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Image Sharing

Image Sharing. Review and Update 2011. David S. Mendelson, M.D. Professor of Radiology Chief of Clinical Informatics The Mount Sinai Medical Center Co-chair IHE International Board. Image sharing- Why?. Benefit of historical exam during interpretation

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Image Sharing

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  1. Image Sharing Review and Update 2011 David S. Mendelson, M.D. Professor of Radiology Chief of Clinical Informatics The Mount Sinai Medical Center Co-chair IHE International Board

  2. Image sharing- Why? • Benefit of historical exam during interpretation • Rapidly growing cost of healthcare especially growing utilization of imaging • Overutilization • Prevent duplicate exam because a recent exam is inaccessible • Radiation exposure • Quality • Expedites clinical care through easy availability of imaging examination

  3. Issues that govern sharing Imaging Exams • What is our product? • Who are our customers? • What are the mechanisms of sharing? • What are the impediments? • Technology • Policy

  4. Our Product – Information! • Imaging Exam • Order • Direct patient history • Prior exams • Report • Demographics • Referring Clinician • Reporting Team • Indication • Narrative • Procedure • Impression • Structured report

  5. Issues that govern sharing Imaging Exams • What is our product? • Who are our customers? • What are the mechanisms of sharing? • What are the impediments? • Technology • Policy

  6. Radiology Physician Patient 2nd Radiology Patient Consulting Physician Clinical Trial

  7. Issues that govern sharing Imaging Exams • What is our product? • Who are our customers? • What are the mechanisms of sharing? • What are the impediments? • Technology • Policy

  8. Film • Are you old enough to remember film? • Still exists • Clinical offices

  9. The “CD”- “better than sliced bread” or “be careful what you ask for – you may get it” • Portable • Compact • Can hold thousands of images • Inexpensive ($0.50 or less) • What’s wrong here?

  10. The New Film Library

  11. CDs- Problems • Different data formats • Non-Dicom • Different viewers • End-user confusion • Defective Discs • Disc must be in your possession • Patient Identity • Wrong Patient on Disc • Time consuming • Clinician’s are confused • They share their confusion with their Radiologist

  12. Our Colleagues Help!

  13. CD- Opportunities to improve • Importing a disc provides the opportunity to correct • Robust import solutions -commercial • Standard import interface • Reconciliation process • Trained personnel • Standards • DICOM • PDI extensions (IHE- Portable Documents for Imaging) • BIR- (IHE- Basic Image Review) • Minimum requirement for review

  14. Mechanisms of Sharing- Reports • Mail • RIS • FAX • E-Mail • PACS • VPN • Internet • EMR-Patient Portal • PHR

  15. When to release a Report vs. Image? • The patient is entitled • Legal • Practical • Is the patient prepared for the information in the report? • Immediate use to clinician • May be meaningless to most patients other than a curiosity

  16. Network/Internet base sharing • Replace the CD (SneakerNet) with the Internet • Convenience vs. Security • New opportunities • Shared Image processing • Efficiencies

  17. Network/Internet base sharing • Proprietary applications • Usually used within an enterprise or a limited domain with legal agreements • Health Information Exchange (HIE) • Multiple enterprises with a set of legal agreements • Often have selected their own standards- not truly open standards based • Sustainability

  18. Network/Internet • VPN/Enterprise Portal • Clinical Staff • Patient • Temporary credentials • Enterprise- multi-sites; proprietary solution • Multiple PACS and RIS feed one central archive • All credentialed can view that archive • Point to Point networks • HIE • Standards based or proprietary sharing network • IHE model • Patient Centric model / PHR

  19. Challenges to exchange • Who pays for an exchange infrastructure • What is the persistence of the information in the exchange • Are images different from other forms of healthcare data • Easy secure access is good for the patient • Does it endanger the provider?- is this an impediment? • Economic adjustments and evolution are likely to occur • Balance of cost control vs. Quality • Reduction in Radiation exposure • Not all patients agree

  20. Point to Point • A limited number of entities establish direct connections • Usually requires a direct formal relationship (legal) • Can be successful to address very specific interoperability problems • Doesn’t scale

  21. HIE • Requires legal relationships between participants • Requires patient identity management • Enables a greater number of entities to participate • May be scalable • HIE to HIE • Consent issues • Commonly all or nothing rather than episode or event based • Patients may wish to only expose limited pieces of data

  22. Sharing Healthcare Information in the Cloud Primary Doctor Hospital Specialist Imaging Center Hospital Patient Patient Surrogate

  23. Cloud Computing • WHO • Enterprise • HIE • Consumer • WHAT • Services • Transactions • Archive

  24. IHE-XDS (Cross-Enterprise Document Sharing) • XDS.a • XDS- I.a • XDS.b • ?? XDS-I.b • a vs. b • Related to web standards and transactions

  25. XDS

  26. XDS-I

  27. Canada Health Infoway

  28. A Standards Based Solution NIBIB/RSNA Image Sharing Project

  29. Goals of Contract • NIBIB contract • Bootstrap an IHE based network • Primary emphasis is Consumer Control through PHRs • Can be extended to other forms of sharing • HIE • Security and Confidentiality are drivers • Replacement / Alternative to CD

  30. NIBIB contract summary • Consumer Control • Employ IHE solutions whenever possible • IHE generally has not focused on consumer driven solutions but rather on institutional and enterprise workflow • 5 Academic Institutions • Mayo Clinic • Mount Sinai Medical Center • University of California San Francisco • University of Chicago • University of Maryland • Establish a clearinghouse • Engage PHRs • 300,000 patients over 2 years

  31. Image Sharing/Elements of Solution • Edge Server • Register a patient • Listens to a Radiology Information System (RIS)- looking for a complete exam • Retrieves Image set from PACS and Report from RIS • Send both to clearinghouse • PHI hidden; an RSNA ID and 2nd factor security token are used to identify the patient • Clearinghouse (XDS-I) – functions as a secure router • Transiently hold encrypted patient data • PHR • Consumer controls upload and future access • Must have RSNA ID available and know answer to 2nd factor question • Develop web based viewers • Download full DICOM data set • Misc Consumers

  32. Software architecture

  33. Project design assumptions • Security is paramount • Restrictive policy • PHI is never unsecured • Consumer controls the flow of information by placing it in the PHR • Diminishes the need for BAAs between enterprises • Imaging Site to Clearinghouse • Clearinghouse to PHR

  34. Image Enabled PHR

  35. Report

  36. Advantages of Approach • Push model • No Query of PACS from outside the firewall • Full DICOM data set is available • Web viewers • Download and Import to PACS • Report is available • Historical exams can be sent simultaneously • Consumer controls flow of information • Affords the patient the ability to select what information to share • Is this good?

  37. Future Directions • Refine Workflow • Initial workflow is to replace a CD • Exam updates • Download DICOM data and archive in a local PACS • Edge server as a platform • Radiation Monitoring • Peer Review • Quality Metrics

  38. Research CTP- The RSNA Clinical Trial Processor • CTP is a stand-alone program that provides all the processing features of a MIRC site for clinical trials in a highly configurable and extensible application. It connects to FieldCenter applications and can also connect to MIRC sites when necessary. CTP has the following key features: • Single-click installation. • Support for multiple pipelines. • Processing pipelines supporting multiple configurable stages. • Support for multiple quarantines for data objects which are rejected during processing. • Pre-defined implementations for key components: • HTTP Import • DICOM Import • DICOM Anonymizer • XML Anonymizer • File Storage • Database Export • HTTP Export • DICOM Export • FTP Export • Web-based monitoring of the application's status, including: • configuration • logs • quarantines • status

  39. Issues that govern sharing Imaging Exams • What is our product? • Who are our customers? • What are the mechanisms of sharing? • What are the impediments? • Technology • Policy

  40. Conclusions • We live in a heterogeneous world needing multiple solutions • CDs and portable media have both advantages and drawbacks • Compliance with standards helps • We are transitioning to network/internet solutions • Security and confidentiality are even more difficult • ONC and State policies will foster these solutions • Solutions are evolving • Proprietary solutions are often easier to implement • Solutions based on open standards will provide the patient with greater flexibility • Interoperability will require an adjustment to the way we all think of healthcare data

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