Integrating the Healthcare Enterprise: Building the Electronic Health Record Cor Loef – Co-chair IHE Rad TC Acknowledgement for presentation input to: Christoph Dickmann – Member IHE Rad TC Charles Parisot – Co-chair IHE IT-I PC

Business need: share in the Care setting Radiology Reports and Images Between Radiology and imaging specialists non-imaging professionals Within an enterprise Cross-enterprise in a healthcare region By network or media

Care Cycle Definition The array of health services and care settings that address: health promotion disease prevention diagnosis, treatment, management, and rehabilitation of a disease, injury, and/or disability…. Source: CDC, US government

The Care Cycle Approach Set of tools to identify: Different paths someone may follow through the care cycle Disciplines and roles Sites of care Technology requirements Social and political changes required Costs Potential future care cycles

Deriving Care Cycles PCP office ED Cardiol- ogist ICU/CCU Non- imaging testing Home Floor OR / Cath Lab invasive Imaging Rehab Clinical guidelines Observations Industry leaders Literature

Pragmatic definition of EHR Integrated data and workflow Multimedia data access text, image, waveform, … Communication among stakeholders in the care cycle clinicians, caregivers, consumers, … Support different views of data Clinical records Details: episode, visit, study Longitudinal records Summaries: episode, visit cross-department and cross-enterprise users Linking summaries and clinical details

EHR goals in IHE (compatible with U.S. NHII goals) Informed Clinical Practice IHE integrates clinical data and functions for an EHR Interconnected Clinicians Beyond the department: community or regional scope Personalized Care Web-based data access and summary data Support for higher-level goals Better outcomes Increased patient safety More efficient healthcare operations

EHR complexity Business dilemmas Coordination and cooperation Significant, long-term investment Investors may not be main beneficiaries Coordination and cooperation Active collaboration among multiple stakeholders Identify and work out commonalities and barriers Integration and interoperability Implement existing standards Develop additional standards  Evolutionary system specification (system of systems)

Focus: Image-enabled EHR (connect two “worlds”) Non-imaging data Patient data Clinical data Laboratory results Surgery reports Prescriptions, meds Letters or notes Integrate with imaging data and processes Imaging data Patient data Images and evidence Radiology Cardiology Nuclear Medicine Integrate with non-imaging data and processes Departmental/ clinical information system world compared to imaging system world: both complement each other from an EHR viewpoint

Potential use cases of an image-enabled EHR Using images Neurologist: reviewing stroke patient transfer to ward Nurse: preparing GI ward round for Dr. X GP: seeing a post-MI patient after hospital discharge Patient: be prepared for an obstetric visit Producing images/ evidence Cardiologist: during catheter intervention Radiologist: starting an abdomen CT Physician: counseling at diabetes outpatient clinic Oncologist: planning radiotherapy The left column describes use cases from the image usage point of view. The right column describes use cases from the image production or specific service point of view. Information need may include current or longitudinal evidence

Image-enabled EHR Pregnancy outpatient clinics encounter evaluate acquire Image/ Report Repository store new data Ultrasound report and images index Document Registry register (XDS architecture) The next 2 slides show use cases from 2 encounters of the same patient in different care institutions. The example is taken from pregnancy care before and for childbirth. The flow of information illustrates the primary IHE mechanism of document sharing.

Image-enabled EHR Childbirth inpatient stay evaluate Document Registry Image/ Report/ Document Repositories index Document Repository store new data Report, letters (incl. images) retrieve index query register (XDS architecture)

Sharing Imaging Documents (XDS-I) Radiology department patient Onco- logist GP (follow-up) Document availability Images, report (PACS, RIS) report Longitudinal record system: across encounters Care record sys-tems: specific care delivery Retrieve Shared re- pository Query for re- ports Retrieve selected imaging report references Document Registry Register report & image references Your local imaging systems keep their DICOM objects, these are not copied to the shared information network. Shared repositories are not imaging-specific, a general “infrastructure” can be used. Imaging Information via native DICOM (imaging specialists) or WADO (general-purpose, web-based). You can learn more about XDS-I in the presentation “What is new in IHE” right here in the infoRAD classroom (please mention day/time).

IHE contributions to EHR implementation EHR realization IHE IT Infrastructure 7 Int. Profiles IHE Radiology 7 Int. Profiles IHE Laboratory 1 Int. Profile IHE Cardiology 3 Int. Profiles IHE Pat. Care Coord. 3 Int. Profile IHE Rad and Card are the major existing imaging-related Technical Frameworks (TF) – and are likely to be needed in a combined way in many scenarios. IHE IT-I Profiles provide common services for EHR system implementation. IHE PCC can be assumed to specify a majority of document contents IHE plans for the coming years include missing integration profiles to cover most EHR services. Each TF can contribute to EHR scenarios with Integration Profiles for Data access Workflow

Basic requirements of EMR/EHR systems Integrated healthcare provider systems EHR sources/ users, user interaction Document handling Storage and retrieval of EHR documents Infrastructure services Basic data and application integration Network EHR storage, inquiry, and retrieval path

EMR/EHR interoperability examples Backend integration (services, data) Source 1 Source 2 Desktop Integration as an EHR enabler Appl. 1 Appl. 2 Appl. 3 Patient identifier matching Single sign on Same patient selected Patient demographics Personnel/ staff data Any user Applications may be for specific purposes (e.g. department / specialist focus), for wider purpose (e.g. enterprise / distribution focus), or for general access/ creation/ viewing purpose (e.g. RHIO/ community-wide document viewing focus) Common person data or services

IHE - Radiology images and reports for an EMR/EHR system Access to Radiology (Rad ARI) Retrieve diagnostic quality images, evidence, reports Simple Image and Numeric Reports (Rad SINR) Access or export reports and related images Key Image Notes (Rad KIN) Mark, annotate, retrieve selected imaging evidence Portable Data for Imaging (Rad PDI) Export/ import/ view media data Nuclear Medicine Image (Rad NM Image) Capture and use complex NM result screens Mammography Image (Rad Mammo Image) Capture and use complex Mammography screens Consistent Presentation of Images (Rad CPI) Consistent image viewing on all review stations

IHE – Cardiology images and reports for an EMR/EHR system Cardiac Catheterization / Echo Workflow (Card CATH, ECHO) Retrieve catheterization and echocardiography imaging evidence Retrieve ECG for Display (Card ECG) Retrieve ECG summaries and results Displayable Reports (Card DRPT) Create and access reports for viewing

IHE - common interoperability services Common patient identification (ITI PIX) Common patient demographics (ITI PDQ) Desktop integration (ITI PSA) Running applications work on the same patient Single sign on (ITI EUA, XUA) Enterprise-wide or cross-enterprise user handling Security and privacy (ITI/ RAD ATNA, Accountability, document integrity DSG) Common staff data (ITI PWP) Health professionals are commonly recognized Now, a comprehensive overview is given on all these aspects of EHR systems that can be enabled or realized by IHE Integration Profiles. You will see, IHE provides many steps in the gradual evolution of your IT system landscape to a comprehensive patient record system. The IHE Integration Profiles provide interoperability added value independently – however, if combined, they can complete the picture of an intra- or cross-enterprise EHR system. Fundamental enablers of cross-system health record system functions. Gradual enhancement and combination is the key.

IHE – documents for general purpose EHR functions Cross-Enterprise Document Sharing for Imaging (Rad XDS-I) Share DICOM instances via web or DICOM connection; share imaging information via web Cross-Enterprise Document Sharing (ITI XDS) Store & retrieve documents and summaries (focus: longitudinal data) Notification of Document Availability (ITI NAV) Send notification/ reference to new shared documents Retrieve Information for Display (ITI RID) Query and retrieve documents and summaries/ lists Needs common services as a basis (e.g. security, patient identification)

IHE - clinical/ textual information for an EMR/EHR system Simple Image and Numeric Reports (Rad SINR) Access original or exported reports Cross-Enterprise Document Sharing (ITI XDS) Cross-Enterprise Doc. Sharing for Imaging (Rad XDS-I) Store & retrieve documents, summaries or reports with longitudinal data Retrieve Information for Display (ITI RID) Access documents and summaries (e.g. imaging, lab, discharge, medications, prescriptions) Sharing Laboratory report (Lab XD*-LAB) Access to laboratory results

IHE - workflow / patient management support Workflow integration (Rad, Card, Lab) Scheduled Workflow Ordering, scheduling and tracking of image acquisition steps Appointment tracking to order placer Reporting Workflow Scheduling and tracking of report creation tasks Patient data integration (Rad, Card, ITI) Patient Information Reconciliation Modification and matching of patient data and imaging evidence Patient Administration Management Creating and changing patient identifiers and encounter data Overall concept (Rad whitepaper) Departmental workflow and interfaces to the enterprise

Envisaged IHE development Extend XDS’ document content Harmonize IHE domain-specific workflow and document content Realize overall workflow concept Link departmental documents, in particular diagnostic reports, to the enterprise EMR Code sets and master files Configuration support Security details, e.g. access control

Image-enabled EHR – IHE progress and plans IHE Integration Profiles from different domains can be combined Combinations of current profiles can cover many EHR scenarios Information integration (imaging, textual) Enhanced functionality beyond one department Intra- and cross enterprise communication Scenarios enable system evolution (organizational change management not to be forgotten) IHE ensures integration testing and future Integration Profile development IHE knows that it does not provide specifications to completely realize image-enabled EHR systems yet. But it has clear plans how to get there within the next few years.