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IHE Cardiology Profiles

Learn about the general workflows and specific procedures in cardiology, including catheterization, echocardiograms, stress testing, and nuclear cardiology, and how to enhance content display and retrieve ECGs for display. Explore real-world use cases and best practices for improving efficiency and collaboration in the cardiology department.

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IHE Cardiology Profiles

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  1. IHE Cardiology Profiles Information Technology Association of Canada Jon Elion MD, FACC Chief Medical Officer, Agfa Healthcare Co-Chair, IHE-Cardiology Planning Committee

  2. Special Thanks to the Contributors • Bob Baumgartner, McKesson • Anand Kumar and Glenn Marshall, Siemens • Harry Solomon and Charles Parisot, GE Healthcare • Bryan Jennings, Medical Micrographics • Ellie Avraham, Kodak Health Imaging • Tim Becker, University of Kiel • Stephen Ferber, Technology Solutions • Nicholas Steblay, Boston Scientific • Kevin O’Donnell, Toshiba Medical Systems • John Donnelly, IntePro Solutions • Didi Davis, Eclipsys

  3. Topics • Cardiology Workflows General • Cath Workflow • Echo Workflow • Stress Workflow • Content Display Requirements • Retrieve ECG for Display • Stress Echo • Stress • Nuclear Cardiology • Displayable Reports

  4. Cardiology vs. Radiology • CT scanners are rarely unplugged and wheeled down the hall • Cardiac cath procedures are inherently multimodality • It is rare for a cardiac cath to be ordered ahead of time • Cardiology reports have graphics in addition to text • Both disciplines have emergency cases, unregistered patients, and “John Doe” situations • Cardiology has more procedures (as opposed to just images), and more structured results

  5. General Workflow

  6. Topics • Cardiology Workflows General • Cath Workflow • Echo Workflow • Stress Workflow • Content Display Requirements • Retrieve ECG for Display • Stress Echo • Stress • Nuclear Cardiology • Displayable Reports

  7. Cath Lab • Multiple re-entry of Patient ID • Error prone • Results fragmented across systems • Results inconsistently time-tagged • Custom solutions for data sharing • Difficult to manage • Not coordinated with HIS • Unidentified patients (emergency) • Un-ordered cath exams • Diagnostic and interventional • Ad hoc scheduling of cath labs • Change of rooms during procedure 7 6 5 8 10 9 11 4 3 2 1

  8. Order Image Acquisition Department System Placer Manager Modality Scheduler/ Order Filler ADT Register/ Admit Patient Patient Registration [Rad-1] Create Order Placer Order Mgmt - New [Rad-2] Schedule Procedure Procedure Scheduled [Rad-4] Start Procedure Query Modality Worklist [Rad-5] Select Patient Administrative Process Flow

  9. Procedure Performance Process Flow Image Acquisition Acquisition Department System Order Modality n Manager/ Scheduler/ Order Modality Placer ImageArchive Filler Modality Procedure Modality Procedure Step In Progress [Card-1] Step In Progress [Card-1] UpdateSchedule Query Modality Worklist [Rad-5] Modality Procedure Modality Procedure Step In Progress [Card-1] Step In Progress [Card-1] Modality Images/ Perform Evidence Stored [Card-2] Acquisition Perform Modality Images/Evidence Stored [Card-2] Acquisition Modality Procedure Modality Procedure Step Completed [Rad-7] Step Completed [Rad-7] Storage Order Status Commitment [Card-3] Update [Rad-3]

  10. Use Cases • C1: Patient Registered at ADT, Ordered by the Order Placer • C2: Patient Registered at ADT, Ordered by DSS/OF • C3: Patient Registered at ADT, Procedure Not Ordered • C4: Patient Registered at DSS/OF and Procedure Ordered • C5: Patient Not Registered • C6: Patient Updated During Procedure • C7: Change Rooms During Procedure • C8: Cancel Procedure • C9: Post-Procedure Evidence Creation • C10: EP Ablation / Implantation Lab (only for the EP lab)

  11. Topics • Cardiology Workflows General • Cath Workflow • Echo Workflow • Stress Workflow • Content Display Requirements • Retrieve ECG for Display • Stress Echo • Stress • Nuclear Cardiology • Displayable Reports

  12. Use Cases • E1: Patient Registered at ADT and Procedure Ordered • E2: Intermittently Connected Modality • E3: Intermittently Connected Modality with ad hoc Procedure, Patient Registered, Scheduled Procedure • E4: Intermittently Connected Modality with ad hoc Procedure, Patient Registered, Unscheduled Procedure • E5: Intermittently Connected Modality with ad hoc Procedure, Patient Unregistered, Unscheduled Procedure • E6: Stress Echo Staged Protocol • E7: Echo Measurements Evidence Creation

  13. Topics • Cardiology Workflows General • Cath Workflow • Echo Workflow • Stress Workflow • Content Display Requirements • Retrieve ECG for Display • Stress Echo • Stress • Nuclear Cardiology • Displayable Reports

  14. So what is Stress Testing? • Uses graded exercise or medication to increase the work of the heart (“stress”) • Continuous 12 lead ECG monitoring during study (looking for arrhythmias, changes in ST segments) • Used as a screening tool or to test effectiveness of therapy • May be done “standalone” or with imaging (echo, nuclear)

  15. Stress Workflow Diagram

  16. Stress Workflow – Actors and Options

  17. Use Cases • Case S1: Cardiac Stress Test, ECG Only • Limited use with lower sensitivities and specificities • Screening tool only • Case S2: Cardiac Stress Test with Imaging • More common use case • Echocardiography – requires Consistent Time to combine clinical data from Stress Monitor and Echo Modality

  18. Topics • Cardiology Workflows General • Cath Workflow • Echo Workflow • Stress Workflow • Content Display Requirements • Retrieve ECG for Display • Stress Echo • Stress • Nuclear Cardiology • Displayable Reports

  19. ECG Needs • ECGs Accessible Everywhere! • Need broad distribution of ECGs using ubiquitous technology (Web). • Allow medical applications to easily retrieve and display ECGs in a platform/vendor neutral way. • High-quality ECG documents. Avoid artifacts on zoomed ECGs and arbitrary display geometries. • Vector images required (not rasterized) • Facilitate apps for serial comparison (side-by-side synchronized display).

  20. RED Profile Scope • Reused IHE-ITI RID as it existed: • Retrieve list of cardiology documents, including ECGs in ready-to-display format (HTML) • Retrieve single document, including an ECG • ECGs served in displayable format (PDF, SVG) • Compatibility with existing RID clients

  21. RED Scope (cont.) • Make ECG-specific extensions to RID • Place requirements on ECG source to ensure high-quality ECG documents. • Add ECG-specific request for list of ECGs to be returned as XML allowing more client flexibility. • Add SVG (vector graphics) as allowed ECG document format.

  22. PDF • ECG Source required to support PDF so it is compatible with existing RID clients. • PDF is a common document type and most computers already have a viewer. • ECG Source required to use vector graphics for waveforms in PDF. • Gives high quality line drawings at any screen resolution and zoom factor. • Rasterized (e.g. scanned, bitmapped) ECG “images” not allowed.

  23. Example ECG (PDF)

  24. Example 1200x Zoom ECG (PDF)

  25. ECG Profile Actors • Display – A system that can request and display preformatted (“presentation-ready”) data using Web technologies. • Information Source– A system that responds to requests for patient-related ECG data by encoding it in a presentation-ready format using Web technologies. • Same actors as RID Profile

  26. ECG ProfileTransaction Diagram Retrieve ECG List [CARD-5] Retrieve Specific Info for Display [ITI-11] Information Display Source Retrieve ECG Document for Display [CARD-6]

  27. ECG List XML Example

  28. ECG List XML Example Formatted with Style sheet

  29. Topics • Cardiology Workflows General • Cath Workflow • Echo Workflow • Stress Workflow • Content Display Requirements • Retrieve ECG for Display • Stress Echo • Stress • Nuclear Cardiology • Displayable Reports

  30. Stage and Views • Stress Echo Option • Stage Number & View Number • Stage Code Sequence & View Code Sequence

  31. Benefit: Viewing Consistency

  32. Topics • Cardiology Workflows General • Cath Workflow • Echo Workflow • Stress Workflow • Content Display Requirements • Retrieve ECG for Display • Stress Echo • Stress • Nuclear Cardiology • Displayable Reports

  33. Stress: Protocol and Stage • Procedure : Exercise Stress • Protocol: Bruce • Stages: • Standard Bruce has 7 stages • Stage 1: 1.7 mph @ 10 % grade • Stage 7: 6.0 mph @ 22 % grade Important Note: A procedure can be considered complete irrespective of the protocol being complete!

  34. Attribute Summary

  35. Topics • Cardiology Workflows General • Cath Workflow • Echo Workflow • Stress Workflow • Content Display Requirements • Retrieve ECG for Display • Stress Echo • Stress • Nuclear Cardiology • Displayable Reports

  36. Nuclear Cardiology • Image formats • Stress and Rest raw data review • Stress and Rest processed data • Gated SPECT data • Quantitative data • Screen captures, “snap shots” • Color maps • Gray scale is default • Color overlays can be applied

  37. Perfusion Display • Standard perfusion display • Stress/Rest • Short axis • Horizontal long axis • Vertical long axis

  38. Perfusion Display - Color • Standard perfusion display • Stress/Rest • Short axis • Horizontal long axis • Vertical long axis • Color map can be overlaid on the image

  39. Gated SPECT Display • Apical, mid and basal short axis slices • Mid-ventricle vertical and horizontal long axis slices

  40. Quantitative Display • Output from 3rd party quantitative perfusion and gated software can be displayed

  41. Topics • Cardiology Workflows General • Cath Workflow • Echo Workflow • Stress Workflow • Content Display Requirements • Retrieve ECG for Display • Stress Echo • Stress • Nuclear Cardiology • Displayable Reports

  42. Purpose of Displayable Reports Profile • DRPT provides a methodology to create, finalize, archive, read, revise and distribute cardiology clinical reports from the department to the enterprise and beyond

  43. Example Displayable Reports

  44. Displayable Reports ProfileActors • Report Creator – A system that generates and transmits clinical reports. • Report Manager – A system that manages the status of reporting, and distributes reports to report repositories. • Report Repository – A departmental system that receives reports and stores them for long-term access. • Enterprise Report Repository – A system that receives reports and/or references (pointers) to reports, and stores them for access throughout the healthcare enterprise. • Report Reader – A system that can query/retrieve and view reports encoded as DICOM objects.

  45. Displayable Reports ProfileTransaction Diagram

  46. DRPT and XDS • Displayable Reports Profile specifies production of reports within an organization • Cross-enterprise Document Sharing (XDS) Profile specifies distribution of reports outside the organization • Typically, only a subset of internally generated reports will be shared outside

  47. PDQ-IDCPresent & Future Issues

  48. Challenge of PDQ-IDC Implementation PDQ (ITI-21): Patient Demographic Query IDC: Implantable Devices (Cardiac) (IEEE standard 1073: ACC designated nomenclature) In an urgent and/or emergent patient, how do we import demographic information into an IT infrastructure?

  49. Implantable Cardiac Devices • Pacemakers – therapy for heart rate problems • Defibrillators – therapy for life threatening heart rhythms • Cardiac Resynchronization – therapy for congestive heart failure

  50. Current State of the Art • IDC: Implantable Defibrillators, Cardiac • Can also be pacemakers, single or dual chamber • The patient and/or MD cannot easily identify their device unless they happen to have their ID card with them. • In an emergent or urgent case where patient is unconscious, or unknown, how do we identify the device? • Vendor limitation from programmer to IDC • No central registry, domestically or internationally

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