Managing the Acquisition Workflow Nikolaus Wirsz, PhD Siemens Healthcare Member of the DICOM Standards Committee and Working Group Ten – Strategic Advisory

Managing the Acquisition Workflow Introduction Modality Worklist Modality Performed Procedure Step Storage Commitment Instance Availability Notification Conclusions April 8-10, 2008 DICOM International Conference & Seminar

DICOM International Conference & Seminar Introduction DICOM Constructs Information Object Definitions (IOD): Images, Evidence Documents Service Class Specifications: Storage, Query/Retrieve, … Data Structures and Semantics Message Exchange … … to support User Tasks Interactions Between Systems Process Steps in the Diagnostic Chain … and improve clinical processes: Acquisition Workflow Post-Processing Workflow Reporting Workflow The DICOM Standards define a variety of elements – Service Class Specifications, Information Object Definitions (IOD), Data Structure and Semantics, Message Exchange, Media Storage and others – that medical imaging applications can utilize to create, exchange, store and print information objects (images, evidence documents, reports) to facilitate the interoperability of medical imaging equipment regardless of device manufacturer. Moreover the DICOM Standards have been enhanced with a number of Service Classes for Workflow Management to support and improve clinical processes. Enabling an unobstructed information flow from system to system eliminates the need of redundant and error-prone manual re-capture of data, ensures consistency and integrity of patient data and allows the medical staff to focus on the tasks at hand rather than dealing with the intricacy of disparate devices and IT systems. The DICOM Service Classes for Workflow Management provide capabilities to sustain and optimize several tasks associated with the diagnosis and treatment process: data entry, procedure scheduling, image acquisition, post- processing, import of patient data from other facilities, reporting and billing. April 8-10, 2008 DICOM International Conference & Seminar

The Acquisition Workflow Sustain & Optimize Process Tasks in the Radiology / Imaging Department Data Entry Procedure Scheduling Image Acquisition Procedure Tracking Image Storage Management Unobstructed Information Flow “Assembling the Puzzle” Key DICOM Services for Acquisition Workflow Support Modality Worklist Modality Performed Procedure Step Storage with Storage Commitment Instance Availability Notification Image Management (PACS) Departmental Information System (RIS) Workflow Management Registration Order Entry Scheduling Tracking Modality Worklist 1 Performed Procedure Step 2 Storage & Storage Commitment 3 Instance Availability Notification 4 Acquisition Modality A bundle of DICOM Service Classes have been conceived around the image acquisition workflow to ease the integration of imaging equipment (modalities) into the overall clinical process: Modality Worklist (MWL) Modality Performed Procedure Step (MPPS) Storage with Storage Commitment Instance Availability Notification (IAN) April 8-10, 2008 DICOM International Conference & Seminar

Modality Worklist (MWL) 1 Modality Worklist (MWL) Provide Demographics, Procedure and Schedule Details to the Modality Modality (SCU) Queries the RIS (SCP) Query Matching Key Attributes Date / Time of Procedure Modality Type (e.g. CT) Station AE Title (a specific Device) Patient Name / ID Accession # (identifies an Imaging Order) Requested Procedure ID … Query Examples Today‘s Worklist CT Procedures Worklist CT Room 1 Worklist John Doe‘s Procedures of a Chest Imaging Order 1a Departmental Information System (RIS) Results: C-FIND Resp. 1b Query: C-FIND Req. 1a Image Acquisition Modality Modality Worklist The DICOM Modality Worklist SOP Class facilitates the communication of information from an order scheduling system such as an RIS (Radiology Information System) to an imaging modality and provides the operator with a list of ready to perform examination tasks already including essential information such as patient data and procedure details. This information is then added to the acquired images ensuring that images are unambiguously associated to the proper patient and pertinent to the requested order for examination. Modalities supporting the DICOM Modality SOP Class automatically gather the information from the scheduling system thus eliminating the need to manually reenter patient and procedure information at the equipment. April 8-10, 2008 DICOM International Conference & Seminar

Modality Worklist (MWL) 1 Modality Worklist (MWL) 1b RIS (SCP) Returns Query Results to Modality (SCU) Null (No Match) One or More Worklist Entries Worklist Entry (Unit of Service) = Scheduled Procedure Step (SPS) Query Return Key Attributes Patient Data Name, ID, Demographics Allergies, Special Conditions Scheduling Information Date / Time Procedure Information Description, Protocol Codes Contrast & Medication Administration Order Information Accession #, Study UID Requesting Physician ... Departmental Information System (RIS) Results: C-FIND Resp. 1b Query: C-FIND Req. 1a Image Acquisition Modality April 8-10, 2008 DICOM International Conference & Seminar

Modality Worklist (MWL) 1 Modality Worklist (MWL) Deployment of the Modality Worklist Service Modalities Query & Receive Worklists from RIS Modality Displays Worklist to Operator Operator Selects a Worklist Entry (SPS) to Perform Acquisition of Images (Based on SPS Details) Insert Patient & Procedure Data into the Image Header Benefits of Using the Modality Worklist Eliminate Redundant Data Capture Avoid Error-Prone Manual Tasks Facilitate Data Consistency: Unambiguous Association of Images to Proper Patient / Procedure 1a 1b Departmental Information System (RIS) Results: C-FIND Resp. 1b Query: C-FIND Req. 1a Image Acquisition Modality April 8-10, 2008 DICOM International Conference & Seminar

Modality Performed Procedure Step (MPPS) 2 Modality Performed Procedure Step (MPPS) Feedback Acquisition Data to Scheduling System (RIS) Modality (SCU) Sends Acquisition Information to the RIS (SCP) Tracking of Modality Procedure Status IN PROGRESS: MPPS N-CREATE COMPLETED: MPPS N-SET DISCONTINUED: MPPS N-SET (incl. Reason for Discontinuation) Logging of Procedure Related Data Identification Attributes: Accession # SPS ID Patient Name / ID / Demographics ... List (Series) of Images Protocol Codes for the Actually Performed Acquisition Materials Used (Chemicals, Supplies) Radiation Dose Exposure Values 2a 2b Departmental Information System (RIS) Image Acquisition Modality MPPS COMPLETED: N-CREATE 2b 2a MPPS IN PROGRESS: N-SET Modality Performed Procedure Step The DICOM Modality Performed Procedure Step SOP Class closes the information loop between the scheduling system and the equipment performing the procedure. The status of the requested procedures – scheduled, in progress, completed, cancelled – can be closely monitored to facilitate performance statistics and to derive provisions for improvements of the imaging department’s efficiency. Notification of completion of procedures can be used by scheduling systems to initiate preparations for follow-up actions such as post- processing or reporting. Also details of the effectively performed procedure – the particular examination type, number of images, materials used – is essential input for charging of medical services. April 8-10, 2008 DICOM International Conference & Seminar

Modality Performed Procedure Step (MPPS) 2 Modality Performed Procedure Step (MPPS) MPPS Use Cases (according to IHE) Benefits of Using MPPS Keeping Schedules Up-to-date Better Management of Resources Gather Information Required for Billing Trigger for Subsequent Processes: Post-Processing, Reporting SPS PPS results in 1 Simple Case Unscheduled Case SPS PPS results in 1 Departmental Information System (RIS) Modality Worklist 1 Performed Procedure Step 2 Image Acquisition Modality Append Case SPS PPS results in 1 PPS* *appended Group Case SPS PPS results in 1 April 8-10, 2008 DICOM International Conference & Seminar

Storage with Storage Commitment 3 Storage with Storage Commitment Secure Ownership and Safekeeping of Clinical Results Modality (SCU) Requests Storage Commitment from PACS (SCP) Modality Transmits Images (or other Objects) to PACS: C-STORE Operations for Images Modality Issues Storage Commitment Request to PACS: N-ACTION including List of Instances to Retain PACS Notifies Modality of Success (or Failure) : N-EVENT-REPORT Image Management (PACS) Acquisition Modality 3b Request Storage Commitment: N-ACTION 3c Confirm Storage Commitment: N-EVENT-REPORT 3a Transfer Images: C-STORE 3a 3b Storage Commitment The DICOM Storage Commitment SOP Class provides the means to reliably transfer information objects for safekeeping for example from the imaging modality to an image management system such as PACS. Once the receiving system has acknowledged that images have been safely stored, the imaging modality can remove the images from local storage and re-use the available space for images from exams to follow. With such a mechanism in place loss of images can be effectively prevented, an important factor for patient safety and reduction of radiation exposure. Furthermore medical staff can be relieved from the burden of having to double-check or manually confirm the safe storage of images. 3c April 8-10, 2008 DICOM International Conference & Seminar

Storage with Storage Commitment 3 Storage with Storage Commitment Benefits of Using Storage Commitment Confidence in a Dependable Storage of Clinical Evidence Eliminate Double-Check / Manual Confirmation Time Avoid Loss of Clinical Information due to Network Troubles Storage Breakdowns Avoid Unnecessary Re-Examinations (Reduce Radiation Exposure) Modality can Remove Images from Local Storage and Re-Use Available Space for Exams to Follow Image Management (PACS) Acquisition Modality 3b Request Storage Commitment: N-ACTION 3c Confirm Storage Commitment: N-EVENT-REPORT 3a Transfer Images: C-STORE April 8-10, 2008 DICOM International Conference & Seminar

Instance Availability Notification (IAN) 4 Instance Availability Notification (IAN) Inform about Availability of Image Data PACS (SCU) Notifies the RIS (SCP) that Images are Available for Retrieval & Use List of Instances (Images) Location (Retrieve SCP) of Images Availability Status Online Nearline OffLine Unavailable Use of IAN to Initiate Subsequent Processes Post-Processing Interpretation / Reporting Distribution of Images to Other Locations 4 Image Management (PACS) Departmental Information System (RIS) Instance Availability Notification: N-CREATE 4 Instance Availability Notification The DICOM Instance Availability Notification SOP Class can be used by an information object receiver such as an image management system (PACS) to inform other systems such as scheduling systems or workflow management systems (typically an RIS) of the arrival and availability of information objects. This allows for timely preparations of consecutive tasks (post-processing, reporting, patient discharge or transfer) and for book-keeping of images such as storage location and availability (on-line, near-line, off-line, unavailable). April 8-10, 2008 DICOM International Conference & Seminar

Instance Availability Notification (IAN) 4 Instance Availability Notification (IAN) Benefits of Using Instance Availability Notification In-Time Notification Avoids Excessive Queries for the Whereabouts of Images Completion of Acquisition Workflow: Ready-to-Use Results Enable Transition to the Next Process Steps of the Imaging Workflow Allow for Timely Preparations of Tasks & Resource Allocation for Additional Procedures Post-Processing Reporting Patient Transfer / Discharge Image Management (PACS) Departmental Information System (RIS) Instance Availability Notification: N-CREATE 4 April 8-10, 2008 DICOM International Conference & Seminar

Integrating the Healthcare Enterprise Forum (Organization) for Advancing Integration in Clinical Practice Interoperability Frameworks for Implementing and Deploying Standards-Based (HL7 & DICOM) Integrated Solutions IHE Integration Profiles Interoperability Building Blocks to Solve Specific Integration Issues: e.g. Workflows Packages of DICOM / HL7 Services: e.g. Scheduled (Acquisition) Workflow (SWF) Integration Profile Refer to: IHE Radiology Technical Framework Vol. I – Scheduled Workflow (SWF) Integration Profile http://www.IHE.net/Technical_Framework/ IHE Scheduled Workflow (SWF) Integration Profile – includes Acquisition Workflow Management – The Integrating the Healthcare Enterprise (IHE) Initiative is a concentrated undertaking of both healthcare providers and industry aimed at advancing integration in clinical practice and fostering communication between vendors of medical Information Technology and has successfully proven that established healthcare IT standards such as DICOM and HL7 are key in achieving these goals. IHE is working to refine these standards and has published specifications – the IHE Technical Frameworks – to provide the industry with a valuable unambiguous compendium for implementing standards consistently. The IHE Technical Frameworks define a series of interoperability building blocks – the Integration Profiles – that address specific integration aspects including workflows. The IHE Scheduled Workflow Integration Profile is intended to resolve issues surrounding the Acquisition Workflow and is – not surprisingly – comprised of the afore mentioned DICOM Service Classes. April 8-10, 2008 DICOM International Conference & Seminar

Conclusions DICOM Services for Acquisition Workflow Management Improve Interoperability of Imaging Equipment Ensure Data Consistency Facilitate Reliable Data Management Improve Process Efficiency Better Quality of Imaging Services Image Management (PACS) Departmental Information System (RIS) Workflow Management Registration Order Entry Scheduling Tracking Modality Worklist 1 Performed Procedure Step 2 Storage & Storage Commitment 3 Instance Availability Notification 4 Acquisition Modality The DICOM Service Classes for Management of the Acquisition Workflow along with other similar services for supporting additional workflows such as importing, post-processing and reporting are a significant step forward in elevating interoperability of medical imaging equipment, improving efficiency of clinical process and ultimately contribute to a better quality of healthcare services. April 8-10, 2008 DICOM International Conference & Seminar

Thank you for your attention ! References http://medical.NEMA.org/ http://www.HL7.org/ http://www.IHE.net/ Glossary ADT Admission – Discharge – Transfer AE Application Entity DICOM Digital Imaging and Communications in Medicine (http://medical.NEMA.org) DIS Departmental Information (Management) System DIMSE DICOM Message Service Element DIMSE-C DICOM Message Service Element-Composite DIMSE-N DICOM Message Service Element-Normalized DSS / OF Departmental System Scheduler / Order Filler HIS Hospital Information (Management) System HL7 Health Level Seven (www.HL7.org) IHE Integrating the Healthcare Enterprise (www.IHE.net) IAN Instance Availability Notification ID Identifier IE Information Entity IOD Information Object Definition MWL Modality Worklist MPPS Modality Performed Procedure Step OP Order Placer PACS Picture Archiving & Communications System PIR Patient Information Reconciliation PPWF Post-Processing Workflow PPS Performed Procedure Step RIS Radiology Information (Management) System RWF Reporting Workflow SCP Service Class Provider SCU Service Class User SOP Service-Object Pair SPS Scheduled Procedure Step SWF Scheduled Workflow UID Unique Identifier Thank you for your attention ! April 8-10, 2008 DICOM International Conference & Seminar