Waveform, Workflow, Archiving …

1. Waveform, Workflow, Archiving… Assessment of Standard Interfaces Opportunities for Cooperation

2. Three Levels for Connectivity Standards DeviceConnectivity DepartmentalIntegration Hospital/AmbulatoryWorkflow EMR Integration Three Examples  Overlap  Coordination Needed RISR-PACS Radiology Imaging Modalities Image proc. CAD, … DICOM Enterprise Archive ADTOrder Placer EMR, … DICOM CardiacIS, C-PACS Rest, Stress, Holter ECG Cardiology Cardiac MonitorsHemodynamics Captors, Actuators Bed-SideMonitors ICUIS ClusterMonitor ICU SCP ? HL7 ?DICOM ?1073 ? 1073 HL7

3. Three Topics, Three Opportunities ? • Persistent Waveform Objects • Departmental Workflow Integration • Enterprise Archiving of Images & Waveforms

4. DICOM WaveformsQuick Refresher

5. Key Aspects of DICOM • DICOM domain is communications for imaging-based care • DICOM is an Object-based standard • Persistent objects • Inter-object referential capability • Binary tagged data element format • Objects are hierarchically organized • Patient / Study / Series (modality) “folders” • DICOM: Persistent Object workflow services over TCP/IP • Generally in client-server architecture • Object transfer, storage, storage commitment, query and retrieval • Media-Interchange (CD, DVD, Floppy, etc.) with clinical directory. • Network Archiving • Departmental workflow management (worklist, performed steps) • Broadly used and accepted world-wide for many years.

6. DICOM Waveforms • Supplement 30: Waveform – in DICOM 2001 • Introduces general structure for waveform composite (persistent) objects • Waveform channels identified by coded-entry triplet • Coding Scheme / Code Value / Code Meaning • Allows externally defined terminology (e.g., SCP-ECG for leads) • Triplets also used in HL7 and DICOM Structured Reporting • Triplet values may be constrained by Templates defined in Part 16 • Specific waveform Object Definitions (particularly for cardiology) • Hemodynamics • Cardiac Electrophysiology • Electrocardiography (12-lead, ambulatory, general) • Basic Voice Audio • In progress, Ultrasound Doppler Waveform (Suppl 56)

7. DICOM Waveform Object • Waveform object encodes digital data from adiscrete time period • Multiple channels; all channels have common time base • Flexible waveform sample format • 8 or 16 bit data; Signed, unsigned, u-law, A-law • Separate sampling frequencies for each channel, or multiplexed channels at common frequency • Objects may be temporally contiguous, or temporally selective • “Store and forward” (not for real time monitoring) • Waveform object encodes full definition of each channel • Quality being sampled, Sensor location (anatomic),Function (measurement or stimulus), Resolution and range, Technique (e.g., pull-back) • Based on HL7 V2 definition • Waveform object encodes DICOM + HL V2 context information in header • Equipment information (manufacturer, serial number, location) • Temporal frame of reference (synchronization with other objects, in particular images) • Waveform object encodes optional annotation • Identify features or regions of interest • Generated by acquisition unit • Constructed of label and time or sample reference Streams of Waveform Samples

8. Waveforms Standardization for Departemental Integration-Key Objectives-

9. Waveforms: why integrated & separated ? • Integrated with other persistent objects • Images • Supporting the waveforms (e.g., for documentation of EP catheter location) • Supported by waveforms (e.g., simultaneous ECG for IVUS post processing) • Various categories of Structured Reports with waveform references. • Clinical reports • Measurement reports (e.g., hemodynamics, or ECG) • Procedure Log documents (full procedural context for waveform acquisition) • Key object selection (electronic “Post-It”) • Workflow integration: • worklists and status monitoring of scheduled tasks • including distribution of patient demographics • Object archiving and retrieval – Key for archiving of recorded vitals signs • Web accessible as persistent objects (presented or original data) • Focused on Full Fidelity Acquired Data: • No Presentation: to be addressed independently. • Compression: compact encoding, separate from the object definition • Clearly distinguished from derived measurements and reports • Patient/Visit/Order context driven by HL7

10. Departmental Workflow IntegrationDICOM and HL7…..Much more than combining standards !

11. Patient Registration/UpdateOrder Management (HL7) Worklist Modality Worklist Procedure Scheduled (HL7) Store Images StorageCommitment Storage Commitment List of Images Modality Performed Procedure Step Performed Step: Status = Completed Performed CT Head Pat Name/ID, Dose, Accession #, Study UID Complete List of Images IHE Scheduled Workflow RIS PACS &Archive • A Closed Loop • Update IS Scheduling • Match Procedure with Order • Support Billing Based on MPPS • Avoid Reading incomplete Procedures

12. DICOMModality Worklist ScheduledProcedure Step A Report ScheduledProcedure Step B One or more series of images One or more series of images DICOMModality Worklist PerformedProcedure Step P1 PerformedProcedure Step P2 AcquisitionModality AcquisitionModality Structuring the Departmental Workflow with an Enterprise perspective Radiology Department ORDER A request for RadiologicService Set of Codifiable, Billable, Acts Requested Procedure 1

13. What is IHE ? • An Initiative Sponsored by Users: HIMSS plus clinical societies (e.g.RSNA) • Active Industry Leadership, shaping direction • Leverage existing standards (HL7, IEFT, DICOM, etc.) in an industry defined integration framework • Proceed in pragmatic incremental steps to deliver easier to integrate product implementations • Proven approach in IT & Radiology (over 100 vendors already participate).

14. Enterprise Archiving of Images and Waveforms

15. Scheduled Workflow Post- Processing Workflow Patient Information Reconciliation ChargePosting Admit, order, schedule, acquire images, notify of completed steps Schedule, perform, & notify image processing & CAD steps Collection of billable procedure details Unknown patients and unscheduled orders Consistent Presentation of Images Key ImageNotes Simple Image and Numeric Reports Simple reports with image links and, optionally, measurements Hardcopy and softcopy grayscale presentation state Flag significant images Presentation of Grouped Procedures Subset a single acquisition Access to Radiology Information Consistent access to images and reports Basic Security Audit Trail Consolidation & Node Authentication IHE Integration Profiles

16. What is Unique about IHE ? • A User/Vendor Team Effort : • Voluntary and Open to All Vendors. It is not a consortium. • Professional Associations Engaged (e.g. HIMSS leadership) • Starts from concrete user integration needs, selects standards, sets a technical framework, provides a test-bed, and demonstrates/educates marketplace. • Does not define product architectures or features, only the glue between products. • Successful. Benefits both small and large vendors, worldwide : North America, Europe, Asia.

17. Industry is invited to shape and expand IHE • A kick-off meeting in order to : • Review the current state of integration in the healthcare information technology industry • Identify IT Infrastructure priorities necessary for building an EMR • Establish the structure and timeline for implementation. • All vendors are invited : • Product marketing & technical leadership • When & where : • November 4-5, 2002 • Malvern, (near Philadelphia, PA) • Respond to invitation : ihe@rsna.org

18. Patient Registration/UpdateOrder Management (HL7) Worklist Modality Worklist Procedure Scheduled (HL7) Store Images StorageCommitment Storage Commitment List of Images Modality Performed Procedure Step Performed Step: Status = Completed Performed CT Head Pat Name/ID, Dose, Accession #, Study UID Complete List of Images IHE Scheduled Workflow RIS PACS &Archive • A Closed Loop • Update IS Scheduling • Match Procedure with Order • Support Billing Based on MPPS • Avoid Reading incomplete Procedures

19. Enterprise Archiving of Images and Waveforms

20. Enterprise Archiving for complex clinical data: images and waveforms • Large and "specialized" complex clinical data sets call for archiving outside of central EMR database • Images are being handled by PACS (radiology, cardiology, etc.) and hospital wish to also share resource for waveforms • A consistent set of standards is required to achieve this integration of image and waveform enterprise archiving in an EMR driven environment.

21. Enterprise ArchivingDICOM : 10 years of experience Media Interchange (Inst. + DIR) EnterprisePersistent Objects Repository Store (Class/Instance UID) DepartmentalIS System RIS, PACS, CIS, etc. Storage Commitment Retrieve (Instance UID) Store (Class/Instance UID) Transparent Persistent Object Payload (except for Class) Study/Patient Query (Study Root) Series PersistentObject Instance WebAccess Native or presented forms

22. e.g.EPR "Form ofthe reference" Persistent Objects Repository Web Access to Persistent DICOM Objects "Form ofthe reference" Retrieve a "presentation view" Client AccessingHealthcareDocuments Retrieve a "Data Set" Data Set "Retrieve": -Preferred transfer Syntax -Default transfer Syntax ? Retrieve one "entire document" (either in a presentation view or as a data set) using its "Persistent Document Instance UID" Presentation View "Retrieve": -Type of encoding for images (JPEG, GIF, etc.) -Type of document presentation format (PDF, HTML, CDA-L1) -Size of Images • Intent is not to offer a "Query": • Need is only to get access to an object

23. Waveforms Standardization for Departemental Integration-Key Objectives-

24. Waveforms: why integrated & separated ? • Integrated with other persistent objects • Images • Supporting the waveforms (e.g., for documentation of EP catheter location) • Supported by waveforms (e.g., simultaneous ECG for IVUS post processing) • Various categories of Structured Reports with waveform references. • Clinical reports • Measurement reports (e.g., hemodynamics, or ECG) • Procedure Log documents (full procedural context for waveform acquisition) • Key object selection (electronic “Post-It”) • Workflow integration: • worklists and status monitoring of scheduled tasks • including distribution of patient demographics • Object archiving and retrieval – Key for archiving of recorded vitals signs • Web accessible as persistent objects (presented or original data) • Focused on Full Fidelity Acquired Data: • No Presentation: to be addressed independently. • Compression: compact encoding, separate from the object definition • Clearly distinguished from derived measurements and reports • Patient/Visit/Order context driven by HL7