IHE Radiology Integration Profiles Overview San Diego, Jan 2003

1. IHE Radiology Integration Profiles OverviewSan Diego, Jan 2003 Charles Parisot IHE Planning Committees: IT, Radiology, Laboratory, Cardiology GE Medical Systems – Information Technology

2. Post- Processing Workflow Patient Information Reconciliation ChargePosting Schedule, perform, & notify image processing & CAD steps Collection of billable procedure details Unknown patients and unscheduled orders Consistent Presentation of Images Key ImageNotes Simple Image and Numeric Reports Simple reports with image links and, optionally, measurements Hardcopy and softcopy grayscale presentation state Flag significant images Presentation of Grouped Procedures Subset a single acquisition Access to Radiology Information Consistent access to images and reports Basic Security Audit Trail Consolidation & Node Authentication IHE Radiology Integration Profiles Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps HL7 San Diego – January 2004

3. Problems • Before the Technologist performs the acquisition, how do I make sure the correct info is used ? • Paper based workflow with data re-entry • Risk of error AND Inefficient • Stale information • Changes between time of print and time of data entry • Cancel orders, Generic Order / Order Changes • After the Technologist completes acquisition, how do I let all systems know ? • When are things ready to be read (PACS) • When can things be deleted (Modality) • How do I know what to bill (RIS) • When do I wake up the referring physician HL7 San Diego – January 2004 The solution is……

4. IHE Radiology Scheduled Workflow IHE Radiology Scheduled Workflow : Transactions HL7 San Diego – January 2004

5. Patient Registration/UpdateOrder Management Proposed Protocols Loaded and Reviewed Worklist Modality Worklist Pt A, …, SPS=P1, P4 Pt C, …, SPS=P1, P5 Pt B, …, SPS=P2 Pt E, …, SPS=P4 Procedure Scheduled Order Protocolized Store Images StorageCommitment Storage Commitment List of Images With Performed Acquisition Protocols Performed Step: Status = Completed Modality Performed Procedure Step Performed Procedure: CT Head Performed Protocol Code=P1 Scheduled Protocol Code=P1, P5 Pat Name/ID, Dose, Accession #, Study UID Complete List of Images IHE Scheduled Workflow RIS PACS &Archive • A Closed Loop • Update IS Scheduling • Match Procedure with Order • Support Billing Based on MPPS • Avoid Reading incomplete Procedures HL7 San Diego – January 2004

6. CLINICIANOR REFERING DOC:The Imaging Dept Customer RADIOLOGIST : In Charge of producing theReport TECHNOLOGIST(and RADIOLOGIST)In charge of acquiring images, etc. IHE Workflow is User Driven ORDER:A request for imaging service (Accession Number) Information Unit has its Prime User REQUESTED PROCEDURE : Units of work resulting in one Reportwith associated codified, billable acts(Requested Procedure ID) PROCEDURE STEP :The smallest unit of workin the workflow (modality worklist entry) HL7 San Diego – January 2004

7. Problems • John Doe Trauma Clean-Up • Recovering After Systems Are Down • Error in manual entry at modality • VIP Privacy The solution is…… HL7 San Diego – January 2004

8. Patient Information Reconciliation Unknown patients and unscheduled orders Integration Profiles Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps HL7 San Diego – January 2004

9. PACS is synchronized with all patient registration and order information updates through Dept Scheduler. Image Manager/Archive Modality IHE Scheduled Workflow + IHE Patient Information Reconciliation ADT Patient Registration • When Institution Policy assumes pre-registration of ER patients (John/Jane Doe), IHE supports 3 possible cases: • Unidentified Patient registered at ADT and order placed at Order Placer • Unidentified Patient registered at ADT and order placed at Department Scheduler/Order Filler • Unidentified Patient registered at ADT but acquisition completed at Modalityprior to Order Order Placer Dept Scheduler HL7 San Diego – January 2004

10. Image Manager/Archive Modality IHE Scheduled Workflow + IHE Patient Information Reconciliation ADT Patient Registration • When Institution Policy allows departments to register ER patients, IHE supports 2 possible cases: • Unidentified Patient assigned Temporary Departmental ID andScheduled at Dept Scheduler/Order Filler • Image Acquisition Completed Without Scheduling at Dept Scheduler/OrderFiller(Patient ID entered at Modality) • Supports cases when ADT or Dept Scheduler is down Order Placer Dept Scheduler HL7 San Diego – January 2004

11. Problems • Schedule and track post-processing workflow steps for accuracy of work • Share workload among workstations, chain workflow steps to avoid redundancy • Store and Query/Retrieve of Evidence Documents for CAD, Image Processing etc. The solution is…… HL7 San Diego – January 2004

12. Post- Processing Workflow Patient Information Reconciliation Schedule, perform, & notify image processing & CAD steps Unknown patients and unscheduled orders Integration Profiles Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps HL7 San Diego – January 2004

13. Source Data Worklist PACS System CAD *Workstation 3-D *Workstation Workstation ReportRepository Work Status Results AcquisitionModality Post-Processing Workflow Profile Post-Proc. Workflow Manager Work Status … Results HL7 San Diego – January 2004

14. Problems • How to standardize the Charge Posting and billing for work performed • How to Reduce System Interface Installation Time between Clinical Systems and the Charge Processors • How to avoid Billing System needing to know the Radiology Internals The solution is…… HL7 San Diego – January 2004

15. Post- Processing Workflow Patient Information Reconciliation ChargePosting Schedule, perform, & notify image processing & CAD steps Collection of billable procedure details Unknown patients and unscheduled orders Integration Profiles Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps HL7 San Diego – January 2004

16. Account Management ADT Terminal Study Performed Report Generated / Signed CAD *Workstation 3-D *Workstation ReportRepository 3-D Performed CAD Performed AcquisitionModality Charge Posting Profile Post Charges *Billing System Charge Poster / Materials Used … HL7 San Diego – January 2004

17. Workflow • RIS indicates to the Billing System that procedures are available for Technical and/or Professional billing – maintain accuracy • Charge Posted Transaction may be sent at various times in the workflow - flexibility • Regulations and site policies determine when a procedure is eligible for Charge Posting HL7 San Diego – January 2004

18. Problems • Ensuring print quality outside of the department • Radiologist discussing images with remote physicians • Capture image manipulation to avoid redundant work (coronal CT, MR reading, etc.) The solution is…… HL7 San Diego – January 2004

19. Post- Processing Workflow Patient Information Reconciliation ChargePosting Schedule, perform, & notify image processing & CAD steps Collection of billable procedure details Unknown patients and unscheduled orders Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Integration Profiles Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps HL7 San Diego – January 2004

20. With Presentation State Area Of Interest Area Of Interest The Radiologist’s Transformations Are Saved +Zoom +Annotation Original Image Original Image No Presentation State All the Transformations Are Completely Lost +Windowing The Radiologist Saves a New Presentation State: What the Reviewing Physician Sees: Consistent Presentation of Images On a Calibrated Display Original Image Inconsistent Presentation On an Uncalibrated Display Radiologist Views Images

21. DICOMStandard Display Function Barten Curve Luminance Just Noticeable Differences Grayscale Standard Display Function (GSDF) 6 modalities 4 cameras, 26 workstations The current way= 180 calibrations The IHE way= only 36 calibrations Soft CopyReview Acquisition FilmReview Independent device calibrationdelivers consistency with simplicity HL7 San Diego – January 2004

22. Problems • An hematologist/oncologist orders: • “CT CAP, Lymphoma, R/O disease” • We do “CT CHEST, ABDOMEN, PELVIS w/CON” • 3 orders in RIS, 3 accession numbers, 3 CPTs, 3 reports • Chest radiologist will read chest • Body Imager will read abdomen and pelvis • With One Spiral CT Exam what do we do ? The solution is…… HL7 San Diego – January 2004

23. Post- Processing Workflow Patient Information Reconciliation ChargePosting Schedule, perform, & notify image processing & CAD steps Collection of billable procedure details Unknown patients and unscheduled orders Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Presentation of Grouped Procedures Subset a single acquisition Integration Profiles Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps HL7 San Diego – January 2004

24. Report:CHEST Report:ABDOMEN Abdomen View Chest View Chest View MODALITY Abdomen View Performs a single exam Operator groups 2 procedures IHE – Presentation of Grouped Procedures Requested Procedure:CHEST Requested Procedure:ABDOMEN RIS / PACS HL7 San Diego – January 2004

25. Presentation of Grouped Procedures • PGP maintains the link back to each one of the grouped procedures: • without breaking the acquisition apart • Without duplicating images • PGP ensures that each image subset related to a requested procedure is identified and ready to be presented.  This is key for quick display of new and prior studies. HL7 San Diego – January 2004

26. Problems • “Dave, you read that 3000 slice MR study last night. Can you highlight the 5 most important images for me” • Thinking… “#$@%!%# You”, says “Sure” • “Dr., I just reviewed 40 cases and marked my questions on yellow stickies. Can you review those” • Tech to radiologist: “The patient wouldn’t hold still” The solution is…… HL7 San Diego – January 2004

27. Post- Processing Workflow Patient Information Reconciliation ChargePosting Schedule, perform, & notify image processing & CAD steps Collection of billable procedure details Unknown patients and unscheduled orders Consistent Presentation of Images Key ImageNotes Hardcopy and softcopy grayscale presentation state Flag significant images Presentation of Grouped Procedures Subset a single acquisition Access to Radiology Information Consistent access to images and reports Integration Profiles Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps HL7 San Diego – January 2004

28. The radiologist selects Key Images, and creates appropriate Notes. The referring physician views the Key Image Note prepared by radiologist. Note 3: Note 3: for refering physician Hematoma everywhere for refering physician In this image you can see the hematoma. Results in improved communication between the radiologist and the referring physician HL7 San Diego – January 2004

29. Key Image Notes • There is more to teamwork than images and reports • With IHE, it is possible to attach « electronic post-it™ » to images to increase informal but critical communication between: • The Technologist and the Radiologist about specific examination events • The Radiologist and the Technologist about image quality issues • The Radiologist and other department clinicians (surgeon, orthopedist,..) • The Radiologist and collegues about selecting images for conferences • The Radiologist to the Referring Provider, …..etc. • This IHE Integration Profile is the cost effective solution (increases radiology and overall efficiency). HL7 San Diego – January 2004

30. Post- Processing Workflow Patient Information Reconciliation ChargePosting Schedule, perform, & notify image processing & CAD steps Collection of billable procedure details Unknown patients and unscheduled orders Consistent Presentation of Images Key ImageNotes Simple Image and Numeric Reports Simple reports with image links and, optionally, measurements Hardcopy and softcopy grayscale presentation state Flag significant images Presentation of Grouped Procedures Subset a single acquisition Access to Radiology Information Consistent access to images and reports IHE Integration Profiles Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps HL7 San Diego – January 2004

31. Simple Image& NumericReports • Based on DICOM SR • Allows to include without transcription:- measurements- Image links- structured content • Integrated with the imaging workflow • Friendly to XML implementations • Easy to export to the CPR (HL7) HL7 San Diego – January 2004

32. Simple Image and Numeric Report • Report content is more than words….. • With IHE, it is possible to add value to reporting with input from modalities and image processing applications (e.g. Measurements). • This IHE Integration Profile is the cost effective solution for sharing reports and inclusion of image enabled reports into the Electronic Patient Record. HL7 San Diego – January 2004

33. Problems • How did Person X view MVP’s ankle images? • How to maintain Clinical Use and Privacy • authorized persons must have access to medical data of patients, and the information must not be disclosed otherwise. • How to guarantee: • Confidentiality • Integrity • Availability • Authenticity The solution is…… HL7 San Diego – January 2004

34. Post- Processing Workflow Patient Information Reconciliation ChargePosting Schedule, perform, & notify image processing & CAD steps Collection of billable procedure details Unknown patients and unscheduled orders Consistent Presentation of Images Key ImageNotes Simple Image and Numeric Reports Simple reports with image links and, optionally, measurements Hardcopy and softcopy grayscale presentation state Flag significant images Presentation of Grouped Procedures Subset a single acquisition Access to Radiology Information Consistent access to images and reports Basic Security Audit Trail Consolidation & Node Authentication Integration Profiles Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps HL7 San Diego – January 2004

35. Image Manager & Archive Diagnostic Workstation ReportRepository Report & ImageReview Basic Security Profile Audit Record Repository … … “Images Queried / Retrieved” “Reports Retrieved” “Reports Printed” “Images Printed” “Reports Stored” “Reports Queried / Retrieved” HL7 San Diego – January 2004

36. IHE Basic Security HIPAA-Readiness • IHE Year 4 has a proposal for a basic set of Security functions defined • User Log-on • Node Authentication • Audit Trail • This targets the HIPAA requirement for Accountability and Access control • Is this sufficient for HIPAA in the Radiology imaging domain? Who decides? HL7 San Diego – January 2004

37. Where is More Information Available? www.rsna.org/IHE IHE Technical framework – V5.5 Non-Technical Brochures : IHE Primer and IHE FAQ IHE Integration Profiles: Guidelines for Buyers IHE Connectathon Results IHE Integration Statements from Vendors HL7 San Diego – January 2004