID Mgt e.g. access to last 6 months historical labs and encounter summaries e.g. get a current list of allergies or med list from a source e.g. order a lab test, track status and receive results Security Document Sharing Dynamic Information Access Workflow Management Source persisted and attested health records Specific info snapshot provided on demand 2 or more entities synchronize a task

14. Combining IHE ProfilesDocument Content & Modes of Document Exchange Doc Content Profiles (Semantics content) Scanned Doc XDS-SD Pre-Surgery PPHP Functional Status Assesment FSA Consent BPPC Emergency EDR PHR Exchange XPHR Discharge &Referrals XDS-MS Imaging XDS-I Laboratory XD*-Lab Document Exchange Integration Profiles Document SharingXDS Reliable Pt-PtInterchange XDR MediaInterchange XDM

15. Use of a shared XDS infrastructure to access Radiology Reports and Images (XDS-I) Between Radiology and : • Imaging specialists • Non-imaging clinicians • Patients Hospital PACS Y Radiology -to-Radiology Patient Home PACS Z Radiology -to- Physicians Imaging Center Physician Practice Same XDS Infrastructure (Registry and Repositories) for medical summaries and imaging information !

16. Sharing Radiology Reports and Imagesin a Regional Health Information Network Regional Health Information Network Radiology Enterprise B PACS B Patient Id= 3547F45 • Report 5/21/1998 : CT Head B • Study 5/21/1998 : CT Head B • Report 2/18/2005 : Chest Xray A • Study 2/18/2005 : Chest Xray A Cross-Enterprise Registry PACS A Physician Office Radiology Enterprise A

17. Register Imaging Information for sharing Priorimaging Reports & Studies Register Imaging Information for sharing Query for Documents Physicians and Systems within a Regional Health Network - Routine Imaging Referral Regional Health Information Network Radiology Enterprise B Cross-Enterprise Registry Patient Id= 3547F45 • Report 5/21/1998 : CT Head B • Study 5/21/1998 : CT Head B Physician Office Radiology Enterprise A

18. Register Imaging Information for sharing Register Imaging Information for sharing Notification of Doc Availability Physicians and Systems within a Regional Health Network - Routine Imaging Referral Regional Health Information Network Radiology Enterprise B Cross-Enterprise Registry Physician Office Radiology Enterprise A

19. Prior Imaging Report & Study Query for documents Notification of Doc Availability Imaging Report & Study Physicians and Systems within a Regional Health Network for a Routine Imaging Referral Regional Health Information Network Radiology Enterprise B Patient Id= 3547F45 • Report 5/21/1998 : CT Head B • Study 5/21/1998 : CT Head B • Report 2/18/2005 : Chest Xray A • Study 2/18/2005 : Chest Xray A Cross-Enterprise Registry Physician Office Radiology Enterprise A

20. XDS-I Dependencies • XDS-I depends on IT Infrastructure Cross-Enterprise Document Sharing (XDS) • New Actors • Imaging Document Source • Imaging Document Consumer (should be grouped with Document Consumer) • Same Actors as in XDS • Document Consumer • Document Registry • Document Repository • Added extension to support imaging data (images and reports)

21. XDS-I Actors and Transactions Patient Identity Source Patient Identity Imaging Document Consumer Feed Query Document Documents Document Consumer Registry Register Document Set Retrieve Provide & Register Document Document Set Document Imaging Document Source Repository Retrieve Images Retrieve Presentation States Retrieve Key Image Note Retrieve Evidence Documents WADO Retrieve

22. XDS-I Transaction requirements • XDS-I Actors: • Imaging Document Consumer • at least one Retrieve ( [RAD-55], [RAD-16], [RAD-17], [RAD-27], [RAD-31] [RAD-35]) • Imaging Document Source • Provide and Register Document Set [RAD-54] • WADO Retrieve [RAD-55] • Retrieve Images [RAD-16], Retrieve Presentation States [RAD-17] Retrieve Reports [RAD-27], Retrieve Key Image Note [RAD-31], Retrieve Evidence Documents [RAD-45] • XDS Actors • Document Repository • Provide and Register Document Set [RAD-54]

23. Options • Imaging Document Source must support at least one of the following options: • Extensive Set of DICOM Instances • PDF Report • Text Report wrapped in a CDA Document

24. Sharing of Extensive DICOM Instance Set

25. Register Manifest Query Registry DICOM Manifest DICOM Manifest Retrieve Manifest Reference to image 1 Reference to image 1 Reference to image 2 Reference to image 2 Reference to image 3 Reference to image 3 Retrieve Images Manifest Manifest Manifest Manifest Manifest Clinical IT System Clinical Encounter Document Registry Document Repository

26. Sharing of Extensive DICOM Instance Set • The shared Document is a manifest • a Key Object Selection DICOM Instance • title : manifest • Imaging Document Source is required • to ensure that the referenced images from within a published manifest are available to be retrieved • Imaging Document Source is responsible • for replacing a previously submitted manifest Document when a change occurs to the manifest content (eg. Change of the DICOM SOP instances referenced within the manifest)

27. Sharing of Imaging Report

28. Radiology Report Header: Report Type: OB / Gyn BPD ….. ... Findings: ….. Gestational Impressions: Age ... Text wrapped into CDA Report PDF Report Radiology system Report Source

29. Register Report Query Registry Radiology Report Header: Report Type: OB / Gyn BPD Retrieve Report ….. ... Findings: ….. Gestational Impressions: Age Report Report Report ... Clinical IT System Clinical Encounter Document Registry Document Repository Radiology system Report Source

30. Sharing of Reports • The shared Report Document format is • PDF, Text wrapped in a CDA • A report can • embed selected images in its PDF format • include fully resolved hyperlinks (interactively clickable) that point to the selected images • Imaging Document Source is responsible • for formatting the hyperlink to reference relevant images as a DICOM WADO URI or as IHE RID Request for Document • Imaging Document Source is required • to ensure that image references are valid links

31. SubmissionSet DocumentEntry DocumentEntry Study Manifest Report Linking Report to Complete Set of Images Document Registry Document Repository

32. SubmissionSet 1 SubmissionSet 2 DocumentEntry Report Study Manifest Linking Report to Complete Set of Images Document Registry DocumentEntry Document Repository

33. SubmissionSet 3 SubmissionSet 1 SubmissionSet 2 SubmissionSet 4 DocumentEntry DocumentEntry DocumentEntry Prior Study Manifest Prior Report Report Study Manifest Linking Report to Prior Images and Prior Report Document Registry DocumentEntry Document Repository

34. BPD ... ….. Linking Report to Selected Images Radiology Report Header: Report Type: OB / Gyn ….. Findings: Gestational WADO URI Link to image Age ... Relevant Image Radiology system Report Source

35. XDS-I Metadata • Radiology specific • Acquisition Modality (e.g. CT, MR) • Anatomic Region (e.g. Arm, Elbow, Hand) • Requested procedure (e.g. MRI Knee with contrast) • Query example • find all “CT of the Head” of patient John Doe for the last 2 years

36. patient Onco-logist GP(follow-up) Radiologydepartment Documentavailability Care record sys-tems: specific care delivery report Images, report(PACS, RIS) Retrieve Query for re- ports Retrieve selected imaging report references Shared re- pository Register report & image references Longitudinal record system: across encounters Document Registry Sharing Imaging Documents (XDS-I)

37. How to Participate As a User or Vendor Committee Member • Become a member of relevant Domains Planning or Technical Committees As a User, Consultant or Vendor Interested Observer • Provide Public Comments on Technical Framework Supplements • Attend Demonstrations, Educational Events and Workshops

38. How to Use IHE As a Vendor Implementer • Implement IHE Integration Profiles • Test systems through Connectathon process • Publish an IHE Integration Statement for products As a User Implementer or Consultant • Use IHE Integration Profiles to develop interoperability strategy • Use Connectathon Results and Integration Statements to evaluate vendors • Demand IHE Integration Profile compliance in RFPs

39. Providers and Vendors Working Together to Deliver Interoperable Health Information Systems in the Enterprise and Across Care Settings http://www.ihe.net

40. More Resources - www.ihe.net • Frequently Asked Questions • Integration Profiles in Technical Frameworks: • Cardiology • IT Infrastructure • Laboratory • Patient Care Coordination • Patient Care Devices • Radiation Oncology • Radiology • Connectathon Results • Vendor Products Integration Statements • Participation in Committees and Connectathons