IHE Cardiology Stress Wil Lapointe (IDX Systems) Barry Brown (Montara Instrument) John Gatewood Burdick Rich Fronek Burdick 2/10/2005 v0.1

IHE Cardiology Page 2 Stress Problem Statement Exercise stress testing studies are performed on equipment that regulates the treadmill elevation and speed, times the study, obtains electrocardiograms at discrete intervals, and reports out the performance of the patient on the treadmill at each stage of work. The exercise study is completed by a physician, or trained allied health individual, and then interpreted. Exercise stress testing is performed alone, or in conjunction with an imaging protocol such as a thallium nuclear cardiology study, or stress echocardiography. The management of the exam must take into account all potential modalities. This proposed IHE integration profile will be used to manage the ordering and performance of an exercise stress test, with or without imaging, and to disseminate the results.

IHE Cardiology Page 3 Stress Diagram

IHE Cardiology Page 4 Stress Workflow Diagram DSS/ Order Filler Stress Monitor Enterprise Report Repository Image Display  Procedure Scheduled (ORM)  Procedure Status (ORM)  Procedure Report (ORU) Query Modality Worklist [RAD-5]  Modality PS in Progress [CARD-1]  Modality PS Completed [RAD-7]  Pt. Registration [RAD-1] Patient Update [RAD-12] Placer Order Management [RAD-2] Filler Order Management [RAD-3] Procedure Updated Report Manager  Procedure Report (ORU) Report Repository Report Creator   [RAD-25]: Report Issuing  RAD-14: Query Images CARD-4, RAD- 16: Retrieve Images RAD-44: Query Evidence Documents RAD-45: Retrieve Evidence Documents    Report Reader [RAD-26]: Query Reports [RAD-27]: Retrieve Reports   [RAD-28]: Structured Report Export Image Manager/ Image Archive Need list of stress measurements and codes; may be draft or final Converted from procedure report to DICOM SR? or encapsulated PDF? or encapsulated HL7 v2? Dependent on format for revised RAD-25 Procedure Scheduled [RAD-4] Procedure Status (ORM – Report sent) 

IHE Cardiology Page 5 Actors Stress Monitor Patient Monitoring System – New for Year 2 Enterprise Report Repository Receives HL7 Structured Report Exports from Report Manager– New for Year 2 Report Reader Query/Rerieves from the Report Manager – New for Year 2 Report Creator Report Manager New for Year 2 ADT Patient Registration Same as in current Cardiology TF 1:2.3 Order Placer Same as in current Cardiology TF 1:2.3 Department System Scheduler/Order Filler Same as in current Cardiology TF 1:2.3 Acquisition Modality Same as in current Cardiology TF 1:2.3 Image Manager/Image Archive Same as in current Cardiology TF 1:2.3 Performed Procedure Step Manager Same as in current Cardiology TF 1:2.3 Image Display Same as in current Cardiology TF 1:2.3 Time Client Same as in current Cardiology TF 1:2.3 Display Same as in current Cardiology TF 1:2.3 Information Source Same as in current Cardiology TF 1:2.3 …

IHE Cardiology Page 6 New Transactions for Stress Procedure Scheduled [Rad-4], Same as in current Radiology TF 2:4.4 Control Codes NW,PA,CH,CA,DC HL7 interface to Stress Monitor for MWL and ORM Procedure Status ORU – Report Sent Report Issuing [Rad-25] Revised fRadiology TF 2:4.25 for Stress Procedure Reports Convert Procedure Reports to DICOM SR, Encapsulated PDF?, Encapsulated HL7? Query Reports [Rad-26] Dependant on format of revised Rad-25 Retrieve Reports [Rad-27] Dependant on format of revised Rad-25 Structured Report Export [Rad-28] Same as in current Radiology TF 2:4.28 ORU Event between Report Manager and Enterprise Report Repository Need list of Stress measurements and codes Query Evidence Document [Rad-44] Same as in current Radiology TF 2:4.44 Image Archive and Image Display Image Display queries the Image Archive Retrieve Evidence Document [Rad-45] Same as in current Radiology TF 2:4.45 Image Archive and Image Display DICOM Evidence Documents retrieved from Image Archive to Image Display

IHE Cardiology Page 7 Transactions (Imaging) Patient Registration [RAD-1] Same as in current Cardiology TF 1:2.4 Placer Order Management [RAD-2] Same as in current Cardiology TF 1:2.4 Filler Order Management [RAD-3] Same as in current Cardiology TF 1:2.4 Procedure Scheduled [RAD-4] Same as in current Cardiology TF 1:2.4 Query Modality Worklist [RAD-5] Same as in current Cardiology TF 1:2.4 Modality Procedure Step In Progress [CARD-1] Same as in current Cardiology TF 1:2.4 Modality Procedure Step Completed [RAD-7] Same as in current Cardiology TF 1:2.4 Modality Images/Evidence Stored [CARD-2] Same as in current Cardiology TF 1:2.4 …

IHE Cardiology Page 8 …Transactions Storage Commitment [CARD-3] Same as in current Cardiology TF 1:2.4 Patient Update [RAD-12] Same as in current Cardiology TF 1:2.4 Procedure Update [RAD-13] Same as in current Cardiology TF 1:2.4 Query Images [RAD-14] Same as in current Cardiology TF 1:2.4 Retrieve Images [CARD-4] Same as in current Cardiology TF 1:2.4 Maintain Time [ITI-1] Same as in current Cardiology TF 1:2.4 Retrieve Summary Info for Display [ITI-11] Same as in current Cardiology TF 1:2.4 Retrieve ECG List [CARD-5] Same as in current Cardiology TF 1:2.4 Retrieve ECG Document for Display [CARD-6] Same as in current Cardiology TF 1:2.4

IHE Cardiology Page 9 Stress Scenario The study is ordered by a physician, either inside the performing institution, or by referral from outside the institution. The study is scheduled for the patient, transportation is arranged if the patient is an inpatient, equipment is scheduled, radiopharmaceuticals are ordered for nuclear imaging, a room is reserved for the examination, and personnel are scheduled. The study is performed by a physician or trained professional (such as a nurse, physicians assistant, or trained exercise technician). If there is a nuclear imaging component to the study, administration of the radiopharmaceuticals must be documented, including technical parameters of the dose. The patient is subjected to increasing stages (levels) of exercise on the treadmill, and the equipment collects ECG waveforms, patient performance (symptoms, heart rate, blood pressure), and equipment settings (speed, elevation, duration). A typical exercise examination goes through progressive stages until a clinical end-point is reached, such as achieving a pre- determined heart rate or emergence of symptoms preventing the patient from continuing (arrhythmia, hypotension, angina, fatigue, etc.). A procedure may be complete, even though fewer than the full number of planned stages have been acquired. The exercise study is interpreted by a physician, and the results reported. If there is an imaging component to the study, it may be interpreted separately by a different physician; the IHE profile must address the combination of interpretations from multiple physicians. The results, including the supporting evidence (ECGs, images) must be distributed electronically to the referring physician, who may not be located within the performing institution. The IHE profile must also deal with common exceptions to the workflow. As an example, a patient is scheduled for a regular stress test (without imaging). He arrives at the laboratory and is identified as having an abnormal electrocardiogram precluding the use of the electrocardiogram for the interpretation of the test, and rendering a regular stress of no diagnostic value. The performing laboratory recognizes the need to perform an imaging stress test on the patient. The profile must account for a new replacement order for the revised examination, obtaining advanced beneficiary notice (approval from the payer) to proceed with the examination, rescheduling the test including the imaging modality resources, potentially ordering the radiopharmaceutical, and generally reconciling the change in test type across the devices and systems. (Cont…)

IHE Cardiology Page 10 Stress Scenario (Cont) An additional use case is exemplified by the use of a pharmacologic agent for stress. In this case a patient is brought to the laboratory for perfusion testing using a pharmacologic product like adenosine or dipyridamole. The patient is infused the agent while the heart rate and blood pressure are monitored and recorded, and the ECG is monitored. The study is accompanied by an imaging modality, and reported in a similar fashion that exercise testing is reported. The stress test can use many techniques for inducing cardiac stress, each noted in the table below, and may or may not use an additional imaging modality

IHE Cardiology Page 11 In Scope / Out of Scope <Brief scoping statement describing the integration problem boundary. Ideally you want the reader to be able to read this and be capable of judging what is in or out of scope. FeatureIn/Out Note: list functionality especially at borders of what is included/excluded – i.e., included features that could reasonably be descoped by the Technical Committee, or excluded fetures that could be included

IHE Cardiology Page 12 Phased Approach Should we implement a phased approach?

IHE Cardiology Page 13 Open Issues 1. Should all stress phases/stages be handled by the Stress Monitor in a single scheduled procedure step. No phase status will be reported back to imaging. 2. Is consistent timing required between stress modalities and imaging.