Your Problems; IHE Solutions

1. Your Problems;IHE Solutions Kevin O’Donnell, Toshiba Medical Systems Chris Lindop, GE Healthcare

2. Learning Objectives • Review well-known sources of pain still commonly afflicting radiologists, department managers, PACS administrators and referring physicians in practice today • Enumerate some of the specific ways the quality, speed, cost and efficiency of the care you provide may be being degraded • Understand how you should be benefiting from new electronic infrastructure and integrated systems • Learn which IHE Integration Profiles would be good first steps for each problem

3. Images on CDs • Scenario: • “A referred patient arrives with relevant prior imaging on a CD” • And then the fun starts…

4. Your Problems with CDs • “I plug the CD into my workstation and nothing happens” • The CD format is not compatible with my workstation • The images are not in DICOM • The images are DICOM but are not properly encoded • The CD tries to auto-launch a viewer that collides with the one on my workstation • Impact • Time is wasted • Relevant clinical data is inaccessible

5. Your Problems with CDs • “Every CD seems to have a different viewer” • It costs me time trying to learn them all • I don’t work as quickly when I don’t know how to use them • The viewers lack specific features I need • The viewers require additional software that I do not have • My IT group has security concerns about running “unknown” software from CDs • Impact • More wasted time • Less effective review of data

6. Your Problems with CDs • “The Images are in the PACS but are messed up” • The patient ID is wrong, it doesn’t come up in a query • I can’t display the new images with the old • The unknown procedure codes mess up my hanging protocols • Impact: • More lost time • More drags on effectiveness

7. How It Should Work • I insert the CD into my workstation • The DICOM Viewer installed on my workstation displays the CD contents my way • I decide to import the data into my PACS • The CD content is retrieved from the disk • The content is reconciled and automatically prepared for importation into the patient’s electronic medical record • The images and reports are reviewed on PACS in thecontext of the current patient encounter • I insert the CD into a “random” PC (uncommon) • CD may have a DICOM viewer • CD may have “Browser” versions of images and report

8. IHE Solution Two relevant Integration Profiles • (PDI) - Portable Data for Imaging • Uses only the most common, most compatible DICOM CD format • Adds requirements to remove common sources of problems • Based on cross-testing between vendors • (IRWF) – Import Reconciliation Workflow • During image import, the details are fixed to match (or not conflict with) local values • Patient IDs, Name • Procedure Codes, Accession Numbers, etc.

9. Acquisition Workflow • Scenario: • “ I order an imaging procedure for my patient.” • Really,what could be simpler?

10. Your Problems with Workflow • “Why are my techs entering patient and procedure information on all the systems?” • Why is this a manual task? • My techs should be doing scans, not duplicating data entry • All too often, data entry mistakes are made • Patient records get fragmented • Priors are not always available at time of reading • Impact • Degraded care, reduced productivity

11. Your Problems with Workflow • “Why is it so hard to close an order?” • Somewhere in the process of getting the images and distributing the reports, the accession # keeps getting messed up • Studies get disconnected and go unread • Billing details don’t match what was actually performed (so the payor doesn’t want to pay) • Impact • Delayed care, reduced productivity, lost revenues

12. Your Problems with Workflow • “Why aren’t my images showing up on PACS?” • If patient info was mistyped at acquisition, the query won’t match • Someone spends time searching or we re-scan • Network failure; modality didn’t know they weren’t on PACS and deleted them • We make techs manually confirm all images are on the PACS • It only takes a couple minutes • At 100,000 studies per year, that’s only 416 8-hour shifts of work • Impact • Delayed care, increased dose, reduced productivity

13. Your Problems with Workflow • “When a name needs to be fixed I never know when/if the patient record will be properly reassembled.” • John Doe’s get scanned and identified later • images/report needs to be reintegrated • Patients get incorrectly entered (or mis-selected in a worklist) • Peoples names change (e.g. marriage) • People are changing things on the modality, in the PACS, in the RIS, sometimes inconsistently, or at different times • So their clinical history is missing, or their images have been moved and I can’t find them, or both • Impact • Delayed care, incomplete information, reduced productivity

14. How It Should Work • Registration feeds the Scheduling System • Patient demographics are entered once at registration & centrally managed • Modalities download Worklists • Patient demographics & Procedure detail entry is automatic, fast, accurate & up-to-the-minute • Relevant clinical and protocol information details are included • Procedure code in worklist can optionally trigger protocol selection • PACS is notified of scheduled procedures • Relevant priors can be automatically pre-fetched • Modalities report procedure progress to RIS and PACS • Accession # consistently replicated in Images and Reports • Better tracking/closure of orders, better billing • PACS receipt of Images is automatically confirmed by Modality • Fewer Lost Studies

15. IHE Solution Two relevant IHE Integration Profiles • (SWF) – Scheduled Workflow • Integrates Registration, Scheduling, Acquisition Workflow and Image Content • Bridges HL7 and DICOM spaces properly • Most current products support it (but ask for it to be sure) • (PIR) – Patient Information Reconciliation • Facilitates coordinated reconciliation between PACS, RIS and HIS • Handles John Does, fixing mistakes and back-filling orders for unscheduled exams

16. Cross-Enterprise Image Sharing • Scenario • An ER patient with abdominal pain has a lesion on their x-ray. The H&P noted an earlier x-ray (in another state) with an abnormal finding. I need the prior images STAT! • OK, no one expects this to be easy…

17. Your Image Sharing Problems • “How do I even find out who has the images?” • Patient said it was “an imaging center in downtown LA”How many imaging centers are there in downtown LA? • Patient was not sure of the name of the PCP • Impact • Time wasted trying to track down and obtain the images • Potentially unnecessary procedures (imaging, surgery)

18. Your Image Sharing Problems • How do I find the matching Patient Record at the other institution? • Patient doesn’t know their patient ID from the other site • I only have the Patient ID for my institution • The other site doesn’t really want to let me go browsing their patient database • Impact • More delays and uncertainty

19. Your Image Sharing Problems • How do I get the Images? • Mail? No - need images STAT • Fax? Not good for sending images • E-mail? Do we both have secured e-mail systems? How do I view them? • Their web viewer? No account on their system - No experience with their product • Impact • Delayed care or incomplete information

20. Your Image Sharing Problems • What about security and privacy policies? • I don’t have privileges at the other hospital. • Who do I have to talk to to get access to the data? • Isn’t there some way to get emergency access?I’m just trying to treat the patient. • Impact • Delayed care and/or incomplete information

21. How It Should Work • My EHR Terminal handles everything: • I select my patient on my system • I select the RHIO that supported my patient’s care • My system automatically matches the patient and lets me confirm(either by ID cross-reference table or demographics matching) • I ask for a list of relevant priors. Success! • We have no BAA with the other site so I click “Break Glass”. My ID and access of the data is logged for later security review. • My system pulls the images and reports electronically from the other system for my review • I determine there is no change in the lesion & diagnose an Aortic Transsection, avoiding unnecessary surgery

22. IHE Solution • (XDS-I) Cross-Enterprise Document Sharing for Imaging • Shares images, diagnostic reports and related information between healthcare enterprises • (PIX) Patient ID Cross-referencing • Cross-index patient IDs across multiple sites • (PDQ) Patient Demographics Query • Query and retrieve a patient’s demographic and visit information • (ATNA) Audit Trail and Node Authentication • Systems Authentication • PHI-related audit events management • (BPPC) Basic Patient Privacy and Consent • Patient privacy consents & enforcement

23. Teaching Files or Clinical Trials • Scenario: • This study I’m reading would make a good case for my/our teaching files or • This study should be included in a clinical trial we are participating in • It seems so simple…

24. Your Teaching/Clinical Trial Problems • “Where did I put my notes?” • Why am I the one digging through PACS for the studies? • Tracking down images after the fact is a pain • Impact • Inefficient use of time • Can’t find study later • Lower participation in clinical trial • No cool images to share

25. Your Teaching/Clinical Trial Problems • “How am I supposed to get the images to the clinical trial, or to my teaching file account?” • The images are raw material; I need to get them to a system where I can work up a proper teaching file • We’re in 5 clincal trials, each with their own file server; I need to get the images to the right one. • Impact • Inefficient use of time • Becomes “more trouble than it’s worth”

26. Your Teaching/Clinical Trial Problems • “De-identifying the data for HIPAA is painful” • What are “DICOM Attributes” and why is PHI hiding in so many of them? • The tools provided require an IT savvy that I do not have • PACS Admin says I screwed up the images when I edited them • Impact • Inefficient use of time • Becomes “more trouble than it’s worth” • Might fail to protect patient privacy

27. How should it work? • I flag the image(s) of interest • I identify the clinical trial and/oradd a few notes about the clinical context (optional) • Images are de-identified automatically • Images and supporting information are bundled and automatically routed to the appropriate destination • Teaching File Authoring System; • Clinical Trial Export Node • Later, I login to my Teaching File account: • My images and notes are waiting for me • I finalize the teaching case and put it in our repository

28. IHE Solution • (TCE) – Teaching File & Clinical Trial Export • Automatic De-identification • Automatic Routing • Can include brief notes • Compatible with free RSNA MIRC tools • Teaching File Server • Teaching File Authoring Tool • Clinical Trial Node • mirc.rsna.org

29. Integration Challenge Notice the pattern? • Scenario: • I want to do something that requires some of the (literally) dozens/hundreds of systems in my department to collaborate…

30. Your Integration Problem • “My systems claim to be standards-based, but they still can’t integrate to do what I want.” • Some of my systems use different parts of the same standard • Some of my systems use the same standard in different ways • Some of my systems use multiple standards • Some of my systems use the “enhanced proprietary standard” preferred by the vendor • My vendors have different ideas about what each other should do • Many of my vendors products have never been directly tested together • Impact • Lack of interoperability • Costly point-to-point integration • Long install & deployment cycle • Have to do it over again with each new system

31. IHE Solution • Working with vendors, care providers and standards organizations, IHE: • Distills a clear description of the problem • Determines the right way to solve it using standards(IHE Profile) • Documents the solution in an implementation guide (IHE Technical Framework) • Coordinates cross-vendor testing of the solution (IHE Connectathon) Go see the rest of the profiles

32. IHE in Action • Visit IHE Demonstrations at RSNA 2007 • Cross-Enterprise Document Sharing for Imaging [XDS-I] • Teaching File & Clinical Trial Export [TCE] • IHE Product Showcase and participating Vendor Booths • Visit IHE Demonstrations at HIMSS 2008 • Integration Showcase • Covers IT, Radiology, Cardiology, …. • Visit www.ihe.net/profiles • There are MANY more Profiles • Start learning about them and IHE

33. Summary • Become familiar with the IHE Profiles that address your pain points • Make IHE Profiles part of your purchase and upgrade requirements; List them in your RFP