Integrating the Healthcare Enterprise

1. Integrating the Healthcare Enterprise Using IHE to Improve Nuclear Medicine Cross-vendor Connectivity Jerold Wallis Mallinkcrodt Institute of Radiology IHE NM Technical Committee co-chair SNM DICOM Committee chair SNM 2007

2. Vendor and User expertise HealthcareConnectivityProblem Healthcare Site Includes IHE in RFP Proposed solution Using existing standards Public Demonstration “Integration Profile” Vendor implements solution into REAL product Vendor testing at Connect-a-thon SNM 2007

3. NM Image with Cardiac option Image Fusion New in 2006-7 SNM 2007

4. IHE Radiology Integration Profiles Scheduled Workflow Charge Posting Presentation ofGrouped Procedures Teaching Files & Clinical Trials Export Reporting Workflow KeyImageNotes ImageFusion ImageFusion Simple Image & Numeric Reports NMImage NMImage Cardiac NM Option Consistent Presentation ofImages EvidenceDocs Access to Radiology Information XDS for Imaging Portable Data for Imaging Patient Info. Recon-ciliation Post-Processing Workflow Audit Trail & Node Authentication - Radiology Option SNM 2007

5. Using IHE:Your Three Step Program • Select Specific IHE Profiles • List those Profiles in your RFP • Check Vendors IHE Integration Statements SNM 2007

6. Selecting IHE Profiles Review the Profiles : • What they do • Benefits for your situation Some Helpful Resources: • IHE User’s Handbook - Radiology • RSNA Demonstrations • Educational Material (e.g. Workshop Presentations) • IHE Technical Framework – Radiology • Connectathon Results www.ihe.net SNM 2007

7. RFPs • Be Brief? • “The system must support DICOM” • Be Effective? • “The system must support the following DICOM services according to the following 100 pages of specifications: …” • Be Both: • “The system must support the IHE Nuclear Medicine Image Profile as the Acquisition Modality actor.” SNM 2007

8. IHE Integration Statements • Explicit claim by the vendor, for a specific product version • Lists profiles, actors, options • Short & Sweet • Sample Vendor IHE Integration Statement • Version 2.1 of the CardioCT 5000 supports IHE Scheduled Workflow as an Acquisition Modality SNM 2007

9. SNM 2007

10. NM Image – The Problem • Support in Products is inconsistent • DICOM NM objects are different • NM Display needs are different • NM Cardiac Display needs are different • Poor communication during product purchase • NM Users are not adept at getting these requirements accurately included in RFPs • Vendors are not adept at accurately representing their support for such features SNM 2007

11. General NM Viewing Suboptimal Click and move mouse down to adjust window level, right to adjust window center SNM 2007

12. If sent as Short axis Images not displayed in a useful format. If sent as screen snapshots(ie, static Secondary Capture) Can’t separately adjust stress and rest images Can’t view gated cine Cardiac Viewing Suboptimal SNM 2007

13. New this year ! = NEW • Cardiac option • Better addresses cardiac needs • Minor restructuring of remaining profile SNM 2007

14. NM ImageGoal • Use general Radiology Infrastructure to satisfy Basic NM Data Needs • Access to NM Images • Access to usable presentations of NM Images • Access to Clinical Processing Results SNM 2007

15. Image Displays Acquisition Modalities Evidence Creators Image Manager/ Archives Display NM and Secondary Capture (SC & MFSC) Images Support specified display capabilities Handle specific NM DICOM attributes NM Image Actors SNM 2007

16. General NM Option Whole body display Cardiac NM Option ACC NM Cardiac display Options: Image Displays Displays must support at least one of these options! SNM 2007

17. Understood by dedicated NM systems Often Misunderstood by general storage and display systems Multiframe Dynamic Anterior Posterior Multi-energy NM Image Format • Image vectors SNM 2007

18. Image Display Allow user to select different vectors/framesets of complex multi-frame images SNM 2007

19. 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 • Apply local color tables to grayscale screens • Add new local color tables to system • Display Series Description tag SNM 2007

20. Upper and Lower Levels Upper and lower window levels (Not just center/width) Separate Design is up to vendor SNM 2007

21. Display Formats A1 A2 A3 A4 A5 A6 A7 A8 A9 … … … … … … … … … … … … … … … … … … … … … … A32 … A1 A2 B1 B2 C1 C1 • Grid display • Frames from one image set • Fit display • Frames from multiple image sets SNM 2007

22. ACC NM Cardiac Display • Generate long axis from short axis images (MPR) SNM 2007

23. ACC NM Cardiac Display • Generate long axis from short axis images (MPR) • Display of 2 image sets (Stress and Rest) SNM 2007

24. Short ACC NM Display Example Stress Rest Stress • Follow ACC guidelines for display • Use patient state tags to set display order • Controls for adjusting stress and rest • Image alignment, • window upper and lower levels. Rest Vertical Stress Rest Horizontal Stress Rest SNM 2007

25. NM Profile: Cardiac Option • Created with support of • ACC • ASNC • Demo at • ACC in March 07 SNM 2007

26. MPR Option: Image Displays • Adds Image Display requirements to support Review of SPECT NM Images with Multi-planar reconstruction (MPR) • Transaxial • Sagittal • Coronal Replaces Review Option SNM 2007

27. Image Displays Acquisition Modalities Evidence Creators Image Manager/ Archives Create NM objects as specified (Series, attribute & vector handling) Include specific codes in Cardiac studies NM Image Actors SNM 2007

28. Image Displays Acquisition Modalities Evidence Creators Image Manager/ Archives Create NM objects as specified (Series, attribute & vector handling) Include specific codes in Cardiac studies Use Cardiac codes during processing NM Image Actors SNM 2007

29. Render Static Result Screens Single frame DICOM Secondary Capture or Multi-frame (preferred, displayed by stepping, not cine) Render Dynamic Result Screens Multi-Frame Secondary Capture Grayscale Byte True Color Result Screen Export Option:(Evidence Creators) SNM 2007

30. Image Displays Acquisition Modalities Evidence Creators Image Manager/ Archives Store/Retrieve NM & Secondary Capture (SC & MFSC) Objects Return Series Description at time of query NM Image Actors SNM 2007

31. Image Fusion Profile • Fusion- The Integration Problem • Results not readily transferable between systems • Results presented on different systems may not appear the same. SNM 2007

32. Fusion- The Integration Solution • A collection of DICOM objects exists to address the problem. • Their use is constrained and clarified to avoid misinterpretation and promote compatibility. SNM 2007

33. Spatial Registration Object SRO • Not required for already-registered PET-CT data from a hybrid scanner Image 1 Image 2 Transformation SNM 2007

34. Blending Presentation State SRO BPS Image 1 Transformation Window – 1 Image 2 Window – 2 Color Table Transparency SNM 2007

35. Blending state can be searched and retrieved from PACS Can be used to retrieve the image data and the alignment automatically. User selects a Blending state. Automatically load referenced objects. Alignment applied, PET re-sampled to CT and displayed fused automatically . Display is required to provide Scrolling through volume Adjustment of fusion blending and window levels MPR Side-by-side display Fusion- Display Blending State Registration Object PET CT SNM 2007

36. Essential Clinical Features • MPR • Fusion • Side-by-side • Registered SNM 2007

37. NM Image and Image Fusion Profile Status • Published for Trial Implementation. http://www.ihe.net/ • Vendors: Complying with the profiles will help meet users needs. • Users: Ask vendors “Do you offer systems that comply with the NM Image and Image Fusion profiles?” SNM 2007

38. Other IHE Profiles? SNM 2007

39. 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

40. Patient Information Reconciliation (PIR) Fixing erroneous (or unknown) Patient info Propagating changes across systems

41. Consistent Presentation of Images Tracks changes Uses display calibration to adjust for perceptual differences

42. Key Image Note (KIN) Add notes/comments to images Flag important images for referring MD, consults, etc

43. Portable Data for Imaging (PDI) • DICOM Image CDs • Reliable interchange • A Web Content Option • Provides guidelines for including web-viewable content on media. • Allows for both DICOM and JPEG content

44. Import Reconciliation Workflow (IRWF). Patient Data Bringing in outside exams into your PACS Resolving issues such as foreign Patient ID and Accession Number PDI Disk PACS A Radiology Site B

45. Teaching File and Clinical Trial Export (TCE). Exporting images teaching files clinical trials De-identifying Remapping of identifiers to pseudonymous values.

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