Integrating the Healthcare Enterprise Applying the IHE Framework to Cardiology Joseph Biegel Mitra IHE Planning Committee

HIMSS Applying the IHE to Cardiology - Topics Quick IHE OverviewQuick IHE Overview Motivations for IHE in Cardiology?Motivations for IHE in Cardiology? Common and distinct needs in CardiologyCommon and distinct needs in Cardiology Data Complexity and WorkflowData Complexity and Workflow Applying Scheduled Workflow in CardiologyApplying Scheduled Workflow in Cardiology Challenges and next steps…Challenges and next steps…

HIMSS What is IHE about? Its an initiative promoting and supporting the integration of systems in the healthcare enterprise.Its an initiative promoting and supporting the integration of systems in the healthcare enterprise. Integration Goal: Improve the efficiency and effectiveness of clinical practice by:Integration Goal: Improve the efficiency and effectiveness of clinical practice by: –Improved Information Flow –Advanced Multi-System Functions

HIMSS Why is IHE needed? Serious Integration Challenges in Healthcare:Serious Integration Challenges in Healthcare: Systems need Information other systems haveSystems need Information other systems have But, systems communicate poorly or not at allBut, systems communicate poorly or not at all Result: - tedious, inefficient workflows - data that is inconsistent or unavailableResult: - tedious, inefficient workflows - data that is inconsistent or unavailable Responsibility for information flow between systems, and between departments, is often unclear.

HIMSS Who is IHE? Participants:Participants: –Professional Societies (RSNA/HIMSS/…) –Vendors (over 30 companies) –Standards Group Committee Members RSNA and HIMSS sponsor IHE to provide a neutral forum for working on the Big PictureRSNA and HIMSS sponsor IHE to provide a neutral forum for working on the Big Picture

HIMSS What Does IHE Do? Users and vendors work together to identify and design solutions for integration problemsUsers and vendors work together to identify and design solutions for integration problems Intensive process with annual cycles:Intensive process with annual cycles: –Identify key healthcare workflows and integration problems –Research & select standards to specify a solution –Write, review and publish IHE Technical Framework –Perform cross-testing at Connectathon –Demonstrations at tradeshows (RSNA/HIMSS)

HIMSS Arent DICOM / HL7 Sufficient? Standards are vital (HL7, DICOM, ICD, …)Standards are vital (HL7, DICOM, ICD, …) –They provide tools & technologies But Standards alone are insufficientBut Standards alone are insufficient –They are open to interpretation –There is room for optional variations –They avoid specifying how to apply them to particular real world scenarios

HIMSS How is IHE related to Standards? IHE attacks real world integration problemsIHE attacks real world integration problems HL7 and DICOM provide dictionariesHL7 and DICOM provide dictionaries IHE defines a phrasebook that solves real world problems by assembling pieces provided by DICOM/HL7IHE defines a phrasebook that solves real world problems by assembling pieces provided by DICOM/HL7

HIMSS What are Key IHE Concepts? Generalized Systems -> ActorsGeneralized Systems -> Actors Interactions between Actors -> TransactionsInteractions between Actors -> Transactions Problem/Solution Scenarios-> Integration ProfilesProblem/Solution Scenarios-> Integration Profiles For each Integration Profile:For each Integration Profile: the context is described (which real-world problem)the context is described (which real-world problem) the actors are defined (what systems are involved)the actors are defined (what systems are involved) the transactions are defined (what must they do)the transactions are defined (what must they do)

HIMSS Scheduled Workflow Profile Registration Orders Placed Orders Filled Film Folder Image Manager & Archive Film Lightbox report Report Repository Diagnostic Workstation Modality acquisition in-progress acquisition completed images printed Acquisition Modality

HIMSS Radiology Thats nice, but it is Radiology… Henry Gray (1825–1861). Anatomy of the Human Body ardiology Cardiology

HIMSS PatientComplaint Nuclear Study Labs Cath Hemo Interventional Procedure Echo Physician ECG Cardiologist Simplified view of Cardiology

HIMSS Why IHE in Cardiology? Cardiology workflow is complexCardiology workflow is complex Multiple diagnostic tests are very commonMultiple diagnostic tests are very common –Large number of manual demographic input steps is common. –This leads to inefficiency, invalid data in clinical archives and can lower the quality of care

HIMSS Why IHE in Cardiology (2) ? The Cardiology position in the IT technology adoption cycle makes the IHE an ideal foundationThe Cardiology position in the IT technology adoption cycle makes the IHE an ideal foundation The concepts of the IHE TF have broad general applicability, many can be directly leveraged in CardiologyThe concepts of the IHE TF have broad general applicability, many can be directly leveraged in Cardiology Some of Cardiologys special requirements can be well met by the IHE TFSome of Cardiologys special requirements can be well met by the IHE TF The TF could be adapted to meet Cardiology specific needsThe TF could be adapted to meet Cardiology specific needs

HIMSS Common Needs Cardiology departments have needs similar to Radiology departmentsCardiology departments have needs similar to Radiology departments –Both are driven by imaging modalities –Workflow is similar at a very high level –Need to manage distributed departmental resources –Desire an integrated patient-centered view –Need for administrative reporting –Need to improve lab efficiency via workflow management

HIMSS Distinct Cardiology Needs Clinical data content is more complexClinical data content is more complex –Procedural data with rich report content Direct tie to billingDirect tie to billing –Clinical results data mining is a priority Cardio departments are often more driven/isolated by subspecialtyCardio departments are often more driven/isolated by subspecialty Legacy installed base without clear connectivity path is largeLegacy installed base without clear connectivity path is large Strong individual patient focus than a system or procedure focusStrong individual patient focus than a system or procedure focus Cardio departments are revenue centersCardio departments are revenue centers

HIMSS Complexity of Core Data RadiologyRadiology –Diagnostic Imaging CT,MR,US,NM…CT,MR,US,NM… Scanned FilmScanned Film –Text Reports –Measurements Cardiology –Diagnostic Imaging XA, US, NM, CT, MR –Waveforms ECG, Hemo, EP, Stress –Extensive numeric measurements –Lab data –Complex Reports Stress,Holter, Cath

HIMSS Cardiology Workflow Elements Workflow elements in common with Radiology:Workflow elements in common with Radiology: –Patients are admitted –Demographics entered (often multiple times for the same patient) –Imaging studies are performed and read –Reports generated

HIMSS Cardiology Workflow Elements Additional Workflow elements:Additional Workflow elements: –Echo, ECG & lab data often prerequisites to treatment –Consumable materials and clinical data tied to procedures –Monitoring data is part of the Cath procedure –Echo as follow on to a Cath procedure –Interpretation generally uses multiple clinical inputs

HIMSS Scheduled Workflow Works for Cardiology Minimizing redundant demographic input and producing valid header data in the clinical archive is important in CardiologyMinimizing redundant demographic input and producing valid header data in the clinical archive is important in Cardiology –Multiple modality inputs of Cardiology drives the value –Basic problem is well addressed by the Scheduled Workflow and Patient Reconciliation Integration Profiles in IHE Year 3

HIMSS Patient Information Reconciliation Profile Works for Cardiology Extends Scheduled WorkflowExtends Scheduled Workflow –Handle unidentified patient (e.g. emergent) –Handle demographic information mistakes –Propagate changes to all affected systems, update all affected data Reduces incorrectly identified or lost studiesReduces incorrectly identified or lost studies Can reduce lost charge postings (billing)Can reduce lost charge postings (billing)

HIMSS Can you Just Do It? We have done some investigations and prototype clinical testing to examine the utility of applying the concepts of Scheduled Workflow and Patient ReconciliationWe have done some investigations and prototype clinical testing to examine the utility of applying the concepts of Scheduled Workflow and Patient Reconciliation Key PiecesKey Pieces –HIS, RIS, Modality & PACS The HIS is the sameThe HIS is the same So far this is easy…So far this is easy…

HIMSS Modality Connectivity in Cardiology Imaging Modalities often have at least some DICOM servicesImaging Modalities often have at least some DICOM services –DICOM Store SCU support common in new systems –Some legacy conversion solutions –DICOM MWL becoming common –DICOM MPPS and Storage Commitment getting there That was the good news…That was the good news…

HIMSS Modality Connectivity in Cardiology Critical care monitoring is out of scope for now.Critical care monitoring is out of scope for now. Waveform systems are challenging.Waveform systems are challenging. –Some Hemo systems and ECG information systems support HL7 ADT and ORM messaging allowing functionality similar to DICOM MWL. –Others have proprietary connectivity capabilities which could be rigged to enable MWL style modality messaging.

HIMSS The Cardiology RIS (CIS) Ask 10 people what a CIS is and you will get 9 answers…Ask 10 people what a CIS is and you will get 9 answers… One of the key elements we need is an electronic source of order and schedule data that drive department workflow and support OP/OF and PPS Manager ActorsOne of the key elements we need is an electronic source of order and schedule data that drive department workflow and support OP/OF and PPS Manager Actors This is often not readily available in Cardiology departments todayThis is often not readily available in Cardiology departments today

HIMSS HIS DICOM Image Manager/ Archive & Report Repository Patient Demographics, Schedules DMWL MPPS DMWL MPPS ECG ECG LAB ECHO ECHO LAB CATH CATH LAB HEMODYNAMICS Patient Demographics, Schedules Patient Demographics, Schedules Storage Commitment Images & Reports Waveform & Report Waveform & Report Scheduled Workflow in Cardiology CIS (Performed Procedure Step Mgr, Order Placer/Filler Actors) ADT,ORM

HIMSS Easy Wins for IHE in Cardiology Workflow in the Cath lab can be streamlinedWorkflow in the Cath lab can be streamlined –Minimize data re-entry –Automate pre-fetching Since Scheduled Workflow leverages DICOM MPPS, near real time updates on Cath procedure status are possibleSince Scheduled Workflow leverages DICOM MPPS, near real time updates on Cath procedure status are possible DICOM SR and Waveform allow the use of a common DICOM archive for waveform and imaging systemsDICOM SR and Waveform allow the use of a common DICOM archive for waveform and imaging systems

HIMSS Connectivity Challenges DICOM MPPS is a limiting capability for integrating Cardio modalities.DICOM MPPS is a limiting capability for integrating Cardio modalities. –New Imaging modalities are starting to have IHE Modality Actor support, but the legacy installed base will be an integration challenge. Waveform modalities need to either adopt DICOM modality messaging and storage or the IHE TF needs to be extended to allow HL7 or other methods.Waveform modalities need to either adopt DICOM modality messaging and storage or the IHE TF needs to be extended to allow HL7 or other methods. –There are underlying standards (IEEE, SCP-ECG) that could be leveraged by the IHE in the future.

HIMSS Clinical Challenges in Cardiology for the IHE IS driven order creation in Cardiology is not generally availableIS driven order creation in Cardiology is not generally available GSPS and Key Image Note have value, but are clearly limited todayGSPS and Key Image Note have value, but are clearly limited today –Cardiologists use motion images and color data that depicts cardiac function Simple Image and Numeric ReportsSimple Image and Numeric Reports –Pictorial diagrams for anatomy, function and viability are needed for clinical reports –Extensions to manage specific frames of cine objects and waveform objects would be needed

HIMSS Other Technology Challenges Some Cardiology tasks are still hard to do digitalSome Cardiology tasks are still hard to do digital –Pediatric Echo is just now able to enter the digital era Huge volume of data required to do a search mission on a tiny fast beating heartHuge volume of data required to do a search mission on a tiny fast beating heart Extensive measurements needed to understand the clinical situationExtensive measurements needed to understand the clinical situation –EP data volume –Real-time critical care monitoring

HIMSS IT, the CIO and That Archive… The IT department and the CIO should become strong advocates for moving the IHE into CardiologyThe IT department and the CIO should become strong advocates for moving the IHE into Cardiology –As IHEs track record grows in Radiology integration projects, doing it again down the hall begins to form a value proposition for IT management –Leverage common archive infrastructure

HIMSS Conclusions The value is clear.The value is clear. –Applying and extending the IHE to Cardiology could save millions of dollars in product development costs –It could improve the quality and efficiency of care IHE Scheduled Workflow and Patient Reconciliation Integration Profiles are nearly ready to go in Cardiology.IHE Scheduled Workflow and Patient Reconciliation Integration Profiles are nearly ready to go in Cardiology. There are challenges.There are challenges. Need to extend the Technical Framework for some Cardiology specific needs.Need to extend the Technical Framework for some Cardiology specific needs.

HIMSS What Should You Do Now? Require support or at least a clear upgrade path to Acquisition Modality Actor for new imaging system RFPs and purchase specificationsRequire support or at least a clear upgrade path to Acquisition Modality Actor for new imaging system RFPs and purchase specifications Hug your Cardiologist and tell them a bit about why they need to know about the IHE…Hug your Cardiologist and tell them a bit about why they need to know about the IHE… Help to build support within the key clinical professional societiesHelp to build support within the key clinical professional societies –Have your CIO talk to the Cardiology chair and say, I need your help so that I can help you…

HIMSS Questions?