Integrating the Healthcare Enterprise

1. Integrating the Healthcare Enterprise What’s New in IHE Kevin O’Donnell Toshiba Medical Systems Rita Noumeir Ph.D. Softmedical

2. IHE Radiology Activities • New Supplements in 2004 • Portable Data for Imaging Profile • NM Image Profile • Departmental Workflow White Paper • Instance Availability Notification Option • Appointment Notification Option • PDI Demonstration and Success Stories at RSNA 2004

3. Charge Posting Presentation of Grouped Procedures Reporting Workflow KeyImageNotes Simple Image & Numeric Reports NMImage Consistent Present-ation of Images EvidenceDocs Access to Radiology Information Portable Data for Imaging IHE Radiology Integration Profiles Scheduled Workflow - Patient Info. Recon-ciliation Post-Processing Workflow Basic Security

4. IHE IT Infrastructure Activities • New Supplements in 2004 • Audit Trail and Node Authentication (ATNA) • Cross-Enterprise Document Sharing (XDS) • Patient Demographics Query (PDQ) • Personnel Whitepages (PWP) • Interoperability Showcase at HIMSS 2005

5. Patient Demographics Query Patient Identifier Cross-referencing for MPI Retrieve Information for Display Retrieve Information for Display Retrieve Information for Display Cross-Enterprise Document Sharing Enterprise User Authentication Enterprise User Authentication Patient Synchronized Applications Patient Synchronized Applications Registration, distribution and access across health enterprises of clinical documents forming a patient electronic health record Access a patient’s clinical information and documents in a format ready to be presentedto the requesting user Access a patient’s clinical information and documents in a format ready to be presented to the requesting user Access a patient’s clinical information and documents in a format ready to be presentedto the requesting user Synchronize multiple applications on a desktop to the same patient Synchronize multiple applications on a desktop to the same patient Map patient identifiers across independent identification domains Audit Trail & Node Authentication Patient Identifier Cross-ref for MPI Enterprise User Authentication Patient Identifier Cross-referencing for MPI Personnel White Pages Patient Identifier Cross-referencing for MPI Provide users a single name and central authentication across all systems Map patient identifiers across independent identification domains Centralized privacy audit trail and node to node authentication to secure a domain. Access to Workforce contact Information Map patient identifiers across independent identification domains Map patient identifiers across independent identification domains Consistent Time Consistent Time Coordinate time across networked systems Coordinate time across networked systems IHE IT Infrastructure Integration Profiles

6. IHE Lab Activities • IHE Lab • Initiated by IHE-Europe & IHE-Japan • Lab Workflow Profile Published • Current Work Underway: • Point Of Care Testing (LPOCT) • Automation Manager (LDA) • Patient Information Reconciliation (LPIR) • Code Set Distribution (LCSD) • www.gmsih.fr/ihe

7. IHE Cardiology Activities • New Domain in 2004 • Sponsored by ACC, ESC, GMSIH • New Supplements • Cath Lab Workflow Profile • Echo Workflow Profile • ECG Report Retrieval for Display Profile • Demonstration at ACC 2005 (Where, when)

8. IHE Regions • IHE-North America • U.S., Canada (Health Infoway Project) • Connectathon in January 2004 (Chicago) • 40+ Vendors with 75+ Systems • Demonstrations at RSNA, HIMSS, ACC • Additional Presentations at SCAR, SPIE • IHE-Europe • France, Germany, Italy, UK, Norway, Netherlands & Spain • Connectathon in April 2003 (Padova, Italy) • ~35 Vendors, ~75 Systems, 16 Profiles • Presentations/Demos at ECR, DRK, SIRM, Hopital Expo, UKRC • IHE-Asia • Japan, S. Korea, Taiwan & China • Connectathon in March 2003 (Yokohama, Japan) • Presentation/Demo at JRC

9. Portable Data for Imaging Profile(PDI) CDs that Work!

10. Media Importer Image/ Report Display Printer John Doe Distribute Imaging Information on Media CD Creator CD

11. Value Proposition • Greater Reliability • removes/clarifies typical sources of errors • adds a testing process • Optional Support for Web Data • View in a browser • Import Cleanup Requirements (Media Importer) • ability to fix patient IDs, etc.

12. CDROM Structure DICOMDIR Directory of DICOM files README.TXT INDEX.HTM Web content (optional) IHE_PDI Directory of web files Other optional content

13. CD File Naming Conventions • File naming conventions apply to all files on the CD including: • DICOM File Names • Non-DICOM File Names • DICOM Viewer Application Name • The name of DLLs present on the CD

14. DICOMDIR Requirements • DICOMDIR validation specs • No Compression

15. Media Readers • Indicate to the user when they find DICOM instances that are not supported • Do not automatically run software found on the media for security reasons. Media Importers • Support reconciliation with local Patient IDs, Accession #s, etc.

16. Media Identification • Human-readable identification : • Patient Name • Media Creation Date • Name of the Originating Institution • Indication of the type of content: “DICOM ONLY” or “DICOM PLUS WEB”

17. README.TXT Institution: This disk was created by: The Radiological Society of North America (RSNA) 820 Jorie Boulevard, Oak Brook, IL 60523 Media Creator Application: This disk was created using: OFFIS DICOM Toolkit (DCMTK), version 3.5.3. (for the DICOMDIR file) ... Vendor_X Software (for rendering Web Option data) … Contact Information: If you have any questions about how this disk or the data on it were generated, please contact: Chris Carr Director of Informatics, RSNA 820 Jorie Boulevard, Oak Brook, IL 60523 ph: (630)368-3739 fax: (630)571-7837 email: carr@rsna.org Web: www.rsna.org/ihe Media Organization: DICOM composite objects are located in the folder DICOM. Subfolders within the DICOM folder represent different sources of images. PDI Web Option data is located in the folder IHE_PDI. This disk conforms to the IHE Portable Data for Imaging (PDI) Integration Profile. For details on this specification, please refer to Volume 1, Chapter 15 & Volume 3, Section 47 of the IHE Radiology Technical Framework, available at: http://www.rsna.org/IHE This disk also conforms to the DICOM General Purpose CD-R Interchange Profile. For details on this specification, please refer to Part 10 & Part 11, Annex D of the DICOM Standard, available at: http://medical.nema.org/ Site Configurable Information Release Information Release Information Site Configurable Information Note: Taken from RSNA 2004 PDI Demo CD

18. INDEX.HTM • PDI - IHE Portable Data for Imaging • RSNA 2004 Demonstration • This is a sample CD containing data ….. • Institution/Privacy... • Web Content - Reports and Images • The following are web viewable versions of DICOM Reports and Images on this disk. • Vendor_A CR • Vendor_B (XR ) …. • Additional Data • What is PDI? - An Overview of IHE Portable Data for Imaging • Manifest of Importable Data • This section should contain a list, or a link to a list, of all DICOM SOP instances on this disk that can be imported by a Media Importer Actor. • DICOM Viewer • This CD does not contain a DICOM viewer application. If it did, this section would contain a link to that viewer and a discussion of operating system requirements. • README File • For technical details about this disk and contact information for the source, see:README.TXT • Acknowledgements • Disclaimers • The data is for demonstration purposes only and not for diagnostic imaging. … Site Configurable Title Site Configurable Generic Information Generated Information on CD Content and Links Application Specific Information Information of DICOM VIEWER Link to README.TXT Other Site Configurable Information

19. Nuclear Medicine Profile(NM)

20. NM Image – The Problem • DICOM NM objects are different and support in products is inconsistent • NM clinical display practices are different and support in products is inconsistent • Clinical Analysis Programs are used extensively (particularly for Cardiology), but no support for distribution and display of those Result Screens • NM Users are not adept at getting these requirements accurately included in RFPs • Vendors (especially of general purpose systems) are not adept at accurately representing their support for such features

21. NM – The Solution • New Profile • for Users to request and Vendors to claim • No New Actors or Transactions • Additional requirements on existing actors and transactions • Two New Options • New Informative Text in Vol. 1 • Clarifications of NM Workflow mapping to SWF • Explanation of NM Data • Explanations of NM Clinical Display concepts • New Normative Text in Vol. 2 • Connectathon to help test and confirm

22. NM Image Profile • Acquisition Modalities • Create NM objects as specified (additional attribute & vector handling) • Include specific codes in Cardiac studies • Evidence Creators • Create NM objects as specified (additional attribute & vector handling) • Include specific codes in Cardiac studies • Result Screen Export Option • Image Manager/Archives • Store/Retrieve NM & Secondary Capture (SC & MFSC) Objects • Support Query on Study Description • Image Displays • Display NM and Secondary Capture (SC & MFSC) Images • Support specified display capabilities

23. Image Display • Display NM and Result-Screen Images • Support specified NM essential display capabilities • Additional attribute handling • e.g. Patient State, Image Orientation, Detector Sequence, View Code Sequence • Review Option

24. Image Display • Handle multi-frame / multi-vector images • Multiple simultaneous cines • Grayscale and color result screens • Dynamic and static result screens • Original resolution and scaled • Separate adjustment of upper and lower window levels • Apply local color tables to grayscale screens • Add new local color tables to system • Change intensity of grayscale result screens • Display Series Description tag

25. NM Image NM PACS

26. NM Image NM PACS

27. NM Image

28. Image Display • Scale “intelligently” to avoid presenting postage-stamp size NM images • Allow user to select different vectors/framesets of complex multi-frame images • Allow user to separately adjust intensity for different framesets (eg, phases) in the same “image”

29. Review Option: Image Displays • Adds Image Display requirements to support Review of NM Images • MPR Display • More series at once • Different series types together • Pixel value display

30. Result Screen Export Option

31. Result Screen Export Option:Evidence Creators • Render Dynamic Result Screens • Based on the following DICOM Objects: • Multi-Frame Grayscale Byte Secondary Capture • Multi-Frame True Color Secondary Capture • Creating multiple single frame objects is NOT sufficient. • Render Static Result Screens • Using single frame DICOM Secondary Captures is sufficient • Using Multi-frame to render single or several related static result screens is recommended • provides better image comment/label attributes • provides implicit display order • displayed by stepping, not cine • Must generate appropriate Secondary Capture objects from any Result Screens created.

32. Appointment Notification Option (Scheduled Workflow Profile)

33. Scheduled Workflow Profile report Registration Film Lightbox Image Manager & Archive Orders Filled Film Folder Diagnostic Workstation Film Report Repository Orders Placed AcquisitionModality acquisitioncompleted acquisitionin-progress imagesprinted Modality acquisitioncompleted

34. Integration Problem • DSS/Order Filler (i.e. RIS) is responsible for scheduling • But, Order Placer has no way to know when or where the appointment will take place So…. • DSS/Order Filler notifies Order Placer of date and time of scheduled exams

35. Value Proposition • Order Placer can track and display scheduled Radiology appointments • Helps synchronization of scheduling processes between enterprise and Radiology

36. Appointment Notification Transaction • Three typical use cases • New booking: initial scheduling of an examination • Re-schedule: change in date/time of examination • Cancellation: examination cancellation • Mechanism • HL7 SIU messages • One message may convey multiple appointments corresponding to a single order • One appointment corresponds to one or more Scheduled Procedure Steps

37. Instance Availability Notification Option(Scheduled Workflow Profile)

38. Scheduled Workflow Profile report Registration Film Lightbox Image Manager & Archive Orders Filled Film Folder Diagnostic Workstation Film Report Repository Orders Placed AcquisitionModality acquisitioncompleted acquisitionin-progress imagesprinted Modality acquisitioncompleted

39. Integration Problem • DSS/Order Filler, Post-Processing Manager, Report Manager need to know when acquired evidence objects are available in the Archive • Procedure Complete status doesn’t necessarily mean the data has been sent to PACS yet • Storage may fail (network problems, etc.) • Existing query mechanism forces “managers” to poll Image Manager/Archive for availability of Instances.

40. Instance Availability Notification • Image Manager notifies Order Filler (and other workflow management actors) of availability of evidence objects. • Evidence Objects = Images, Presentation States, Key Image Notes, Measurements, etc. • Based on New DICOM SOP Class introduced in Supplement 93 • Provides list of all object UIDs and their availability for retrieval, either over network or media

41. Value Proposition • Data Availability Notification is available to all workflow management actors • Uses notification rather than polling for improved timeliness and network efficiency • Workflow Managers can display availability of input data • Workflow Managers can intelligently update or put items on worklists based on data availability • Workflow efficiency improves when there is timely status information.

42. Availability Status • “ONLINE” instances are immediately available • “NEARLINE” instances need to be retrieved from relatively slow media such as optical disk or tape • “OFFLINE” a manual intervention is needed before the instances may be retrieved • “UNAVAILABLE” instances cannot be retrieved

43. Where Is More Information Available? • www.rsna.org/IHE soon to be ihe.net • IHE Radiology Technical Framework V5.5 • IHE IT Technical Framework V1.1 • IHE Lab Technical Framework V1.1 • IHE Cardiology Technical Framework V1.0 • IHENews Mailing List • IHE Primer and IHE FAQ • IHE Integration Profiles: Guidelines for Buyers • IHE Presentations • IHE Connectathon Results • IHE Integration Statement Links

44. Ask your vendors: Which IHE Profiles do they support on which systems?