IHE & YOU—How Does it Work in the Clinic? Linda Wedemeyer, MD, MS--Ophthalmologist Veterans Health Administration Los Angeles, CA

Mrs. Smith Arrives for Appointment The clerk checks her in, providing demographic information to the ADT actor The clerk checks her in, providing demographic information to the ADT actor ADT actor: possibly practice management system or hospital information system ADT actor: possibly practice management system or hospital information system ADT actor sends demographic information to the order filler or order placer ADT actor sends demographic information to the order filler or order placer Order filler: possibly EMR Order filler: possibly EMR Order placer: possibly practice management system Order placer: possibly practice management system

Generic Eye Care Orders Created Order Filler (possibly EMR) creates automatic orders for lensometry and autorefraction. Order Filler (possibly EMR) creates automatic orders for lensometry and autorefraction.

Why do we need Generic Eye Care Orders? Have you ever heard of a physician writing an order every time a pair of glasses gets measured? Have you ever heard of a physician writing an order every time a pair of glasses gets measured? Can you guess what he would say if you asked him to? Can you guess what he would say if you asked him to?

So Why Do We Need Orders at All? For Data Integrity For Data Integrity Right patient, right image, right data Right patient, right image, right data

How do we solve the dilemma? Generic eye care orders Generic eye care orders Automatic creation of orders when a patient is registered Automatic creation of orders when a patient is registered Some of the orders will be performed, and some won’t Some of the orders will be performed, and some won’t The tech decides which ones, as he would normally The tech decides which ones, as he would normally

What is different about a generic order? It may or may not be executed, as decided by the technician or by some other informal process It may or may not be executed, as decided by the technician or by some other informal process Generic orders that are not executed will probably expire in a shorter time frame than more specific orders Generic orders that are not executed will probably expire in a shorter time frame than more specific orders

Generic Eye Care Orders—Mrs. Smith Again, recall that automatic orders were created for lensometry and auto-refraction for Mrs. Smith Again, recall that automatic orders were created for lensometry and auto-refraction for Mrs. Smith Triggered when Mrs. Smith was registered in the clinic Triggered when Mrs. Smith was registered in the clinic

Information Flows to Modality Worklist Generic eye care orders cause Mrs. Smith’s demographic information to be listed on the lensometer and auto- refractor Generic eye care orders cause Mrs. Smith’s demographic information to be listed on the lensometer and auto- refractor Both instruments are acqusition modalities Both instruments are acqusition modalities This list is the Modality Worklist This list is the Modality Worklist

The eye tech calls for Mrs. Smith He brings her to an exam room, takes a history, then measures her glasses. He brings her to an exam room, takes a history, then measures her glasses. The tech arrives at the lensometer with Mrs. Smith’s glasses. The tech arrives at the lensometer with Mrs. Smith’s glasses. On the lensometer, he selects Mrs. Smith’s name on the Modality Worklist On the lensometer, he selects Mrs. Smith’s name on the Modality Worklist This confirms what procedure was actually done This confirms what procedure was actually done He measures the glasses He measures the glasses Measurements are uploaded by the image manager to the storage server Measurements are uploaded by the image manager to the storage server

Tech decides not to perform auto- refraction Mrs. Smith’s vision is 20/20 and she is happy with her glasses Mrs. Smith’s vision is 20/20 and she is happy with her glasses

What happens to the order for auto-refraction? It expires It expires At whatever time the clinic determines At whatever time the clinic determines Time for expiration is set in the Order Filler (possibly EMR) Time for expiration is set in the Order Filler (possibly EMR) Expiration could be triggered by time of day, or perhaps by an event such as completion of physician documentation Expiration could be triggered by time of day, or perhaps by an event such as completion of physician documentation

Tech completes appropriate workup Mrs. Smith is ready for the physician Mrs. Smith is ready for the physician

Physician Sees Mrs. Smith Takes a history Takes a history Performs an exam using multiple instruments--slit lamp, indirect ophthalmoscope, tonometer… Performs an exam using multiple instruments--slit lamp, indirect ophthalmoscope, tonometer… Some of these instruments may produce digital images—generic orders might be used as described above Some of these instruments may produce digital images—generic orders might be used as described above

Physician Elects Further Workup Decides that a fundus photo and visual field are indicated Decides that a fundus photo and visual field are indicated Orders these procedures Orders these procedures Uses either the order placer (possibly practice management system or hospital information system) Uses either the order placer (possibly practice management system or hospital information system) Or the order filler (possibly eye clinic EMR) Or the order filler (possibly eye clinic EMR)

Specific Orders This Time This is a physician generated order, where a specific procedure is ordered for a patient This is a physician generated order, where a specific procedure is ordered for a patient The expectation is that these orders will be executed The expectation is that these orders will be executed They may or may not be set to expire automatically They may or may not be set to expire automatically

Orders Created by physician

Orders Transmitted to Instruments The visual field machine and the camera query the order filler (probably EMR) for the patient’s demographic information The visual field machine and the camera query the order filler (probably EMR) for the patient’s demographic information This creates the Modality Worklists on those devices (acquisition modalities) This creates the Modality Worklists on those devices (acquisition modalities)

Technician Notified Yelling down the hall Yelling down the hall Or tech looks at orders in EMR Or tech looks at orders in EMR

Mrs. Smith is sent to camera--Imager Selects name/demographics

Photos Taken—any IHE Compliant Camera

Images uploaded to storage server

With a couple mouse clicks…

Charge Posting—Procedure Codes The instrument passes procedure codes to the order filler (optional feature) The instrument passes procedure codes to the order filler (optional feature) The order filler maps to CPT codes The order filler maps to CPT codes The order filler notifies the billing system (charger processor or charge poster) that a billable procedure has been completed The order filler notifies the billing system (charger processor or charge poster) that a billable procedure has been completed

Charge Posting—Diagnosis Codes Diagnosis codes added manually using charge processor Diagnosis codes added manually using charge processor By physician or billing personnel By physician or billing personnel Some day we’ll automate this too! Some day we’ll automate this too!

What happens to studies to be read? After the modality performed procedure step After the modality performed procedure step The order filler can be configured to notify the physician that there are results to be read The order filler can be configured to notify the physician that there are results to be read

Physician notified

Images now viewable

Image Display Actor Desktop computer Desktop computer Retrieves images from a storage server Retrieves images from a storage server

Physician reviews the photos

And writes a report In the future, report creation will be standardized in IHE In the future, report creation will be standardized in IHE Once report creation is addressed in IHE eye care, automatic charge posting for the physician’s report can occur Once report creation is addressed in IHE eye care, automatic charge posting for the physician’s report can occur

Tech Calls Mrs. Smith And brings her in to the visual field machine And brings her in to the visual field machine Selects Mrs. Smith’s name on the visual field machine and then performs the procedure Selects Mrs. Smith’s name on the visual field machine and then performs the procedure Data is uploaded to the storage server Data is uploaded to the storage server

Charge Posting—Procedure Codes The instrument passes procedure codes to the order filler (optional feature) The instrument passes procedure codes to the order filler (optional feature) The order filler maps to CPT codes The order filler maps to CPT codes The order filler Notifies the billing system (charger processor or charge poster) that a billable procedure has been completed The order filler Notifies the billing system (charger processor or charge poster) that a billable procedure has been completed

Charge Posting—Diagnosis Codes Diagnosis codes added manually using charge processor Diagnosis codes added manually using charge processor By physician or billing personnel By physician or billing personnel Some day we’ll automate this too! Some day we’ll automate this too!

The physician is notified He retrieves the visual field from the storage server (image archive) He retrieves the visual field from the storage server (image archive) While sitting at his desktop computer (image display actor) While sitting at his desktop computer (image display actor) Reviews the study Reviews the study

And writes a report Some day this will generate a charge Some day this will generate a charge

Diabetic Teleretinal Screening Perfect example for generic orders Perfect example for generic orders Every patient gets the same thing Every patient gets the same thing Every scheduled patient is automatically on the Modality Worklist of the camera Every scheduled patient is automatically on the Modality Worklist of the camera

Integrating the Healthcare Environment (IHE) Eye Care Patient Data Anytime, Anywhere… Patient Data Anytime, Anywhere… Standards make it happen! Standards make it happen!

More information…. IHE Web site: IHE Web site: Technical Frameworks Technical Frameworks –ihe_eyecare_tf_TI_vol1_2006_06_01 (Trial Implementation version) –ihe_eyecare_tf_TI_vol2_2006_06_01 (Trial Implementation version) –ihe_tf_rev6.0ft_vol1_ FINAL (Radiology) –ihe_tf_rev6.0ft_vol2_ FINAL (Radiology) –ihe_CARD_tf_vol2_2.1_FT (Cardiology) Standards used by IHE Eye Care Standards used by IHE Eye Care –DICOM Standard –HL7 Standard IHE Connectathon Oct at RSNA HQ IHE Connectathon Oct at RSNA HQ IHE Showcase at Nov AAO Conference IHE Showcase at Nov AAO Conference Vendor Products Integration Statements Vendor Products Integration Statements