Cardiology Workflow & Display Requirments IHE Vendors Workshop 2006 IHE Cardiology Education Bob Baumgartner, BSN, MBA McKesson Corporation IHE-Cardiology Planning Committee Administrative Co-Chair

Agenda Cardiology Workflows General Content Display Requirements Cath Workflow Echo Workflow Stress Workflow Content Display Requirements Stress Echo Stress Nuclear Cardiology

Cardiology Workflows Cardiology: heart its action and diseases the study of the heart its action and diseases

Workflow is the linchpin to data integrity The Problem This is an example of a cardiology workflow. Any questions! Workflow is the linchpin to data integrity

General Workflow

Agenda Cardiology Workflows General Cath Workflow Echo Workflow Stress Workflow Content Display Requirements Stress Echo Stress Nuclear Cardiology

Cath Lab 7 6 5 8 9 10 11 4 3 2 1 Multiple re-entry of Patient ID Error prone Results fragmented across systems Results inconsistently time-tagged Custom solutions needed for data sharing Difficult to manage Uncoordinated with Hospital Information System Unidentified patients (emergency) Un-ordered cath exams Diagnostic and interventional procedures Ad hoc scheduling of cath labs Change of rooms during procedure 6 7 5 8 9 10 11 4 3 2 1 Anybody recognize this? Unfortunately it’s frighteningly familiar ! It is a typical cath lab control room. I count at least 7 monitors (there are some more in the lab room). Almost every one is a different system. On each one you need to enter the patient name and ID – the same each time (yeah, right …)

Administrative Process Flow ADT Order Placer Image Manager Acquisition Modality Placer Order Mgmt - New [Rad-2] Department System Scheduler/ Order Filler Procedure Scheduled [Rad-4] Register/ Admit Patient Create Order Schedule Registration [Rad-1] Select Query Modality Worklist [Rad-5] Start

Procedure Performance Process Flow Order Department System Image Acquisition Acquisition Placer Scheduler/ Order Manager/ Modality Modality n Filler Image Archive Modality Procedure Modality Procedure Step In Progress [Card-1] Step In Progress [Card-1] Update Schedule Query Modality Worklist [Rad-5] Modality Procedure Modality Procedure Step In Progress [Card-1] Step In Progress [Card-1] Modality Images/ Perform Evidence Stored [Card-2] Acquisition Perform Modality Images/Evidence Stored [Card-2] Acquisition Modality Procedure Step Completed [Rad-7] Modality Procedure Step Completed [Rad-7] Order Status Storage Update [Rad-3] Commitment [Card-3]

Use Cases ALL Use Cases Must be Supported Case C1: Patient Registered at ADT and Procedure Ordered at the Order Placer Case C2: Patient Registered at ADT and Procedure Ordered at DSS/OF Case C3: Patient Registered at ADT and Procedure Not Ordered Case C4: Patient Registered at DSS/OF and Procedure Ordered Case C5: Patient Not Registered Case C6: Patient Updated During Procedure Case C7: Change Rooms During Procedure Case C8: Cancel Procedure Case C9: Post-Procedure Evidence Creation Case C10: EP Ablation / Implantation Lab ALL Use Cases Must be Supported Exception of C10 only required for EP Lab

Case C1: Patient Registered at ADT and Procedure Ordered at the Order Placer Clinical Context Corresponds to traditional Radiology workflow Order placed in central system Also deals with case where emergency identifier has been created Common identifiers known ahead of time IHE Context MPPS in Progress from first modality used to update worklists for others

Case C2: Patient Registered at ADT and Procedure Ordered at DSS/OF Clinical Context Slight difference to Case 1 Order placed NOT in central system but in department Department system provides info to Central ordering system Typical of many institutes, relieves need for HIS terminal in lab IHE Context Filler Order Management (New Order) transaction [RAD-3] is sent from Department System Scheduler/Order Filler to the Order Placer.

Case C3: Patient Registered at ADT and Procedure Not Ordered Clinical Context Slight difference to Case 2 Procedural information is NOT entered at the departmental system The first modality must initiate the process of creating common procedure identifiers (usually hemo) The common procedure identifiers are created by the departmental system based on the information available from the first modality Can generate a “generic cath procedure” if no coded procedural type is available IHE Context Upon receiving the first MPPS the DSS/OF will auto generate a Requested Procedure and its associated Scheduled Procedure Steps utilizing the Study UID provided in the first MPPS. All other modalities use the Query Modality Worklist transaction.

Case C4: Patient Registered at DSS/OF and Procedure Ordered Clinical Context This case accommodates the emergency case where there is not enough time to register the patient on ADT system A temporary patient identifier is created at the department level The order placer is notified only after the patient is registered and manually reconciled on the department system IHE Context The DSS/OF assigns a temporary Patient ID with a temporary name and schedules the required procedures The DSS/OF does not send the Filler Order Management (New Order) transaction to the Order Placer until the patient is registered on the ADT system and reconciliation occurs on the DSS/OF.

Case C5: Patient Not Registered Clinical Context This is the Emergent Case where the patient information is not known or there is not enough time to enter the information A temporary ID is assigned by the department and entered at the first modality and forwards that information to the departmental system to be shared with the other modalities Like in C4 information is sent to the Order Placer post patient registration and reconciliation on the departmental system IHE Context Patient ID and name are selected based upon locally (usually department) base rules The first modality will send an MPPS with the appropriate information to the DSS/OF which will in turn generate the appropriate requested procedure(s) using the Study UID assigned by the first modality

Case C6: Patient Updated During Procedure Clinical Context An unidentified patient may have been registered at the ADT and brought into the cath lab with the temporary ID During the procedure the patient information is updated on the ADT which sends the patient update information This can results is some of the information been associated with the temp ID and the rest with the permanent ID The case defines how the reconciliation occurs. IHE Context The modality may have requested information from the DSS/OF prior the patient update The Image Manager needs to update the items stored to Image Archive as well as any subsequent items received.

Case C7: Change Rooms During Procedure Clinical Context This is the case when the patient is moved due to any of the following reasons: The change from a diagnostic to interventional procedure The need to use the current room for another patient Equipment failure NOTE: This case does not cover the scenario where a patient is moved to the holding area from a procedure room. IHE Context Each modality will issue a MPS (Completed or Discontinued) The DSS/OF will reassign the requested procedure to the new room In the event the DSS/OF does not reassign, each modality in the new room would use the broad Modality Worklist Query This insures consistency of the Study UID for all information

Case 7: Change Rooms During Procedure Department System Image Scheduler/ Manager Acquisition Acquisition Acquisition Acquisition Order Filler Modality Room 1 Modality n Room 1 Modality Room 2 Modality n Room 2 Query Modality Worklist [Rad-5] Modality Procedure Modality Procedure Perform Step In Progress [Card-1] Step In Progress [Card-1] Acquisition Update Schedule Query Modality Worklist [Rad-5] Modality Procedure Modality Procedure Step In Progress [Card-1] Step In Progress [Card-1] Perform Acquisition Modality Procedure Modality Procedure Step Discontinued [Rad-7] Step Discontinued [Rad-7] Reassign Procedure Each modality in Room 1 issues an MPPS Discontinued The Cath DSS/OF has an optional function to reassign the Cath Procedure to a new room, which will create SPSs for the new room modalities. If this option is not used, the DSS/OF will create SPSs for the new room modalities when it receives the MPPS In Progress (N-CREATE) from a modality in the new room. Query Modality Worklist [Rad-5] Modality Procedure Modality Procedure Perform Step In Progress [Card-1] Step In Progress [Card-1] Acquisition Update Schedule Query Modality Worklist [Rad-5] Modality Procedure Modality Procedure Step In Progress [Card-1] Step In Progress [Card-1] Perform Acquisition

Case C8: Cancel Procedure Clinical Context This case allows for the information systems to keep track of cancelled procedures allowing the cath lab staff to appropriately respond to queries regarding that patient. IHE Context When the procedure is cancelled within the department the DSS/OF notifies the Order Placer system and Image Manager The length of time this procedural information is maintained is determined by local policy.

Case C9: Post-Procedure Evidence Creation Clinical Context Allows for imaging and other procedural data to be analyzed post-procedure using specialized software (e.g., QCA, QLV, derived images) This case does NOT apply to core lab analysis for clinical trials or outcome analysis IHE Context This analysis must be performed on a station that groups the Image Display and Evidence Creator Actors The Evidence Creator notifies the IM/IA and DSS/OF of the activity via the MPPS In Progress and Complete transactions The Evidence Creator stores its evidence to the IM/IA via the Storage Commit Transaction.

Case C10: EP Ablation / Implantation Lab Clinical Context Allows for the wide array of specialized equipment used in the EP lab Provides demographic and time synchronization IHE Context Initial implementation is an extension of the CATH profile Support for use cases C1 – C9 Emergency use cases C3 and C5 are highly unusual in the EP lab. New CP

Agenda Cardiology Workflows General Echo Workflow Cath Workflow Echo Workflow Stress Workflow Content Display Requirements Stress Echo Stress Nuclear Cardiology

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

Case E1: Patient Registered at ADT and Procedure Ordered Clinical Context Corresponds to traditional Radiology workflow Order placed in central system Also deals with case where emergency identifier has been created Common identifiers known ahead of time IHE Context The Scheduled Procedure Steps are obtained by the modality through Query Modality Worklist, the acquisition is performed and statused thought Modality Performed Procedure Step.

Case E2: Intermittently Connected Modality Clinical Context Allows for the mobile workflow typical of TTE and TEE Assumes the modality is only intermittently connected to the network Also covers the case of the modality being turned off IHE Context Process flow identical to Case E1 Must be paired with an Image Manager/Image Archive that also supports Intermittent Connectivity MPPS are stored and sent when connection established Image Manage must queue N-Event Report messages for storage commitment

Case E3: ICM with Ad Hoc Procedure, Patient Registered, Scheduled Procedure Clinical Context This extends Case E2 to allow for a scheduled procedure but the modality can’t query the worklist since it is not connected to the network IHE Context The modality will treat this as unscheduled procedure The patient ID and demographics must be manually entered The modality must create the Study Instance UID Manual matching process at DSS/OF to reconcile the scheduled and performed procedure information Post match the DSS/OF will reconcile with the Image Manager to correct for the Study Instance UID

Case E4: ICM with Ad Hoc Procedure, Patient Registered, Unscheduled Procedure Clinical Context This is the drive by echo or Stat echo performed without an order placed in the system IHE Context This case is identical to other unscheduled procedure cases Modality creates the Study Instance UID When connected the modality will send a MPPS in Progress DSS/OF will generate an exception for reconciliation Patient demographic reconciliation should occur automatically based on patient ID The Image Manager will use the Patient Update transaction to update the demographics

Case E5: ICM with Ad Hoc Procedure, Patient Unregistered, Unscheduled Procedure Clinical Context This case is similar to Case E4 except the patient is not yet registered. (Emergency Admit) IHE Context Temporary Name and ID entered into the modality DSS/OF will generate an exception Manual match of the temporary ID with the Patient Registration information Patient Update sent to the Image Manager

Case E6: Stress Echo Staged Protocol Clinical Context Allows for appropriate identification of Stages and Views during a stress echo IHE Context Similar to Case E1 Type of stress protocol is specified in the Scheduled Protocol Code Sequence or Scheduled Step Description Within the “perform acquisition” activity there are several stages but typically considered the same procedure step A status of “Discontinued” can indicate technical failure to reach the end point of the exam.

Case E7: Echo Measurements Evidence Creation Clinical Context Measurements are normally obtained during the acquisition on the modality. This case supports the ability to obtain additional measurements on the clinical workstation post acquisition and update the study data. IHE Context This case is similar to Cath C9 The actor participates in both the ECHO and ED profiles Generation of a DICOM SR with reference to original

Now that I got your attention again! Amazing Facts Your heart beats about 70 beats per min 4200 beats per hour 100,800 beats per day 35 million times in a year. Or more than 2.5 billion beats in your life time. AND IT ONLY TAKES ONE IRREGULAR BEAT TO KILL YOU Now that I got your attention again!

Agenda Cardiology Workflows General Stress Workflow Cath Workflow Echo Workflow Stress Workflow Content Display Requirements Stress Echo Stress Nuclear Cardiology

So what is Stress Testing? Uses exercise or medication to increase the work of the heart. Continuous 12 lead ECG monitoring during study Looking for changes in ST segments Used as a screening tool Or to test effectiveness of therapy Done in Non-Invasive Lab, and Cardiologist Office

Stress Image Intensive…multiple samples of 12 lead ECG during the protocol Summary report usually one page in length Physician will do comparisons to previous studies

Stress Options Stress Echo Nuclear Stress Began in the early – mid 1990’s Observation of wall motion and ejection fractions with the heart under stress High specificity for correlating ischemia to functional abnormalities Can be done with exercise but mainly chemical Nuclear Stress Most often combined with exercise or chemical stress testing Use of radioisotope to detect presence and resolution of ischemic regions of the heart Scan immediately post Scan 4 hours to 1 day later Resolution of ischemic area determines viability of muscle

Stress Workflow Diagram Requires that Image Manager / Image Archive and Image Display support images, waveforms and structured reports If a Report Creator wishes to participate in this profile, it does not have to support any transactions directly, however it is required to be grouped either with an Acquisition Modality, or with an Image Display in order to be able to Query/Retrieve the images, waveforms, and evidence documents. The Report Creator is expected to be able to transfer some contents of the created or retrieved objects into the reports it creates, and to send those reports in accordance with another Profile.

Stress Workflow – Actors and Options Option Name Optionality Vol & Section Acquisition Modality Patient Based Worklist Query O RAD-TF 2: 4.5 Broad Worklist Query R (see note 1) PPS Exception Management RAD-TF 2: 4.7 Stress ECG R (see note 2) CARD-TF 2: 4.2 Stress Echo Nuclear Medicine (see note 3) RAD-TF 2: 4.8 Image Manager/ Image Archive Intermittently Connected Modality R CARD-TF 2: 4.3 Echocardiography Availability of PPS-Referenced Instances RAD-TF 3: 4.49 Image Display CARD-TF 2: 4.4 Cardiac NM (see notes 3, 4) RAD-TF 2: 4.16 Note 1: The Broad Worklist Query option facilitates effective workflow in the multimodality environment. Note 2: An Acquisition Modality shall support one of the options Stress ECG, Stress Echo, or Nuclear Medicine. Note 3: Nuclear Medicine (NM) is not formally an option, but is rather a separate IHE Profile. The Image Manager/Image Archive and the Image Display must support the NM Profile. Note 4: The Image Display shall support the Cardiac NM Option of the NM Profile.

Use Cases Case S1: Cardiac Stress Test, ECG Only Limited use with lower sensitivities and specificities Screening tool only Case S2: Cardiac Stress Test with Imaging More common use case Echocardiography – requires Consistent Time to combine clinical data from Stress Monitor and Echo Modality

Agenda Cardiology Workflows General Content Display Requirements Cath Workflow Echo Workflow Stress Workflow Content Display Requirements Stress Echo Stress Nuclear Cardiology

Stage and Views Views Stress Echo Option Stage Number & View Number Apical two chamber Apical four chamber Apical long axis Parasternal long axis Parasternal short axis Parasternal short axis at the aortic valve level Parasternal short axis at the level of the mitral chords Parasternal short axis at the Mitral Valve level Parasternal short axis at the Papillary Muscle level Right Ventricular Inflow Tract View Right Ventricular Outflow Tract View Subcostal long axis Subcostal short axis Suprasternal long axis Suprasternal short axis Stress Echo Option Stage Number & View Number Stage Code Sequence & View Code Sequence Coding Scheme Designator (0008,0102) Code Value (0008,0100) Code Meaning (0008,0104) SRT P5-01201 Image acquisition at baseline P5-01202 Pre-stress image acquisition P5-01203 Mid-stress image acquisition P5-01204 Peak-stress image acquisition P5-01205 Image acquisition during recovery Modality actors supporting the STRESS ECHO option are required to support a number of attributes in Multi-frame Ultrasound Images created for a stress echo procedure. These are transferred with the images so an image viewer that also supports the echo option can view them “unambiguously.” A Stage is a phase in the stress echo exam protocol. A View is a particular combination of the transducer position and orientation at the time of image acquisition. An additional option mechanism is defined in the DICOM Standard, but not required in IHE: Names: Stage Name (0008,2120) and View Name (0008,2127) specify non-standardized textual names for Stages and Views. While View Name (0008,2127) and Stage Name (0008,2120) enable correlating and labeling the images for display, their value sets are undefined. Therefore, IHE requires the use of coded identifiers to unambiguously describe the stage and view in the Stage Code Sequence and View Code Sequence.

Benefit: Stress Echo Viewing Consistency Image Display actors supporting the STRESS ECHO option shall be able to negotiate and accept the JPEG Baseline (Process 1): Default Transfer Syntax for Lossy JPEG 8 Bit Image Compression for Ultrasound Multi-frame images, and shall support the YBR_FULL_422 photometric interpretation. The Image Display actor may organize and present multiple images based on Stage and View for clinical comparison. Stage Number (0008,2122), View Number (0008,2128), Stage Code Sequence (0040,000A), and View Code Sequence (0008,2240) are mandated for the stress echo Modality (see section 4.2.3), and may be used by the Image Display Actor to determine the Stage and View of each image unambiguously.

Agenda Cardiology Workflows General Content Display Requirements Cath Workflow Echo Workflow Stress Workflow Content Display Requirements Stress Echo Stress Nuclear Cardiology

Stress: Protocol and Stage Procedure Protocol Stages

Stress: Protocol and Stage Procedure : Exercise Stress Protocol: Bruce Stages: Standard Bruce has 7 stages Stage 1: 1.7 mph @ 10 % grade Stage 7: 6.0 mph @ 22 % grade Important Note: A procedure can be considered complete irrespective of the protocol being complete!

Attribute Summary Concept Modality Worklist Echo ECG NM Requested Procedure Requested Procedure Code Sequence (0032,1064) Procedure Code Sequence (0008,1032) Protocol Scheduled Protocol Code Sequence (0040,0008) Performed Protocol Code Sequence (0040,0260) CID 12001* CID 3261 CID 3261** Protocol Stage Number Acquisition Context Sequence (0040,0555) >(109055, DCM, “Protocol Stage”) Patient State Stage Number (0008,2122) Stage Code Sequence (0040,000A) CID 12002* Acquisition Context Sequence (0040,0555) >(109054, DCM, “Patient State”) CID 3262 Acquisition Context Sequence (0040,0555) >(109054, DCM, “Patient State”) CID 3101

Agenda Cardiology Workflows General Content Display Requirements Cath Workflow Echo Workflow Stress Workflow Content Display Requirements Stress Echo Stress Nuclear Cardiology

Nuclear Cardiology Image formats Color maps Stress and Rest raw data review Stress and Rest processed data Gated SPECT data Quantitative data Screen captures, “snap shots” Color maps Gray scale is default Color overlays can be applied

Raw Data Images

Perfusion Display Standard perfusion display Stress/Rest Short axis Horizontal long axis Vertical long axis

Perfusion Display - Color Standard perfusion display Stress/Rest Short axis Horizontal long axis Vertical long axis Color map can be overlaid on the image

Gated SPECT Display Apical, mid and basal short axis slices Mid-ventricle vertical and horizontal long axis slices

Gated SPECT Display The whole screen can be gated as an option

Quantitative Display Output from 3rd party quantitative perfusion software can be displayed

Quantitative Display Output from 3rd party quantitative gated software can be displayed

Screen Captures Screen captures can be displayed to show important images