IHE Cardiology Michio Kimura Hamamatsu medical school Hamamatsu medical school Masaaki Hirai Nihon Kohden Co., Nihon Kohden Co.,

Why IHE in cardiology? (1) 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

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

Mission In order to reduce medical errors, improve quality, and efficiency IHE shall develop intercommunication standards to manage order entry, acquisition, and billing, and provide a consistent display of images, waveforms, measurements, and reports leveraging existing IHE technical frameworks.In order to reduce medical errors, improve quality, and efficiency IHE shall develop intercommunication standards to manage order entry, acquisition, and billing, and provide a consistent display of images, waveforms, measurements, and reports leveraging existing IHE technical frameworks.

Cardiac examination workflow Holter ECG Stress ECG Labs ECG Patient complaint Chest X-ray CatheterizationHemodynamics Interventional Procedure Nucleus Echo Stress Echo

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 –Legacy installed base technology issues

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

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

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

Scheduled Workflow Works for Cardiology 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 CIS (Performed Procedure Step Mgr, Order Placer/Filler Actors) ADT,OMG,(ORM) Image & Reports

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

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)

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

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. –MFER(ISO ) is available.

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

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

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

Cardiac Cath/Echo Actors & Transactions Pt. Registration [RAD-1] Patient Update [RAD-12] Pt. Registration [RAD-1] Patient Update [RAD-12] Placer Order Management [RAD-2] Filler Order Management [RAD-3] ADT Query Images [RAD-14] Retrieve Images/Evidence [CARD4] Image Display Modality Image/Evidence Stored [CARD-2] Storage Commitment [CARD3-1] Procedure Scheduled [RAD-4] Procedure Updated [RAD-13] Query Modality Worklist [RAD-5] Performed Procedure Step Mgr Modality PS in Progress [CARD-1] Modality PS Completed [RAD-7] Modality PS in Progress [CARD1] Modality PS Completed [RAD-7] Modality PS Completed [RAD-7] Order Placer Acquisition Modality Image Manager Image Archive DSS/ Order Filler Patient Update [RAD-12] Modality Image/Evidence Stored [CARD-2] Storage Commitment [CARD-3] Evidence Creator Modality PS in Progress [CARD-1] Modality PS Completed [RAD-7] Query Evidence [RAD-44] Instance Availability Notification [RAD-49] Modality PS in Progress [CARD-1]

Cardiac Cath Workflow Use Cases Case C1: Patient Registered at ADT and Procedure Ordered at the Order PlacerCase C1: Patient Registered at ADT and Procedure Ordered at the Order Placer Case C2: Patient Registered at ADT and Procedure Ordered at DSS/OFCase C2: Patient Registered at ADT and Procedure Ordered at DSS/OF Case C3: Patient Registered at ADT and Procedure Not OrderedCase C3: Patient Registered at ADT and Procedure Not Ordered Case C4: Patient Registered at DSS/OF and Procedure OrderedCase C4: Patient Registered at DSS/OF and Procedure Ordered Case C5: Patient Not RegisteredCase C5: Patient Not Registered Case C6: Patient Updated During ProcedureCase C6: Patient Updated During Procedure Case C7: Change Rooms During ProcedureCase C7: Change Rooms During Procedure Case C8: Cancel ProcedureCase C8: Cancel Procedure Case C9: Post-Procedure Evidence CreationCase C9: Post-Procedure Evidence Creation

Echo Use Cases Case E1: Patient Registered at ADT and Procedure OrderedCase E1: Patient Registered at ADT and Procedure Ordered Case E2: Intermittently Connected ModalityCase E2: Intermittently Connected Modality Case E3: Intermittently Connected Modality with Ad Hoc Procedure, Patient Registered, Scheduled ProcedureCase E3: Intermittently Connected Modality with Ad Hoc Procedure, Patient Registered, Scheduled Procedure Case E4: Intermittently Connected Modality with Ad Hoc Procedure, Patient Registered, Unscheduled ProcedureCase E4: Intermittently Connected Modality with Ad Hoc Procedure, Patient Registered, Unscheduled Procedure Case E5 : Intermittently Connected Modality with Ad Hoc Procedure, Patient Unregistered, Unscheduled ProcedureCase E5 : Intermittently Connected Modality with Ad Hoc Procedure, Patient Unregistered, Unscheduled Procedure Case E6: Stress Echo Staged ProtocolCase E6: Stress Echo Staged Protocol Case E7: Echo MeasurementsCase E7: Echo Measurements

Displayable Reports (DRPT) Case R1: Report manager provides local storage and distribution of reportsCase R1: Report manager provides local storage and distribution of reports Case R2: Image manager/archive provides storage and distribution of reportsCase R2: Image manager/archive provides storage and distribution of reports Case R3: Multiple Reports on one Requested ProcedureCase R3: Multiple Reports on one Requested Procedure Case R4: Preliminary, Final and Corrected ReportsCase R4: Preliminary, Final and Corrected Reports

ECG Profile Transaction Diagram Display Information Source Retrieve Specific Info for Display [ITI-11] Retrieve ECG List [CARD-5] Retrieve ECG Document for Display [CARD-6]

ECG Needs ECGs Accessible Everywhere!ECGs Accessible Everywhere! Need broad distribution of ECGs using ubiquitous technology (Web).Need broad distribution of ECGs using ubiquitous technology (Web). –Allow medical applications to easily retrieve and display ECGs in a platform/vendor neutral way. High-quality ECG documents. Avoid artifacts on zoomed ECGs and arbitrary display geometries.High-quality ECG documents. Avoid artifacts on zoomed ECGs and arbitrary display geometries. –Vector images required (not rasterized) Facilitate apps for serial comparison (side-by- side synchronized display).Facilitate apps for serial comparison (side-by- side synchronized display).MFER

ECG Profile Abstract / Scope Provide ECGs and related documents to enterpriseProvide ECGs and related documents to enterprise Reuse IHE-ITI RIDReuse IHE-ITI RID –Retrieve list of documents; retrieve single document –ECGs served in ready-to-display format (MFER,[PDF, SVG * IHE-J option ]) Limited extension for ECG-specific needsLimited extension for ECG-specific needs –Add requirements on display format and quality –[Include XML-based ECG report list * IHE-J option ]

Out of Scope ECG acquisition and reading workflow.ECG acquisition and reading workflow. ECG raw data interchange.ECG raw data interchange. Export of reports to external repository.Export of reports to external repository. Central management and configuration of ECG devicesCentral management and configuration of ECG devices

ECG Profile Value Proposition Use ubiquitous HTTP Get mechanism as defined in IHE-ITI RIDUse ubiquitous HTTP Get mechanism as defined in IHE-ITI RID –Standardized URLs USE MFER(ISO ) for ECG display * IHE-J national extentionUSE MFER(ISO ) for ECG display * IHE-J national extention [Use PDF for easy integration with existing display applications * IHE-J option ][Use PDF for easy integration with existing display applications * IHE-J option ] [PDF vector graphics supports scalable waveforms * IHE-J option ][PDF vector graphics supports scalable waveforms * IHE-J option ] [XML list of ECGs for serial comparison apps * IHE-J option ][XML list of ECGs for serial comparison apps * IHE-J option ]

MFER:ISO/ (measuring R-R interval with caliper)

MFER zoom-in view (measuring with scale)

CDA report with MFER

Example ECG in (vector)PDF Format

Example ECG in SVG Format Example ECG in SVG Format

ECG Profile Actors Display – A system that can request and display preformatted ( presentation-ready ) data using Web technologies.Display – A system that can request and display preformatted ( presentation-ready ) data using Web technologies. Information Source – A system that responds to requests for patient-related ECG data by encoding it in a presentation-ready format using Web technologies.Information Source – A system that responds to requests for patient-related ECG data by encoding it in a presentation-ready format using Web technologies. Same actors as RID ProfileSame actors as RID Profile

ECG Profile Transactions Retrieve Specific Info for Display [ITI-11]Retrieve Specific Info for Display [ITI-11] –Uses HTTP Get query parameters SUMMARY or SUMMARY-CARDIOLOGY –Uses HTTP Get query parameters SUMMARY or SUMMARY-CARDIOLOGY –[Response list of documents (including ECGs) in ready-to- display format (XHTML) * IHE-J option ] Retrieve ECG List [CARD-5]Retrieve ECG List [CARD-5] –Uses HTTP Get query parameter SUMMARY- CARDIOLOGY-ECG –Uses HTTP Get query parameter SUMMARY- CARDIOLOGY-ECG –[Response list of ECGs in processable format (HL7 RIM- derived XML) * IHE-J option ] Retrieve ECG Document for Display [CARD-6]Retrieve ECG Document for Display [CARD-6] –MFER –[Response ECG served in PDF * IHE-J option ] –[SVG allowed if Display actor asks for it and Information Source supports it * IHE-J option ]

Use Case D1: Simple Display Display actor requests list of ECG documents for a specific patient ID.Display actor requests list of ECG documents for a specific patient ID. –RID profile SUMMARY-CARDIOLOGY request returns list as HTML. –[ECG profile SUMMARY-CARDIOLOGY-ECG request returns list as XML with stylesheet. * IHE-J option ] Display actor requests a specific ECG document using a unique document ID.Display actor requests a specific ECG document using a unique document ID. –The ID of the requested document may not have been obtained from the previously retrieved list.

MFER:ISO/ (measuring R-R interval with caliper)

Use Case D2: Advanced Display Display actor requests list of ECG documents for a specific patient ID using ECG profile request type.Display actor requests list of ECG documents for a specific patient ID using ECG profile request type. –[List of ECGs returned as structured XML. * IHE-J option ] Display actor parses structured document list to select related ECGs for serial comparison, for example.Display actor parses structured document list to select related ECGs for serial comparison, for example. Display actor requests the specific ECG documents using the unique document IDs obtained in structured list above.Display actor requests the specific ECG documents using the unique document IDs obtained in structured list above. Display actor displays the ECGs in a meaningful wayDisplay actor displays the ECGs in a meaningful way

Advanced MFER ECG display (3x4)

Advanced MFER ECG display (6x2)

IHE exhibition show in Japanese Circulation Society conference

Future profiles HemodynamicsHemodynamics IVUSIVUS Data harvestingData harvesting Stress ECG/EchoStress ECG/Echo Holter ECGHolter ECG