Integrating the Healthcare Enterprise

1. Integrating the Healthcare Enterprise Nuclear Medicine and IHE: What’s New? Jerold Wallis Mallinkcrodt Institute of Radiology IHE NM Technical Committee co-chair SNM DICOM Committee chair IHE RSNA 2006

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 IHE RSNA 2006

3. New in 2006 • Import Reconciliation Workflow Profile • Bringing outside studies into your PACS • Prior comparisons • Exams done elsewhere to be read locally • Transfer of care • Reconciliation of demographics • Mammography Image • Optimal softcopy image display • Special Mammography issues • NM Image with Cardiac option • Image Fusion IHE RSNA 2006

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 IHE RSNA 2006

5. 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 IHE RSNA 2006

6. General NM Viewing Suboptimal NM PACS IHE RSNA 2006

7. General NM Viewing Suboptimal NM PACS IHE RSNA 2006

8. General NM Viewing Suboptimal Click and move mouse down to adjust window level, right to adjust window center IHE RSNA 2006

9. 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 IHE RSNA 2006

10. New this year ! = NEW • Cardiac option • Better addresses cardiac needs • Minor restructuring of remaining profile IHE RSNA 2006

11. NM Image Abstract / Scope • Content Profile • for Users to request and Vendors to claim • No New Actors or Transactions • New Informative Text in Vol. 1 • New Normative Text in Vol. 2 IHE RSNA 2006

12. 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 IHE RSNA 2006

13. NM ImageStandards Used • DICOM NM Image Object • DICOM Multiframe Secondary Capture • Dynamic Results • Collection of Static Results • DICOM Secondary Capture • Static Results • ACC NM Cardiac Display format IHE RSNA 2006

14. NM ImageTransaction Diagram IHE RSNA 2006

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 IHE RSNA 2006

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! IHE RSNA 2006

17. 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 • Display Series Description tag IHE RSNA 2006

18. Understood by dedicated NM systems Often Misunderstood by general storage and display systems Multiframe Dynamic Anterior Posterior Multi-energy NM Image Format NM Image • Image vectors IHE RSNA 2006

19. 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” IHE RSNA 2006

20. Upper and Lower Levels • Upper and lower window levels • (Not just center/width) • Separate • Design is up to vendor IHE RSNA 2006

21. Display Formats A1 A2 A3 A4 A5 A6 A7 A8 A9 … … … … … … … … … … … … … … … … … … … … … … A32 … Comparison Display A1 A2 B1 B2 C1 C1 • Grid display • Frames from one image set • Fit display • Frames from multiple image sets IHE RSNA 2006

22. ACC NM Cardiac Display • Generate long axis from short axis images (MPR) IHE RSNA 2006

23. ACC NM Cardiac Display • Generate long axis from short axis images (MPR) • Display of 2 image sets (Stress and Rest) • 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. IHE RSNA 2006

24. Short axis ACC NM Display Example • Vertical Long • Horizontal Long IHE RSNA 2006

25. Short ACC NM Display Example Stress Rest Stress Rest • Vertical Stress Rest • Horizontal Stress Rest IHE RSNA 2006

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 IHE RSNA 2006

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 IHE RSNA 2006

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 IHE RSNA 2006

29. Result Screen Export Option IHE RSNA 2006

30. Result Screen Export Option:Evidence Creators • 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 IHE RSNA 2006

31. 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 IHE RSNA 2006

32. Image Fusion Profile IHE RSNA 2006

33. Image Registration and Fusion • Translate • Rotate Rigid Registration • Scale • Warp- optional(Deformable Registration) • Fuse IHE RSNA 2006

34. Image Fusion- General Use Case CT MR • Tech acquires two series of images. • Tech reconstructs images, performs registration, and stores results. • Workstation presents fused view based on full image data for Radiologist or Oncologist. • PACS Display shows Fused views to Referring Physician IHE RSNA 2006

35. Fusion- The Integration Problem • Results not readily transferable between systems • Proprietary or inconsistent implementations • Lack of guidance • Results presented on different systems may not appear the same. • Systems must correctly handle issues such as • Identifying and retrieving the right datasets • Matching data between single-slice and multi-slice datasets • Performing spatial translations • Rendering the fused display IHE RSNA 2006

36. 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. IHE RSNA 2006

37. Spatial Registration Object SRO • Not required for already-registered PET-CT data from a hybrid scanner Image 1 Image 2 Transformation IHE RSNA 2006

38. Blending Presentation State SRO BPS Image 1 Transformation Window – 1 Image 2 Window – 2 Color Table Transparency IHE RSNA 2006

39. Image Fusion Actors Acquisition Modality Evidence Creator [RAD 8] Modality Images Stored ↓ [RAD 57] Blending Presentation States Stored ↓ [RAD 56] Spatial Registrations Stored ↓[RAD 10] Storage Commitment ↓ ↓ [RAD 18] Creator Images Stored ↓ [RAD 57] Blending Presentation States Stored ↓ [RAD 56] Spatial Registrations Stored ↓ [RAD 10] Storage Commitment ImageManager Image Archive ↓ [RAD 14] Query Images ↓ [RAD 16] Retrieve Images ↓ [RAD 15] Query Presentation States ↓ [RAD 17] Retrieve Presentation States ↓ [RAD 58] Retrieve Spatial Registrations Image Display IHE RSNA 2006

40. Load CT and PET images Align images (automatically or manually) and fuse with desired blending factor Store the alignment, including Registration object Blending State (defining the blending factor, window levels and referencing all other objects) Storage can be on PACS or disk. Images do not need to be stored if already stored. Fusion- Preparation Blending State Registration Object CT PET IHE RSNA 2006

41. 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 IHE RSNA 2006

42. Essential Clinical Features • MPR • Fusion • Side-by-side • Registered IHE RSNA 2006

43. What are Benefits to the User? • Consistency of results across vendors. • Fusion on vendor “A” system • Display on vendor “B” system • Easy to list in RFP • Easy to distribute and display fused images • Applies to PET/CT, CT/MR etc IHE RSNA 2006

44. What are Benefits to the Vendor? The Fusion Profile Provides: • A framework for interoperability with other vendors • A baseline feature set to meet clinical needs • Common approach for all modalities IHE RSNA 2006

45. NM Image and Image Fusion Profile Status • Published for Trial Implementation. http://www.ihe.net/Technical_Framework/index.cfm#radiology • 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?” IHE RSNA 2006

46. IHE RSNA 2006

47. Questions? IHE RSNA 2006