Scheduled Workflow The First Profile Kevin O’Donnell, Toshiba Co-chair, IHE Planning Committee HIMSS/RSNA Vendor Workshop, April 2003

Profile Summary Genesis 1: In the beginning, … [ or better yet ] Genesis 11: Tower of Babel “and there confound their language, that they may not understand one another's speech. “ HIMSS/RSNA Vendor Workshop, April 2003

Profile Summary Fundamental Starting Point of IHE Addresses Registration, Scheduling, Acquisition Workflow and Image Content Bridges HL7 and DICOM Spaces Backbone of Radiology Integration HIMSS/RSNA Vendor Workshop, April 2003

Motivation Preserve Order Continuity Improve Demographic Integrity “Close the Loop” maintain accession number, avoid confusion with Filler #, Placer #, etc. Improve Demographic Integrity Data entry errors significant occurrence significant consequences Enter once, pass from system to system HIMSS/RSNA Vendor Workshop, April 2003

Motivation Improve Workflow Efficiency Reliable Storage Use of Worklists less time spent doing data entry/selection enables semi-automation of setup Reliable Storage Storage Commitment fewer lost studies more confidence in results HIMSS/RSNA Vendor Workshop, April 2003

Motivation Improve Order Tracking Reduce Integration Effort at Site MPPS from Modality to RIS & PACS more timely feedback more precise feedback Reduce Integration Effort at Site Get Vendors on the Same Page Provide Implementation Guidance Pre-test at Connectathon HIMSS/RSNA Vendor Workshop, April 2003

acquisition completed acquisition in-progress acquisition completed Scheduled Workflow Profile Report Repository Registration report Diagnostic Workstation Film Lightbox Orders Placed Image Manager & Archive Film Folder Specifies transactions that function to maintain the integrity of patient, image, and order information across systems Integrates modalities with information and imaging systems Biggest Value of IHE Smooth flow of patient, image and order information across systems Status updates of orders Orders Filled Acquisition Modality acquisition completed Film acquisition in-progress acquisition completed images printed Modality HIMSS/RSNA Vendor Workshop, April 2003

IHE Workflow Concepts IHE has selected three UNAMBIGUOUS HL7/DICOM TERMS : ORDER : A request for radiologic service REQUESTED PROCEDURE : A Unit of work resulting in one Report (with associated codified, billable acts) Representation includes: healthcare providers, information systems vendors, imaging systems vendors, and standards groups participating PROCEDURE STEP : The smallest unit of work in the workflow: Scheduled Procedure Step: ‘A unit of work to do’ Performed Procedure Step: ‘A unit of work done’ HIMSS/RSNA Vendor Workshop, April 2003

Workflow Concept Mapping This 3 level workflow structure is user oriented: ORDER: A request for imaging service (Accession Number) CLINICIAN OR REFERING DOC: The Imaging Dept Customer REQUESTED PROCEDURE : Units of work resulting in one Report with associated codified, billable acts (Requested Procedure ID) RADIOLOGIST : In Charge of producing the Report Representation includes: healthcare providers, information systems vendors, imaging systems vendors, and standards groups participating TECHNOLOGIST (and RADIOLOGIST) In charge of acquiring images, etc. PROCEDURE STEP : The smallest unit of work in the workflow (modality worklist entry) HIMSS/RSNA Vendor Workshop, April 2003

Typical workflow: One Order – One Procedure – One Report Normal Workflow Typical workflow: One Order – One Procedure – One Report Radiology Department DICOM Modality Worklist ORDER A request for Radiologic Service Scheduled Procedure Step Acquisition Modality One or more series of images Performed Procedure Step Set of Codifiable, Billable, Acts Requested Procedure Report Representation includes: healthcare providers, information systems vendors, imaging systems vendors, and standards groups participating HIMSS/RSNA Vendor Workshop, April 2003

Multiple Modality Steps DICOM Modality Worklist Radiology Department ORDER A request for Radiologic Service Scheduled Procedure Step A Acquisition Modality One or more series of images Performed Procedure Step P1 Report Set of Codifiable, Billable, Acts Requested Procedure 1 DICOM Modality Worklist Scheduled Procedure Step B Acquisition Modality One or more series of images Performed Procedure Step P2 Representation includes: healthcare providers, information systems vendors, imaging systems vendors, and standards groups participating HIMSS/RSNA Vendor Workshop, April 2003

“HL7 Actors” in SWF HL7 Actors: ADT/Patient Registration Order Placer DSS / Order Filler Image Manager HIMSS/RSNA Vendor Workshop, April 2003

ADT Actor Primary Patient Info Entry HIMSS/RSNA Move through Actor/Transaction Slides quickly Refer to Volume I for the list of required transactions for your actor Refer to Volume II for the details of what is required for each transaction HIMSS/RSNA Vendor Workshop, April 2003

ADT Transactions 4.1 - Patient Registration 4.12 - Patient Update Send Admit: A01 (In Patient), A04 (Out Patient), A05 (Pre-Admission) Cancel: A11 (Cancel Admit), A38 (Cancel Preadmit) 4.12 - Patient Update Transfer: A02 (Patient Transfer) Update Patient Class: A03 (Discharge), A06(Outpatient becomes Inpatient), A07 (Inpatient becomes Outpatient) Update Patient Information: A08 (Update) Merge Patients: A40 (Merge) Cancel: A12 (Cancel Transfer), A13 (Cancel Discharge) HIMSS/RSNA Vendor Workshop, April 2003

Order Placer Actor Primary Order Entry HIMSS/RSNA Vendor Workshop, April 2003

Order Placer Transactions 4.2 - Placer Order Management Send New Order: ORM/NW (New Order) Cancel: ORM/CA (Cancel Order), ORM/DC (Discontinue) 4.1 - Patient Registration Receive 4.12 - Patient Update 4.3 - Filler Order Management HIMSS/RSNA Vendor Workshop, April 2003

Department System Scheduler / Order Filler Actor Primary Scheduling & Order Management HIMSS/RSNA Vendor Workshop, April 2003

DSS/Order Filler Transactions 4.3 - Order Filler Management Send New Order: ORM/SN (New Order) Order Status: ORM/SC (Status Change) Cancel: ORM/OC (Cancel Order) 4.4 - Procedure Scheduled ORM (procedure scheduled) 4.13 - Procedure Updated ORM (procedure updated) HIMSS/RSNA Vendor Workshop, April 2003

DSS/Order Filler (Cont.) 4.1 - Patient Registration Receive 4.12 - Patient Update 4.2 - Placer Order Management HIMSS/RSNA Vendor Workshop, April 2003

“DICOM Actors” in SWF DICOM Actors: DSS / Order Filler PPS Manager Image Manager / Archive Acquisition Modality Evidence Creator Image Display Acq. Modality (Primary Radiology Data Source) Evidence Creator (Auxiliary Radiology Data Source) Image Manager/Archive (Primary Radiology Data Management) HIMSS/RSNA Vendor Workshop, April 2003

Acquisition Workflow Management DICOM: Modality Worklist Management (MWL) Modality Performed Procedure Step (MPPS) HIMSS/RSNA Vendor Workshop, April 2003

Image Management DICOM: Image Storage Storage Commitment Query/Retrieve HIMSS/RSNA Vendor Workshop, April 2003

Additional Workflow Management HL7: ORM Message DICOM: Query (C-FIND) Modality Performed Procedure Step (MPPS) HIMSS/RSNA Vendor Workshop, April 2003

Some Transaction Details 4.5 - Modality Worklist Provided DSS/Order Filler is Responsible for translating HL7 orders into DICOM Worklist 4.6 - Modality PPS In-Progress 4.20 – Creator PPS In-Progress MPPS N-Create (Start), N-Set (Updates) 4.7 - Modality PPS Completed 4.21 – Creator PPS Completed MPPS N-Set (Complete) 4.11 - Image Availability Query C-FIND (Study Root Query, Hierarchical) 4.42 - Performed Work Status Update N-SET (Complete) HIMSS/RSNA Vendor Workshop, April 2003

Administrative Normal Process Flow HIMSS/RSNA Vendor Workshop, April 2003

Procedure Performance Normal Process Flow HIMSS/RSNA Vendor Workshop, April 2003

Assisted Protocol Setting Option Motivation Reduce variance on how procedures are performed Centralize configuration effort Mechanism Order Filler/DSS passes Protocol Codes to the Acquisition Modality inside the Worklist Item HIMSS/RSNA Vendor Workshop, April 2003

PPS Exception Management Option Motivation Provide better feedback on discontinued studies Handle selection of wrong worklist item Mechanism Code (0008,0104) HIMSS/RSNA Vendor Workshop, April 2003

Discontinue Reason Codes Code Meaning (0008,0104) Doctor cancelled procedure Equipment failure Incorrect procedure ordered Patient allergic to media/contrast Patient died Patient refused to continue procedure Patient taken for treatment or surgery Patient did not arrive Patient pregnant Change of procedure for correct charging Duplicate order Nursing unit cancel Incorrect side ordered Discontinued for unspecified reason Incorrect worklist entry selected HIMSS/RSNA Patient condition Vendor Workshop, April 2003

SWF Synergies Additional Content Profiles Post-Processing Workflow Workflow can manage creation of other objects Post-Processing Workflow SWF Status can trigger Post-Processing SWF Output can be input to Post-Processing Reporting Workflow SWF Status can trigger Reporting SWF Output can be input to Reporting Charge Posting SWF Status can trigger/feed Billing Presentation of Grouped Procedures Specializes SWF for Grouped Procedures HIMSS/RSNA Vendor Workshop, April 2003

References Profile - Volume 1, Chapter 3 Transactions - Volume 2 Note Vol. 2, Appendix A, B – Attribute Mapping HIMSS/RSNA Vendor Workshop, April 2003

Patient Information Reconciliation Expect the Unexpected HIMSS/RSNA Vendor Workshop, April 2003

Profile Summary Extension of existing profile Coordinates update of demographic information in workflow and content objects HIMSS/RSNA Vendor Workshop, April 2003

Motivation Handle “exception” cases Trauma/Emergent Cases Patient Unknown or no time for Registration Entry Errors by Operator Other Demographic Changes (e.g. married name) Multiple sources/destinations for updates High risk of unsynchonized/inconsistent data Workflow must continue Need to pull together past & current patient records HIMSS/RSNA Vendor Workshop, April 2003

Use Cases Local policy calls for ADT to pre-register ER patients (“John Doe”, “Jane Doe”): Case 1: Unidentified Patient registered at ADT and order is placed at Order Placer. Case 2: Unidentified Patient registered at ADT and order is placed at DSS/Order Filler. Case 3: Unidentified Patient registered at ADT but acquisition completed at Modality prior to order. HIMSS/RSNA Vendor Workshop, April 2003

Use Cases Local policy allows departments to register ER patients with Departmental IDs: Case 4: Unidentified Patient assigned temporary Departmental ID and scheduled at DSS/Order Filler. Case 5: Image Acquisition completed prior to assigning temporary Departmental ID or Order (Patient ID entered at the Modality). HIMSS/RSNA Vendor Workshop, April 2003

Unidentified Patient - Case 1 Order Placer Department System Database/Scheduler/ Order Filler ADT Image Manager Modality Register J.Doe Patient Registration [1] Placer Order Mgmt NewOrder [2] Schedule Procedure Procedure Scheduled [4] Images Acquired MWL Provided [5] Modality Procedure Step Completed [7] Modality Procedure Step Completed [7] Patient Reconciliation J.Doe -> J.Smith Patient Update [12] Patient Update [12] HIMSS/RSNA Vendor Workshop, April 2003

Unidentified Patient - Case 2 Order Placer Department System Database/Scheduler/ Order Filler ADT Image Manager Modality Register J.Doe Patient Registration [1] Filler Order Mgmt New Order[3] Schedule Procedure Procedure Scheduled [4] Images Acquired MWL Provided [5] Modality Procedure Step Completed [7] Modality Procedure Step Completed [7] Patient Reconciliation J.Doe -> J.Smith Patient Update [12] Patient Update [12] HIMSS/RSNA Vendor Workshop, April 2003

Unidentified Patient - Case 3 Order Placer Department System Database/Scheduler/ Order Filler ADT Image Manager Modality Register J.Doe Patient Registration [1] Images Acquired Modality Procedure Step Completed [7] Modality Procedure Step Completed [7] Filler Order Mgmt New Order [3] Schedule Procedure Procedure Scheduled [4] Patient Reconciliation J.Doe -> J.Smith Patient Update [12] Patient Update [12] HIMSS/RSNA Vendor Workshop, April 2003

Unidentified Patient - Case 4 Order Placer Department System Database/Scheduler/ Order Filler ADT Image Manager Modality Schedule Procedure for J.Doe Procedure Scheduled [4] Images Acquired MWL Provided [5] Modality Procedure Step Completed [7] Modality Procedure Step Completed [7] Register J.Smith Patient Registration [1] Patient Reconciliation J.Doe -> J.Smith Patient Update [12] Filler Order Mgmt New Order [3] HIMSS/RSNA Vendor Workshop, April 2003

Unidentified Patient - Case 5 Order Placer Department System Database/Scheduler/ Order Filler ADT Image Manager Modality Images Acquired for J.Doe Modality Procedure Step Completed [7] Modality Procedure Step Completed [7] Register J.Smith Patient Registration [1] Patient Reconciliation J.Doe -> J.Smith Patient Update [12] Filler Order Mgmt New Order [3] Schedule Procedure Procedure Scheduled [4] HIMSS/RSNA Vendor Workshop, April 2003

Questions, Comments, and/or Suggestions? HIMSS/RSNA Vendor Workshop, April 2003