Distributing Images: Cross-enterprise Document Sharing for Imaging (XDS-I) Access to Radiology Information (ARI) Retrieve Information for Display (RID) Rita Noumeir, Ph.D. Professor University of Quebec

Sharing of Imaging Information across health enterprises Imaging Information includes –extensive sets of DICOM instances including images, evidence documents and presentation states –diagnostic reports provided in a "for display" form –selection of diagnostically significant images associated with the report content Abstract / Scope

Radiology Enterprise A Radiology Enterprise B Physician Office Regional Health Information Network PACS B PACS A Radiology-to-radiology Radiology-to- Physicians Sharing Radiology Reports and Images in a Regional Health Information Network

Radiology Enterprise A Radiology Enterprise B Physician Office Regional Health Information Network Cross- Enterprise Registry Patient Id= 3547F45 Report 5/21/1998 : CT Head  B Study 5/21/1998 : CT Head  B Report 2/18/2005 : Chest Xray  A Study 2/18/2005 : Chest Xray  A PACS B PACS A Sharing Radiology Reports and Images in a Regional Health Information Network

Radiology Enterprise A Radiology Enterprise B Physician Office Regional Health Information Network Query for Documents Register Imaging Information for sharing Prior imaging Reports & Studies Cross- Enterprise Registry Register Imaging Information for sharing Patient Id= 3547F45 Report 5/21/1998 : CT Head  B Study 5/21/1998 : CT Head  B Physicians and Systems within a Regional Health Network - Routine Imaging Referral

Radiology Enterprise A Radiology Enterprise B Physician Office Regional Health Information Network Register Imaging Information for sharing Cross- Enterprise Registry Notification of Doc Availability Register Imaging Information for sharing Physicians and Systems within a Regional Health Network - Routine Imaging Referral

Radiology Enterprise A Radiology Enterprise B Physician Office Prior Imaging Report & Study Regional Health Information Network Query for documents Imaging Report & Study Cross- Enterprise Registry Patient Id= 3547F45 Report 5/21/1998 : CT Head  B Study 5/21/1998 : CT Head  B Report 2/18/2005 : Chest Xray  A Study 2/18/2005 : Chest Xray  A Notification of Doc Availability Physicians and Systems within a Regional Health Network for a Routine Imaging Referral

Value proposition Imaging component of the Electronic Health Record: Shared imaging Record, in a community, region, etc. Effective means to contribute and access imaging documents across health enterprises. –Without XDS-I, access to the radiology report across health enterprises is difficult Scalable sharing of imaging documents between radiology departments, private physicians, clinics, long term care, acute care with different clinical IT systems. Easy access: Care providers are offered means to query and retrieve imaging documents (images and reports) of interest –with the same mechanisms used to query other documents

Value proposition Distributed: Each Care delivery organization “publishes” imaging information for others. Actual images remain in the source/Image Manager. Cross-Enterprise: A Registry provides an index for published information to authorized care delivery organizations belonging to the same clinical affinity domain. Document Centric: Published clinical data is organized into “clinical documents”. using agreed standard document types (DICOM KOS, PDF and/or text report) Document Content Neutral: Document content is processed only by source and consumer IT systems. Standardized Registry Attributes: Queries based on meaningful attributes ensure deterministic document searches.

XDS-I Dependencies XDS-I depends on IT Infrastructure Cross- Enterprise Document Sharing (XDS) New Actors –Imaging Document Source –Imaging Document Consumer (should be grouped with Document Consumer) Same Actors as in XDS –Document Consumer –Document Registry –Document Repository Added extension to support imaging data (images and reports)

Document Consumer Retrieve Document Query Documents Patient Identity Source Patient Identity Feed Imaging Document Source Document Registry Document Repository Provide & Register Document Set Register Document Set Imaging Document Consumer Retrieve Images Retrieve Presentation States Retrieve Key Image Note Retrieve Evidence Documents WADO Retrieve XDS-I Actors and Transactions

XDS-I New Transaction requirements XDS-I Actors: –Imaging Document Consumer at least one Retrieve ( [RAD-55], [RAD-16], [RAD-17], [RAD-27], [RAD-31] [RAD-35]) –Imaging Document Source Provide and Register Document Set [RAD-54] WADO Retrieve [RAD-55] Retrieve Images [RAD-16], Retrieve Presentation States [RAD-17] Retrieve Reports [RAD-27], Retrieve Key Image Note [RAD-31], Retrieve Evidence Documents [RAD-45] XDS Actors –Document Repository Provide and Register Document Set [RAD-54]

Options Imaging Document Source must support at least one of the following options: –Extensive Set of DICOM Instances –PDF Report –NEW Text Report wrapped in a CDA Document –NO Text option –NO multipart Text / PDF option

Sharing of Extensive DICOM Instance Set

Document Registry Document Repository Manifest Reference to image 1 DICOM Manifest Reference to image 2 Reference to image 3 Manifest Clinical Encounter Clinical IT System Query Registry Manifest Retrieve Manifest Reference to image 1 DICOM Manifest Reference to image 2 Reference to image 3 Retrieve ImagesRegister Manifest Manifest

Sharing of Extensive DICOM Instance Set The shared Document is a manifest –a Key Object Selection DICOM Instance title : manifest Imaging Document Source is required –to ensure that the referenced images from within a published manifest are available to be retrieved Imaging Document Source is responsible –for replacing a previously submitted manifest Document when a change occurs to the manifest content (eg. Change of the DICOM SOP instances referenced within the manifest)

Sharing of Imaging Report

Radiology system Report Source ….. Findings: Header : Report Type: OB / Gyn BPD... ….. Radiology Report Impressions : Gestational Age... Text wrapped into CDA Report PDF Report

Radiology system Report Source Document Registry Document Repository Report Clinical Encounter Clinical IT System Query Registry Retrieve ReportRegister Report Report ….. Findings: Header : Report Type: OB / Gyn BPD... ….. Radiology Report Impressions : Gestational Age...

Sharing of Reports The shared Report Document format is –PDF, Text wrapped in a CDA A report can –embed selected images in its PDF format –include fully resolved hyperlinks (interactively clickable) that point to the selected images Imaging Document Source is responsible –for formatting the hyperlink to reference relevant images as a DICOM WADO URI or as IHE RID Request for Document Imaging Document Source is required –to ensure that image references are valid links

XDS-I Actors / Grouping No specific grouping requirement on Imaging Document Source, however: – Imaging Document Source is responsible of ensuring published images in a manifest are available to be retrieved Imaging Document Consumer shall be grouped with a Document Consumer

Linking Report to Complete Set of Images Document Repository Document Registry Study Manifest Report Document Entry Submission Set

Linking Report to Complete Set of Images Document Repository Document Registry Document Entry Submission Set 1 Report Document Entry Submission Set 2 Study Manifest

Linking Report to Prior Images and Prior Report Document Repository Document Registry Document Entry Submission Set 3 Prior Study Manifest Document Entry Submission Set 1 Prior Report Document Entry Submission Set 2 Report Document Entry Submission Set 4 Study Manifest

Linking Report to Selected Images Radiology system Report Source ….. Findings: Header : Report Type: OB / Gyn BPD... ….. Radiology Report Relevant Image Gestational Age... WADO URI Link to image

XDS-I Metadata Radiology specific –Acquisition Modality (e.g. CT, MR) –Anatomic Region (e.g. Arm, Elbow, Hand) –Requested procedure (e.g. MRI Knee with contrast) Query example –find all “CT of the Head” of patient John Doe for the last 2 years

Access to Radiology Information

Access to Radiology Information Abstract /Scope Provides access to radiology information within the rest of the hospital (e.g., ER, OR, cardiology, oncology, etc) –Images, evidence documents, presentation states, key image notes, structured radiology reports Query and retrieve based model Multiple Sources Option –Allows user access to distributed Radiology information –One user’s action, queries to multiple sources, consolidation of results.

Access to Radiology Information constraints DICOM Query/ Retrieve –Defines Matching keys for response filtering by Image Manager/Archive –Defines Return keys to be requested by Image Display –Defines Returned attributes supported by Image Manager/Archive in query responses –Defines Returned attributes required to be displayed on Image Display

Retrieve Information for Display

Display Information Source Retrieve Specific Info for Display [11] Summary of Laboratory Reports Summary of Radiology Reports Summary of Cardiology Reports Summary of Surgery Reports Summary of Intensive Care Reports Summary of Emergency Reports Summary of Discharge Reports List of Allergies List of Medications Retrieve Document for Display [12] Persistent Document Types of Requests Summary of All Reports Summary of Prescriptions Retrieve Information for display Standards: HTTP, Web Service XHTML, PDF, JPEG, CDA

Query Keys – Transaction [11] Retrieve Specific Information for Display Parameter Name Request Type patientID lowerDate Time upperDate Time MostRecen tResults REQ R R O O R Description requestType specifies what type of information shall be retrieved. This parameter shall always be valued. This attribute identifies the subject of the results being queried for. Its value shall include identification of assigning authority. Used to constrain the earliest date/time of creation of information. Used to constrain the latest date/time of creation of information. The numeric value that indicates the number of most recent results to be included into the response, i.e., 1 indicates to provide the latest result.

Query Keys – Transaction [12] Retrieve Document for Display Parameter Name Request Type Document UID Description This parameter is required to have a value of “DOCUMENT”. Identifies document’s UID as known to both actors. REQ R R PreferredC ontentType This parameter is required to identify the preferred format: JPEG. PDF, CDA L1 that the document is to be provided (as MIME content type). R