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Integrating the Healthcare Enterprise

Integrating the Healthcare Enterprise. Improving Clinical Care: IHE Integration Profiles in Detail. Co-authors and Presenters. Charles Parisot Member IHE Technical and Planning Committees GE Medical Systems – Information Technologies Sanjay Jain Co-Chair IHE Planning Committee

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Integrating the Healthcare Enterprise

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  1. Integrating the Healthcare Enterprise Improving Clinical Care: IHE Integration Profiles in Detail

  2. Co-authors and Presenters Charles Parisot Member IHE Technical and Planning Committees GE Medical Systems – Information Technologies Sanjay Jain Co-ChairIHE Planning Committee Cerner Corporation, Radiology and Clinical Imaging Andrei Leontiev Co-Chair IHE Technical Committee IDX Systems

  3. IT/Imaging Integration Challenge IHE, A Novel Approach • An RSNA & HIMSS Initiative promoting and supporting the integration of systems in a healthcare enterprise • To improve efficiency and quality of clinical practice • Serious Integration Challenges: • Systems need info that other systems have • Systems communicate poorly or not at all • Result in tedious inefficient workflows and data inconsistent Understanding the Clinical Benefits..……the IHE Integration Profiles RSNA 2002

  4. Post- Processing Workflow Patient Information Reconciliation ChargePosting 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 Integration Profiles Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps RSNA 2002

  5. Problems • Before the Technologist performs the acquisition, how do I make sure the correct info is used ? • Paper based workflow with data re-entry • Risk of error AND Inefficient • Stale information • Changes between time of print and time of data entry • Cancel orders, Generic Order / Order Changes • After the Technologist completes acquisition, how do I let all systems know ? • When are things ready to be read (PACS) • When can things be deleted (Modality) • How do I know what to bill (RIS) • When do I wake up the referring physician The solution is…… RSNA 2002

  6. Patient Registration/UpdateOrder Management Worklist Pt A, …, SPS=P1, P4 Pt C, …, SPS=P1, P5 Pt B, …, SPS=P2 Pt E, …, SPS=P4 Store Images StorageCommitment Storage Commitment List of Images Performed Step: Status = Completed Modality Performed Procedure Step Performed Procedure: CT Head Performed Protocol Code=P1 Scheduled Protocol Code=P1, P5 Pat Name/ID, Dose, Accession #, Study UID Complete List of Images IHE Scheduled Workflow Modality Worklist RIS Procedure Scheduled Order Protocolized PACS &Archive Proposed Protocols Loaded and Reviewed With Performed Acquisition Protocols • A Closed Loop • Update IS Scheduling • Match Procedure with Order • Support Billing Based on MPPS • Avoid Reading incomplete Procedures RSNA 2002

  7. IHE Workflow Concepts IHE identifies four fundemental workflow information units. ORDER : A request for radiologic service Procedure Steps :The smallest unit of work in the workflow:SCHEDULED PROCEDURE STEP: ‘A unit of work to do’PERFORMED PROCEDURE STEP: ‘A unit of work done’ REQUESTED PROCEDURE : A Unit of Reporting Work with associated codified, billable acts "Assisted Acquisition Protocol Setting" option operatesat the Scheduled and Performed Procedure Step Level RSNA 2002

  8. CLINICIANOR REFERING DOC:The Imaging Dept Customer RADIOLOGIST : In Charge of producing theReport TECHNOLOGIST(and RADIOLOGIST)In charge of acquiring images, etc. IHE Workflow is User Driven ORDER:A request for imaging service (Accession Number) Information Unit has its Prime User REQUESTED PROCEDURE : Units of work resulting in one Reportwith associated codified, billable acts(Requested Procedure ID) PROCEDURE STEP :The smallest unit of workin the workflow (modality worklist entry)  Assisted Protocols provide a New Level of efficiency RSNA 2002

  9. Examples of Protocol Codes • A Scheduled Procedure Step may contain a single Protocol Code: • “Standard Chest X-ray” Protocol Code. This implies PA and Lateral views. • “Screening Mammography” Protocol Code. This implies RMLO and LMLO, RCC andLCC views. RSNA 2002

  10. Examples of Protocol Codes A Scheduled Procedure Step may also contain multiple Protocol Codes for morecomplex SPS with several acquisition or image processing tasks be performed in a sequentialmanner, for example: • “MRI Acquisition” Prot. Code followed by an “MRA Acquisition” Prot. Code. • “CT Head without contrast” Prot. Code followed by a “CT with contrast” Prot. Code. • “CT Lumbar Spine” Prot. Code followed by a “Reformation of the discs” Prot. Code. • “CT Thorax” prot. Code followed by a “Recon with lung kernel” Prot. Code. RSNA 2002

  11. 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 Multiple Modality Steps Radiology Department ORDER A request for RadiologicService Set of Codifiable, Billable, Acts Requested Procedure 1 RSNA 2002

  12. DICOMModality Worklist Set of Codifiable, Billable, Acts Requested Procedure 1 Report ScheduledProcedure Step A One or more series of images AcquisitionModality Requested Procedure 2 ScheduledProcedure Step C NoPerformedProcedure Step PerformedProcedure Step P1 Discontinue Discontinued Procedure Step Radiology Department ORDER A request for RadiologicService RSNA 2002

  13. Worklist Modality Worklist Procedure Scheduled 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 Workflowwith Exception Management RIS If Wrong Worklist Images "removed“ and Step "undone" PACS &Archive Step DiscontinuedWith Reason • A Closed Loop • Update IS Scheduling • Match Procedure with Order • Support Billing Based on MPPS • Avoid Reading incomplete Procedures RSNA 2002

  14. Problems • John Doe Trauma Clean-Up • Recovering After Systems Are Down • Error in manual entry at modality • VIP Privacy The solution is…… RSNA 2002

  15. Patient Information Reconciliation Unknown patients and unscheduled orders Integration Profiles Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps RSNA 2002

  16. PACS is synchronized with all patient registration and order information updates through Dept Scheduler. Image Manager/Archive Modality IHE Scheduled Workflow + IHE Patient Information Reconciliation ADT Patient Registration • When Institution Policy assumes pre-registration of ER patients (John/Jane Doe), IHE supports 3 possible cases: • Unidentified Patient registered at ADT and order placed at Order Placer • Unidentified Patient registered at ADT and order placed at Department Scheduler/Order Filler • Unidentified Patient registered at ADT but acquisition completed at Modalityprior to Order Order Placer Dept Scheduler RSNA 2002

  17. Image Manager/Archive Modality IHE Scheduled Workflow + IHE Patient Information Reconciliation ADT Patient Registration • When Institution Policy allows departments to register ER patients, IHE supports 2 possible cases: • Unidentified Patient assigned Temporary Departmental ID andScheduled at Dept Scheduler/Order Filler • Image Acquisition Completed Without Scheduling at Dept Scheduler/OrderFiller(Patient ID entered at Modality) • Supports cases when ADT or Dept Scheduler is down Order Placer Dept Scheduler RSNA 2002

  18. Problems • Schedule and track post-processing workflow steps for accuracy of work • Share workload among workstations, chain workflow steps to avoid redundancy • Store and Query/Retrieve of Evidence Documents for CAD, Image Processing etc. The solution is…… RSNA 2002

  19. Post- Processing Workflow Patient Information Reconciliation Schedule, perform, & notify image processing & CAD steps Unknown patients and unscheduled orders Integration Profiles Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps RSNA 2002

  20. Source Data Worklist PACS System CAD *Workstation 3-D *Workstation Workstation ReportRepository Work Status Results AcquisitionModality Post-Processing Workflow Profile Post-Proc. Workflow Manager Work Status … Results RSNA 2002

  21. DICOMModality Worklist ScheduledProcedure Step A Report ScheduledProcedure Step B One or more series of images One or more series of images DICOMPost-Processing Worklist M-Perf.Procedure Step P1 PP-Perf.Procedure Step P2 Post-Processing AcquisitionModality Modality and Post-Processing Steps Radiology Department ORDER A request for RadiologicalService Set of Codifiable, Billable Acts Requested Procedure 1 RSNA 2002

  22. Worklist Provided • Modality finds out what post-processing tasks have been scheduled by the Post-Processing Manager (RIS or PACS) • Worklist is provided for workitem codes: Image Processing, Computer Aided Diagnosis, and Computer Aided Detection. • Modality includes received information in the resulting instances RSNA 2002

  23. Evidence Document Stored • Acquisition Modality stores an Evidence Document to PACS • Non-image evidence for diagnostic interpretation • DICOM Structured Reporting documents or Waveforms, e.g. Mammography CAD SR, Basic Text SR, Enhanced SR, Comprehensive SR RSNA 2002

  24. Problems • How to standardize the Charge Posting and billing for work performed • How to Reduce System Interface Installation Time between Clinical Systems and the Charge Processors • How to avoid Billing System needing to know the Radiology Internals The solution is…… RSNA 2002

  25. Post- Processing Workflow Patient Information Reconciliation ChargePosting Schedule, perform, & notify image processing & CAD steps Collection of billable procedure details Unknown patients and unscheduled orders Integration Profiles Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps RSNA 2002

  26. Account Management ADT Terminal Report Generated / Signed CAD *Workstation 3-D *Workstation ReportRepository 3-D Performed CAD Performed AcquisitionModality Charge Posting Profile Post Charges *Billing System Charge Poster Study Performed / Materials Used … RSNA 2002

  27. Workflow • RIS indicates to the Billing System that procedures are available for Technical and/or Professional billing – maintain accuracy • Charge Posted Transaction may be sent at various times in the workflow - flexibility • Regulations and site policies determine when a procedure is eligible for Charge Posting RSNA 2002

  28. Problems • Ensuring print quality outside of the department • Radiologist discussing images with remote physicians • Capture image manipulation to avoid redundant work (coronal CT, MR reading, etc.) The solution is…… RSNA 2002

  29. Post- Processing Workflow Patient Information Reconciliation ChargePosting Schedule, perform, & notify image processing & CAD steps Collection of billable procedure details Unknown patients and unscheduled orders Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Integration Profiles Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps RSNA 2002

  30. With Presentation State Area Of Interest Area Of Interest The Radiologist’s Transformations Are Saved +Zoom +Annotation Original Image Original Image No Presentation State All the Transformations Are Completely Lost +Windowing The Radiologist Saves a New Presentation State: What the Reviewing Physician Sees: Consistent Presentation of Images On a Calibrated Display Original Image Inconsistent Presentation On an Uncalibrated Display Radiologist Views Images

  31. DICOMStandard Display Function Barten Curve Luminance Just Noticeable Differences Grayscale Standard Display Function (GSDF) 6 modalities 4 cameras, 26 workstations The current way= 180 calibrations The IHE way= only 36 calibrations Soft CopyReview Acquisition FilmReview Independent device calibrationdelivers consistency with simplicity RSNA 2002

  32. Consistent Presentation of Images • With films, image quality was the imaging department problem…. • Softcopy image distribution across the healthcare enterprise • Enabled by digital radiology • Avoids lost films, reduce delays • Decreases utilization of staff and equipment • But …need to ensure quality and consistency ! • This IHE Integration Profile is the cost effective and technically correct solution. RSNA 2002

  33. Problems • An hematologist/oncologist orders: • “CT CAP, Lymphoma, R/O disease” • We do “CT CHEST, ABDOMEN, PELVIS w/CON” • 3 orders in RIS, 3 accession numbers, 3 CPTs, 3 reports • Chest radiologist will read chest • Body Imager will read abdomen and pelvis • With One Spiral CT Exam what do we do ? The solution is…… RSNA 2002

  34. Post- Processing Workflow Patient Information Reconciliation ChargePosting Schedule, perform, & notify image processing & CAD steps Collection of billable procedure details Unknown patients and unscheduled orders Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Presentation of Grouped Procedures Subset a single acquisition Integration Profiles Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps RSNA 2002

  35. Report:CHEST Report:ABDOMEN Abdomen View Chest View Chest View MODALITY Abdomen View Performs a single exam Operator groups 2 procedures IHE – Presentation of Grouped Procedures Requested Procedure:CHEST Requested Procedure:ABDOMEN RIS / PACS RSNA 2002

  36. Presentation of Grouped Procedures • PGP maintains the link back to each one of the grouped procedures: • without breaking the acquisition apart • Without duplicating images • PGP ensures that each image subset related to a requested procedure is identified and ready to be presented.  This is key for quick display of new and prior studies. RSNA 2002

  37. Other Group/Split cases… • CT: Head bone / brain separation • CR: Foot/ankle - hand/wrist • E.g., lateral image of foot shared between AP of ankle and AP of foot • DR: Trauma patient AP / Lat re-grouping • I.e., do all the Aps then rotate the patient once then do Lats • MR: MRI/MRA • To be viewed and billed separately • IR: Diagnostic run and therapeutic run • Performed contemporaneously, viewed/billed separately • US: Abdomen and kidneys/ retroperitoneum The solution is…… RSNA 2002

  38. Problems • Will you ask your technologist to push Mr. Smith’s study and report to our Radiation Therapy planning system?” • “No.” The solution is…… RSNA 2002

  39. Post- Processing Workflow Patient Information Reconciliation ChargePosting Schedule, perform, & notify image processing & CAD steps Collection of billable procedure details Unknown patients and unscheduled orders Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Presentation of Grouped Procedures Subset a single acquisition Access to Radiology Information Consistent access to images and reports Integration Profiles Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps RSNA 2002

  40. Access to Radiology Information Emergency Department Referring Physician Radiology DepartmentImages and Reports Remote Clinics Other Departments:- Oncology- Surgery- Neurology- Pediatrics- etc. Electronic Medical Record RSNA 2002

  41. Problems • “Dave, you read that 3000 slice MR study last night. Can you highlight the 5 most important images for me” • Thinking… “#$@%!%# You”, says “Sure” • “Dr., I just reviewed 40 cases and marked my questions on yellow stickies. Can you review those” • Tech to radiologist: “The patient wouldn’t hold still” The solution is…… RSNA 2002

  42. Post- Processing Workflow Patient Information Reconciliation ChargePosting Schedule, perform, & notify image processing & CAD steps Collection of billable procedure details Unknown patients and unscheduled orders Consistent Presentation of Images Key ImageNotes 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 Integration Profiles Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps RSNA 2002

  43. The radiologist selects Key Images, and creates appropriate Notes. The referring physician views the Key Image Note prepared by radiologist. Note 1: Note 1: Note 2: Note 2: for refering physician In this image you can see the renal rupture. for refering physician In this image you can see the renal rupture. for refering physician In this image you can see the hematoma. for refering physician In this image you can see the hematoma. Results in improved communication between the radiologist and the referring physician RSNA 2002

  44. The radiologist selects Key Images, and creates appropriate Notes. The referring physician views the Key Image Note prepared by radiologist. Note 3: Note 3: for refering physician Hematoma everywhere for refering physician In this image you can see the hematoma. Results in improved communication between the radiologist and the referring physician RSNA 2002

  45. Key Image Notes • There is more to teamwork than images and reports • With IHE, it is possible to attach « electronic post-it™ » to images to increase informal but critical communication between: • The Technologist and the Radiologist about specific examination events • The Radiologist and the Technologist about image quality issues • The Radiologist and other department clinicians (surgeon, orthopedist,..) • The Radiologist and collegues about selecting images for conferences • The Radiologist to the Referring Provider, …..etc. • This IHE Integration Profile is the cost effective solution (increases radiology and overall efficiency). RSNA 2002

  46. Can You Make A Report Like This? Institution Identification Patient Identification Study Identification Technique Identification Discussion The liver is normal. There is a focal area of decreased attenuation adjacent to the falciform ligt., likely representing focal fat (image 22). The spleen, both kidneys, the … are normal. Impression CT of the abdomen within normal limits Signature The solution is…… RSNA 2002

  47. Or Like That ? Discussion Comparison is made to the prior study of 4/11/99. The left paratracheal lymph node (image 8, image 11) now measures 2.5x2.7x3.1 cm increasing from 2.0x2.1x2.6 previously. No other mediastinal, upper abdominal or axillary adenopathy is identified. No focal pulmonary lesions are seen. The…………… are normal. Impression Worsening L Paratracheal adenopathy. Signature RSNA 2002

  48. Post- Processing Workflow Patient Information Reconciliation ChargePosting 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 Integration Profiles Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps RSNA 2002

  49. Simple Image& NumericReports • Based on DICOM SR • Allows to include without transcription:- measurements- Image links- structured content • Integrated with the imaging workflow • Friendly to XML implementations • Easy to export to the CPR (HL7) RSNA 2002

  50. Simple Image and Numeric Report • Report content is more than words….. • With IHE, it is possible to add value to reporting with input from modalities and image processing applications (e.g. Measurements). • This IHE Integration Profile is the cost effective solution for sharing reports and inclusion of image enabled reports into the Electronic Patient Record. RSNA 2002

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