Integrating the Healthcare Enterprise

1. Integrating the Healthcare Enterprise Applying the IHE Framework to CardiologyJoseph BiegelMitraIHE Planning Committee

2. Applying the IHE to Cardiology - Topics • Quick IHE Overview • Motivations for IHE in Cardiology? • Common and distinct needs in Cardiology • Data Complexity and Workflow • Applying Scheduled Workflow in Cardiology • Challenges and next steps… HIMSS 2002

3. What is IHE about? • It’s an initiative promoting and supporting the integration of systems in the healthcare enterprise. • Integration Goal: Improve the efficiency and effectiveness of clinical practice by: • Improved Information Flow • Advanced Multi-System Functions HIMSS 2002

4. Why is IHE needed? • Serious Integration Challenges in Healthcare: • Systems need Information other systems have • But, systems communicate poorly or not at all • Result: - tedious, inefficient workflows - data that is inconsistent or unavailable • Responsibility for information flow between systems, and between departments, is often unclear. HIMSS 2002

5. Who is IHE? • Participants: • Professional Societies (RSNA/HIMSS/…) • Vendors (over 30 companies) • Standards Group Committee Members • RSNA and HIMSS sponsor IHE to provide a neutral forum for working on the Big Picture HIMSS 2002

6. What Does IHE Do? • Users and vendors work together to identify and design solutions for integration problems • Intensive process with annual cycles: • Identify key healthcare workflows and integration problems • Research & select standards to specify a solution • Write, review and publish IHE Technical Framework • Perform cross-testing at “Connectathon” • Demonstrations at tradeshows (RSNA/HIMSS) HIMSS 2002

7. Aren’t DICOM / HL7 Sufficient? • Standards are vital (HL7, DICOM, ICD, …) • They provide tools & technologies • But Standards alone are insufficient • They are open to interpretation • There is room for optional variations • They avoid specifying how to apply them to particular real world scenarios HIMSS 2002

8. How is IHE related to Standards? • IHE attacks real world integration problems • HL7 and DICOM provide dictionaries • IHE defines a “phrasebook” that solves real world problems by assembling pieces provided by DICOM/HL7 HIMSS 2002

9. What are Key IHE Concepts? • Generalized Systems -> Actors • Interactions between Actors -> Transactions • Problem/Solution Scenarios -> IntegrationProfiles • For each Integration Profile: • the context is described (which real-world problem) • the actors are defined (what systems are involved) • the transactions are defined (what must they do) HIMSS 2002

10. ECG Physician Nuclear Study Cardiologist Hemo Cath Labs Echo Interventional Procedure Simplified view of Cardiology Patient Complaint HIMSS 2002

11. Why IHE in Cardiology? • Cardiology workflow is complex • Multiple diagnostic tests are very common • Large number of manual demographic input steps is common. • This leads to inefficiency, invalid data in clinical archives and can lower the quality of care HIMSS 2002

12. Why IHE in Cardiology (2) ? • The Cardiology position in the IT technology adoption cycle makes the IHE an ideal foundation • The concepts of the IHE TF have broad general applicability, many can be directly leveraged in Cardiology • Some of Cardiology’s special requirements can be well met by the IHE TF • The TF could be adapted to meet Cardiology specific needs HIMSS 2002

13. Common Needs • Cardiology departments have needs similar to Radiology departments • Both are driven by imaging modalities • Workflow is similar at a very high level • Need to manage distributed departmental resources • Desire an integrated patient-centered view • Need for administrative reporting • Need to improve lab efficiency via workflow management • Legacy installed base technology issues HIMSS 2002

14. Distinct Cardiology Needs • Clinical data content is more complex • Procedural data with rich report content • Direct tie to billing • Clinical results data mining is a priority • Cardio departments are often more driven/isolated by subspecialty • Strong individual patient focus than a system or procedure focus • Cardio departments are revenue centers HIMSS 2002

15. Radiology Diagnostic Imaging CT,MR,US,NM… Scanned Film Text Reports Measurements Cardiology Diagnostic Imaging XA, US, NM, CT, MR Waveforms ECG, Hemo, EP, Stress Extensive numeric measurements Lab data Complex Reports Stress,Holter, Cath Complexity of Core Data HIMSS 2002

16. Cardiology Workflow Elements • Workflow elements in common with Radiology: • Patients are admitted • Demographics entered (often multiple times for the same patient) • Imaging studies are performed and read • Reports generated HIMSS 2002

17. Cardiology Workflow Elements • Additional Workflow elements: • Echo, ECG & lab data often prerequisites to treatment • Consumable materials and clinical data tied to procedures • Monitoring data is part of the Cath procedure • Echo as follow on to a Cath procedure • Interpretation generally uses multiple clinical inputs HIMSS 2002

18. Scheduled Workflow “Works” for Cardiology • Minimizing redundant demographic input and producing valid header data in the clinical archive is important in Cardiology • Multiple modality inputs of Cardiology drives the value • Basic problem is well addressed by the Scheduled Workflow and Patient Reconciliation Integration Profiles in IHE Year 3 HIMSS 2002

19. Patient Information Reconciliation Profile “Works” for Cardiology • Extends Scheduled Workflow • Handle unidentified patient (e.g. emergent) • Handle demographic information mistakes • Propagate changes to all affected systems, update all affected data • Reduces incorrectly identified or “lost” studies • Can reduce lost charge postings (billing) HIMSS 2002

20. Can you “Just Do It”? • We have done some investigations and prototype clinical testing to examine the utility of applying the concepts of Scheduled Workflow and Patient Reconciliation • Key Pieces • HIS, “RIS”, Modality & PACS • The HIS is the same • So far this is easy… HIMSS 2002

21. Modality Connectivity in Cardiology • Imaging Modalities often have at least some DICOM services • DICOM Store SCU support common in new systems • Some legacy conversion solutions • DICOM MWL becoming common • DICOM MPPS and Storage Commitment “getting there” • That was the good news… HIMSS 2002

22. Modality Connectivity in Cardiology • Critical care monitoring is out of scope for now due to real time needs. • Waveform systems are challenging. • Some Hemo systems and ECG information systems support HL7 ADT and ORM messaging allowing functionality similar to DICOM MWL. • Others have proprietary connectivity capabilities which could be “rigged” to enable MWL “style” modality messaging. HIMSS 2002

23. The Cardiology “RIS” (CIS) • Ask 10 people what a CIS is and you will get 9 answers… • One of the key elements we need is an electronic source of order and schedule data that drive department workflow and support OP/OF and PPS Manager Actors • This is often not readily available in Cardiology departments today HIMSS 2002

24. ECG Patient Demographics, ECG LAB Waveform Schedules & Report Images & Reports DMWL CATH DICOM ADT,ORM CIS (Performed Procedure Step Mgr, Order Placer/Filler Actors) HIS MPPS Storage Commitment Image Patient Manager/ Demographics, Archive Waveform Schedules & & Report Report HEMODYNAMICS Repository Storage Commitment CATH LAB Patient Demographics, Schedules Images & Reports DMWL MPPS ECHO ECHO LAB Scheduled Workflow in Cardiology HIMSS 2002

25. Easy Wins for IHE in Cardiology • Workflow in the Cath lab can be streamlined • Minimize data re-entry • Automate pre-fetching • Since Scheduled Workflow leverages DICOM MPPS, near real time updates on Cath procedure status are possible • DICOM SR and Waveform allow the use of a common DICOM archive for waveform and imaging systems HIMSS 2002

26. Connectivity Challenges • DICOM MPPS is a limiting capability for integrating Cardio modalities. • New Imaging modalities are starting to have IHE Modality Actor support, but the legacy installed base will be an integration challenge. • Waveform modalities need to either adopt DICOM modality messaging and storage or the IHE TF needs to be extended to allow HL7 or “other” methods. • There are underlying standards (IEEE, SCP-ECG) that could be leveraged by the IHE in the future. HIMSS 2002

27. Clinical Challenges in Cardiology for the IHE • IS driven order creation in Cardiology is not generally available • GSPS and Key Image Note have value, but are clearly limited today • Cardiologists use motion images and color data that depicts cardiac function • Simple Image and Numeric Reports • Pictorial diagrams for anatomy, function and viability are needed for clinical reports • Extensions to manage specific frames of cine objects and waveform objects would be needed HIMSS 2002

28. Other Technology Challenges • Some Cardiology tasks are still hard to “do digital” • Pediatric Echo is just now able to enter the digital era • Huge volume of data required to “do a search mission” on a tiny fast beating heart • Extensive measurements needed to understand the clinical situation • EP data volume • Real-time critical care monitoring HIMSS 2002

29. IT, the CIO and That Archive… • The IT department and the CIO should become strong advocates for moving the IHE into Cardiology • As IHE’s track record grows in Radiology integration projects, “doing it again down the hall” begins to form a value proposition for IT management • Leverage common archive infrastructure HIMSS 2002

30. Conclusions • The value is clear. • Applying and extending the IHE to Cardiology could save millions of dollars in product development costs • It could improve the quality and efficiency of care • IHE Scheduled Workflow and Patient Reconciliation Integration Profiles are nearly ready to go in Cardiology. • There are challenges. • Need to extend the Technical Framework for some Cardiology specific needs. HIMSS 2002

31. IHE Strategic Cardiology Group • Several draft candidate IHE Solutions for Cardiology defined • These are “ways IHE could help” in Cardiology • Straw Poll on priority from meeting attendees • Priorities factored in need and low-hanging-fruit where IHE could help easily • Subspecialty Priorities also discussed and a poll taken • NEED Expert input from Cardiology thought leaders • Note: Error Reduction, patient safety and data mining are key overall areas of contribution HIMSS 2002

32. Candidate IHE Solutions for Cardiology • Single entry point for patient demographics (error/re-entry reduction, valid header data in clinical archive, etc) • Easy access to Cardiology information for prior study data and referral needs • EKG, Cath, Echo, Reports, Procedure status, results mining • Ordering and results management with status tracking • Procedure Charge Capture HIMSS 2002

33. Candidate IHE Solutions for Cardiology (2) • Security infrastructure • Prior study image/video access for Cath/Echo • Cath reporting: clinical, billing, NCDR (registry) • Improve workflow, errors, speed, consistency HIMSS 2002

34. IHE Cardio Solution Priorities HIMSS 2002

35. Subspecialty Priorities HIMSS 2002