DICOM and IHE, Integrating the Healthcare Enterprise Cor Loef Co-chair DICOM Strategic Advisory Committee Member IHE Planning and Technical Committee Cor Loef Program Manager Interoperability Philips Medical Systems

May 5, Contents Goal of IHE IHE process Integration Profiles and the role of standards in IHE DICOM’s use in the IHE Integration Profiles Current topics Questions and answers

May 5, Integration Hell in the Enterprise Different information islands: Modalities, PACS, HIS, RIS, EPR Different standards and information models : DICOM, HL7, XML Different (proprietary) interpretations and implementations Different information islands: Modalities, PACS, HIS, RIS, EPR Different standards and information models : DICOM, HL7, XML Different (proprietary) interpretations and implementations EPR PACS RIS / HIS Modalities

May 5, Goal of IHE  It’s an initiative promoting and supporting the integration of systems in the healthcare enterprise  Integration Goal: Improve the efficiency and effectiveness of clinical practice by:  Improved Information Flow  Advanced Multi-System Functions  With minimal “integration project pain”

May 5, IHE process Users and vendors work together to identify and design solutions for integration problems Intensive process with annual cycles: –Identify key workflows and integration problems –Research & select standards to specify a solution –Write, review and publish Technical Framework –Perform cross-testing at “Connectathon” –Demonstrations at tradeshows: RSNA/HIMSS, and also JFR, DRK, JMCP

May 5, Image Server CD Exchange Diagnostic Workstation Connection to other Network and/or TeleRadiology Web Distribution Modalities The (multi-vendor) Integrated Imaging Solution Radiology Information System

May 5, Role of standards in IHE IHE attacks real world radiology integration problems Standards such as HL7 and DICOM provide dictionaries IHE defines a “phrasebook” that solves real world problems by assembling pieces provided by DICOM/HL7 IHE is also a way to promote and advance the implementaion of standards

May 5, IHE: Relation to StandardsDICOM HL 7 IHE IHE Technical Framework Technical Framework Selection of options IntegrationSolution A B C Commoninformationmodel

May 5, Use Case Roles & Interaction Diagrams Actor 1Actor 2 TRANSACTIONS Actor 3 Actor 1Actor 2Actor 3 Message 1 Message 2 Message 3 Examples of Actors:Examples of Actors: -ADT / Patient Registration -Acquisition Modality Examples of Transactions:Examples of Transactions: -Register Patient -Images Stored

May 5, Goal of IHE IHE process Role of standards in IHE DICOM’s use in the IHE Integration Profiles Current topics Questions and answers

May 5, IHE Integration Profiles Integration solution for real-world integration problems Set of related transactions among systems Allow buyers to focus on high-level integration, cornerstone for defining requirements in RFP’s Implementation is defined by the IHE Technical Framework

May 5, Year 4 Integration Profiles Access to Radiology Information Consistent access to images and reports Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Key Image Notes Flag significant images Simple Image and Numeric Reports Simple reports with image links and, optionally, measurements Basic Security Audit Trail Consolidation & Node Authentication Presentation of Grouped Procedures Subset of a single acquisition Post- Processing Workflow Schedule, perform, & notify image processing & CAD steps Charge Posting Collection of billable procedure details Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders

May 5, acquisition in progress acquisition completed 1.Scheduled Workflow DICOM: Modality Worklist Query Requirements, with Acquisition Protocol Setting option Required attribute mapping from Worklist to Images Modality Performed Procedure Step, with Exception Management option Store Storage Commitment

May 5, Patient later identified - enter proper data examination orders for J Doe HIS Enter patient as J Doe RIS report 2. Patient Information Reconciliation

May 5, What the Radiologist Displays: What the Reviewing Physician Sees: The Radiologist’s Transformations Are Saved Original Image & Presentation State &Grayscale Standard Original Image Window Level Flip Zoom Area Of Interest Annotate The Radiologist’s Transformations Are Lost Original Image Area Of Interest Prepared Image Original Image 3. Consistent Presentation of Images

May 5, MODALITY 4. Presentation of Grouped Procedures Requested Procedure: HEAD Report: HEAD Report: CHEST Performs a single exam Operator groups 2 procedures Head View RIS / PACS Requested Procedure: CHEST Head View Chest View DICOM: Presentation State Modality Performed Procedure Step

May 5, Report Verification Report and Image Review for Patient Care Images retrieved Verified Report Report & Images retrieved Preliminary Report Report stored for Network Access Image Manager and Archive Images and Exam data presented for diagnosis 5. Simple Image and Numeric Report DICOM: Basic Text SR Enhanced SR Template TID 2000 Codes from DCMR

May 5, Radiologist Flags Images: Referring Physician Sees Key Images First: for refering physician This image shows the renal rupture. Note1 for refering physician This image has the hematoma. Note2 For referring physician: This image shows the renal rupture. Note1 For referring physician: This image has the hematoma. Note2 for refering physician This image shows the renal rupture. Note1 for refering physician This image has the hematoma. Note2 Study & Key Image Notes 6. Key Image Notes DICOM: Key Object Selection Document SOP Class

May 5, Access to Radiology Information Radiology Department – Images and Reports Emergency Department Referring Physician Other Departments: - Oncology - Surgery - Neurology - Pediatrics - etc. Remote Clinics Electronic Medical Record DICOM: C-FIND with required matching and return keys C-MOVE Images and SR

May 5, Charge Posting DSS/ Order Filler Acquisition Modality PPS In Progress/ Completed Charge Processor Reporting Completed Report Manager Charge Posted ADT Account Management DICOM: required billing info in MPPS Film consumption Procedure Type Supplies and devices

May 5, Basic Security System A System B Secured System Secure network Strong authentication of remote node (digital certificates) network traffic encryption is not required Secured System Local access control (authentication of user) Audit trail with: Real-time access Time synchronization Central Audit Trail Repository DICOM: Basic TLS Secure Transport Connection Profile well-known port 2762

May 5, Post-Processing Workflow Post- Processing Manager Image Creator PP worklist Provided PP Workitem Claimed PP Workitem Completed PP PPS Started PP PPS Completed DICOM: General Purpose Worklist Images Evidence Documents: Mammography CAD SR Basic Text SR Enhanced SR Comprehensive SR

Acquisition Modality Image Manager Department Scheduler/ Post-Processing Manager Image Creator MPPS Complete Create Worklist Item Query/ Retrieve Images Post-Processing Task Claimed Post-Processing PPS Started Post-Processing Task Completed Creator Images Stored Post-Processing WL Provided Store Images Post-Processing PPS Completed 10. Post-Processing Workflow: use case

May 5, Goal of IHE IHE process Integration Profiles and the role of standards in IHE DICOM’s use in the IHE Integration Profiles Current topics Questions and answers

May 5, Reporting workflow Security Standard for Audit Records Extension to other clinical domains: Cardio, NM Desktop Integration Current topics

May 5, Integration: back-office and/or front-officemessages ClinicalInformationSystemClinicalInformationSystem Back-Office Integrated Clinical Viewing at the desktop at the desktop Front Office Efficiency ImproveClinicalDecisions

May 5, A Federated System of Context-Managed Applications CCOW approach

May 5, Integration: the EPR approach Electronic Patient Record Radiology PACS Cardiology PACS VL, US, NM PACS HIS RIS Other Clinical System Web Viewers Webserver Report Type: Findings: Conclusions: Ima g e R e f s. : : Header: Thorax ….. ….. ….. Mass ….. ….. Daim. Infiltr. ….. ….. (Poi n t e r ) URL / URI?

May 5, Questions? DICOM and IHE, Integrating the Healthcare Enterprise