April 9 th , 2008 Chengdu, China

1. Health Data Explorer™ for Adobe® Acrobat® April 9th, 2008 Chengdu, China Hugh Lyshkow President, CEO DesAcc, Inc. © 2008 DesAcc, Inc. All Rights Reserved.

2. Agenda • PDF’s Role within Healthcare Standards • The “Health Data Explorer” Plug-in Architecture • Applying Clinical Context to Documents • Using XFA Forms as Health Record Templates • Interoperability and Cross-Enterprise Document Interchange • Workflow Enablement within Acrobat • Integrating Acrobat with 3rd Party Healthcare Applications • Use Case: U.S. Veterans Administration Workflow • Creating Content Specific eLearning Links • Digital Rights Management and Electronic Health Records

3. PDF’s Role within DICOM and IHE Standards (The Jargon Slide) DICOM Encapsulated CDA R2 Encapsulated “Naked” PDF PDF PDF History Demographics Images Reports Q/R, XDS-SD Relevant prior history MWL, PDQ Identifying patient information XDS-I DICOM image acquisition SR, XDS, XDM, XDR Results dissemination Acronyms Clinical Document Architecture Release 2 (CDA R2) Cross-Enterprise Document Media Interchange (XDM) Cross-Enterprise Document Reliable Interchange (XDR) Cross-Enterprise Document Sharing (XDS) for Imaging (XDS-I) and for Scanned Documents (XDS-SD) Digital Imaging and Communications in Medicine (DICOM) Integrating the Healthcare Enterprise (IHE) DICOM Modality Worklist (MWL) DICOM Query/Retrieve (Q/R) DICOM Structured Reports (SR) IHE Patient Demographics Query (PDQ)

4. Health Data Explorer Plug-in Architecture Input MR CT CR US NM SC … PACS RIS HIS DICOM Files CDA R2 Documents “Naked” PDF Files Document Types Protocols DICOM/HL7/POP3/SMTP/MIME Document Manager DICOM Engine eLearning API Components Context Manager Interchange Engine Integration API Health Data Explorer Plug-in to Adobe Acrobat 8 DRM Manager Database Engine Media Manager API Output Health Records as PDF Files and DICOM/CDA/HL7 Encapsulated PDF Formats Clinicians Patients Health Professionals Participants

5. Applying Clinical Context to Patient Documents • Clinical Context Allows for Electronic Data Interchange Without context, each PDF document is the same as any other, i.e. it is just a file. With clinical context, meaning the patient identifiers and clinical codes required to be compliant to DICOM, HL7 and IHE standards, a PDF document can enter into the data workflow underlying patient care. The Health Data Explorer plug-in allows any PDF document to be bound to a clinical context. A “Clinical Context” Toolbar has been added  so that the patient information for the current document is always visible. 1

6. Applying Clinical Context to Patient Documents • Where Does the Clinical Context Come From? • From a Radiology Information System (RIS) Modality Worklist Server • From another PDF document that has clinical context  • From the user manually, through the Clinical Context Wizard  • From Extensible Metadata Platform (XMP) based metadata found in a file • Through the Integration API from 3rd party applications  or CCOW • From the source DICOM files or CDA file from which the PDF was created 1 2 3

7. Using XFA Forms as Health Record Templates • Defining Clinical Forms • Any DICOM element, HL7 field, CDA item or DICOM image can automatically be mapped from a source health record into an Adobe XML Form Architecture (XFA) based PDF file. • Both static and dynamic XFA Forms can be defined. When dynamic forms are used, images and clinical information flows across any number of pages and sub-forms, as needed. • Each element within an XFA Form can be “spring loaded” with JavaScript logic. • Adobe LiveCycle Designer can be used to create any number of XFA Forms.

8. Interoperability and Cross-Enterprise Interchange • Health Data Explorer Adds: • DICOM Receive (C-STORE SCP) • DICOM Send (C-STORE SCU) • DICOM Query (C-FIND SCU) • DICOM Retrieve (C-MOVE SCU) • DICOM Modality Worklist (C-FIND SCU) • DICOM 3.0 Part 10 CD Reading • DICOM E-Mail • Cross-Enterprise Document Media Interchange • Cross-Enterprise Document Reliable Interchange 3 A local database maintains received DICOM image files and DICOM or CDA R2 Encapsulated PDF files. DICOM image files can be converted into XFA Forms from the database, as shown at right -. 1 2

9. Interoperability and Cross-Enterprise Interchange • Transmitting DICOM Encapsulated PDF Files • Advantages: • Maintains the digital signatures, security and functionality of the PDF file. • Any referenced DICOM image files can be embedded into the PDF for diagnostic quality review at a later time. • Size: the efficiency in disk space with which a PDF document can be stored relative to the same document being converted to a static Secondary Capture (SC) image was found in trials to range from 20:1 (30 KB original to 600 KB SC image) for a 1-bit single page PDF document transmitted as a JPEG baseline encoded SC image to 30:1 (200 KB original to 6 MB SC image) for a complex single page RGB PDF document. • Disadvantages: • Other DICOM devices may not yet be capable of receiving and displaying DICOM Encapsulated PDF files.

10. Interoperability and Cross-Enterprise Interchange • Simplifying DICOM Encapsulated PDF Transmission • Specifying the DICOM Conformance of the receiving device: • DICOM Encapsulated PDF • Secondary Capture Image Single Frame • Secondary Capture Image Multi-Frame Grayscale • Secondary Capture Image Multi-Frame Color

11. Interoperability and Cross-Enterprise Interchange • Cross Enterprise Document Interchange • Media Interchange (XDM) • CD-R • E-Mail • USB Device

12. Workflow Enablement within Acrobat • The “Received Health Records” Toolbar Menu • Health Data Explorer adds a new Toolbar to the Adobe Acrobat 8 User Interface: • DICOM Encapsulated PDF file received (C-STORE SCP) from other DICOM devices will automatically be added to the menu and marked as “Unread” • Health Data Explorer can also poll POP3 E-Mail accounts and add any: • Cross-Enterprise Document Media Interchange (XDM) E-Mail messages • Cross-Enterprise Document Reliable Interchange (XDR) E-Mail messages • DICOM E-Mail messages (DICOM 3.0 Part 11)

13. Workflow Enablement within Acrobat • Marking Documents as “Read” and “Verified” • The “Legal Authenticator” Toolbar allows documents to be marked as read and verified within Health Data Explorer’s database and within the document: • After a document is marked as read, it is removed from the “Received Health Records” menu , and the status within the document’s window titlebar  is updated: 2 1

14. Integrating Acrobat with 3rd Party Healthcare Applications • The Health Data Explorer Integration API • Developed for bidirectional interaction with 3rd party software, such as PACS • Example implementation: the “eFilm HIS-RIS” Integration Plug-in

15. Integrating Acrobat with 3rd Party Healthcare Applications • The Health Data Explorer Integration API • Allows Acrobat to act as a Report Repository, providing information to the third party product as to the reported/read status  of records stored within Acrobat. • Lets Key Images be transferred  from PACS to Acrobat (along with source DICOM files) and be mapped into any XFA Form for reporting . 2 3 1

16. Use Case: U.S. Veterans Administration Workflow Slide Courtesy of:

17. Use Case: U.S. Veterans Administration Workflow Slide Courtesy of:

18. Creating Content Specific eLearning Links • The Content Specific eLearning API • When a document is selected, the Clinical Context meta-data that is bound to it is passed to all the installed eLearning plug-ins. Each plug-in returns document specific links that are placed within the added “eLearning Content “ Toolbar menu . 1 3 2 • Content can be free or premium , training related, informational reminders or results from a web service search , and can be specific to the logged-in user. • When selected, a link can open an Adobe Connect session, pre-recorded content, a specific document, or launch a 3rd party application with relevant information.

19. Digital Rights Management and Electronic Health Records • Security is a Serious Issue… • “The reputation of the NHS for securely holding information has suffered a further blow after the loss of another 4,000 medical and personal details came to light on Friday.” ZDNet.co.uk, 18 January 2008 • “The authority which runs Buckinghamshire's hospitals has admitted sending unencrypted computer data about patients…” Bucks Free Press, 27 January 2008 • “Nine NHS trusts in England have admitting losing sensitive information, relating to hundreds of thousands of adults and children.” Whitehaven News, 31 January 2008 • …So Secure Health Records Should Be Stored in PDF • PDF files can be encrypted and digitally signed • Health Data Explorer adds a “Legal Authenticator” Toolbar to Adobe Acrobat: • Providing username/password protected log-in • Allowing for the automatic application of certificates to CDA, S/MIME and DICOM documents • Adobe LiveCycle Rights Management ES can be used to automate the document securing process

20. In Conclusion • Medical standards are increasingly moving towards utilizing PDF for faithfully rendering and archiving patient records. • Health Data Explorer provides mechanisms within Adobe Acrobat for facilitating workflow, document security and integration with 3rd party healthcare applications. • By building DICOM and IHE related protocols directly into Adobe Acrobat, with its installed base of over 600,000,000 copies worldwide, DesAcc believes that clinicians, healthcare professionals and patients themselves can more efficiently and effectively capitalize on the benefits of the PDF standard.