1. IHE Cardiology Image Enabled Office
Harry Solomon

2. Image Enabled Office Problem Statement
An increasing number of clinicians have both imaging equipment and electronic medical records in their offices. The prevalence of imaging equipment is increasing as lower cost systems are being brought to market, and the universal deployment of EMRs is an explicit goal of the U.S. government.
Note: The draft U.S. “meaningful use criteria” for 2015 would require EMRs to handle medical imaging objects, although the extent and nature of such support is undetermined.
This equipment needs to be integrated into the office environment workflow, and the imaging results need to be seamlessly integrated into the EMR.
Note that the systems in an office environment must in may ways be more technically sophisticated than in an in-patient environment, as they must operate with less IT-savvy human supervision, and combine features that would otherwise be distributed across multiple systems.
IHE Cardiology

3. Profile Scope
The Image-Enabled Office (IEO) Profile specifies the integration of an imaging suite (modalities, storage server, and workstations) with an electronic health record system in an ambulatory office setting. This is a fully bi-directional integration, including ordering/scheduling of an imaging exam, status reporting for that exam, report creation, and web-based imaging exam review integration. It also addresses import of referral image exams from exchange media into the integrated office environment. Out of Scope: Exchange with other entities (supported by XDS and XDS-I functionality), except for image import from media
IHE Cardiology

4. Use Case 1
Andy Carditis, a patient, is referred to Belle Plummer, a cardiologist, for consultation regarding a fever and associated heart murmur (potential infective endocarditis). Dr. Plummer orders blood labs and an echo study, which the patient elects to have performed in Dr. Plummer’s cardiology office. The patient and the cardiology office manager schedule the echo for later that day. At the scheduled time, Sue Skann, the sonographer in the office, preps Mr. Carditis. She uses the ultrasound machine to query for the scheduled exams, and selects Mr. Carditis from the list. She performs the echo study, and makes preliminary measurements on the ultrasound machine. The images and measurements are sent to a local mini-PACS image server. On an imaging workstation, Dr. Plummer reviews the images and measurements, and notes the vegetation on the mitral valve. She selects a representative image, and saves a reference to it in a note that is stored on the mini-PACS. She defers creating a report until the lab results will have been returned. The next morning, the lab results are returned electronically and recorded in the office EMR. On the EMR workstation, Dr. Plummer reviews both the lab results and the echo measurements, and creates a report with findings, selected measurements, and the representative image selected the previous day. She orders a two week regimen of intravenous antibiotics, which will be administered by her nurse practitioner. The report is stored in the EMR, and is also sent to the referring primary care physician.
IHE Cardiology

5. Approach Reuse capabilities from existing IHE Profiles:
Radiology Scheduled Workflow
Radiology Import Reconciliation Workflow
Radiology/Cardiology Evidence Documents
Cardiology Displayable Reports
IT Infrastructure Patient Demographics Query
IT Infrastructure Consistent Time
IHE Cardiology

6. In-patient Scheduled Workflow Diagram
ADT
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]
DSS/ Order Filler
Order Placer
Modality PS in Progress [CARD-1]
Procedure Scheduled [RAD-4]
Modality PS Completed [RAD-7]
Patient Update [RAD-12]
Procedure Updated [RAD-13]
Evidence Creator
Image Display
Modality Image/Evidence Stored [CARD-2]
Performed
Query Images [RAD-14]
Procedure
Retrieve Images [CARD-4]
Step Manager
Image
Manager
Image
Archive
Modality PS in Progress [CARD-1]
Modality PS Completed [RAD-7]
Storage
Modality Image/Evidence Stored [CARD-2]
Commitment
[CARD-3]
Modality PS in Progress [CARD-1]
Modality PS Completed [RAD-7]
Acquisition
Modality
Query Modality Worklist [RAD-5]
IHE Cardiology

7. IEO Functional Features
Equivalent to in-patient “top half” systems should be a single actor incorporating both practice management and EMR
Image Manager/Archive should be an actor separate from PM/EMR
Modality, Image Display, and Evidence Creator actors should operate with no changes from Scheduled Workflow / ED
Modality worklist, MPPS, image/evidence storage
Reports should be creatable on either an imaging workstation, or at an EMR workstation
Report Creator actor should operate with no changes from Displayable Reports
Destination of Encapsulated Report is EHRS
Image Manager/Archive shall support a web-based viewer interface
Usable from EMR workstation
Upon MPPS complete (Storage Commitment?), the IM/IA shall send a link to the web viewer for the study to the EHRS
IHE Cardiology

8. System Actors (top level)
EHR-S
Encapsulated Report Submission [CARD-7]
Notify Study Access [CARD-y]
Access DICOM Study for Display [CARD-z]
Procedure Scheduled [RAD-4]
Patient Update [RAD-12]
Procedure Updated [RAD-13]
Encapsulated Report Storage [CARD-9]
Image Manager / Image Archive
Image Display
Patient Demographics Query [ITI-21]
Query Images/Evidence […]
Retrieve Images/Evidence […]
Query Modality Worklist [RAD-5]
Procedure Step in Progress […]
Procedure Step Completed […]
Acquisition Modality
Image /Evidence Stored […]
Storage Commitment [RAD-10]
Importer

9. IEO Issues
Should EHRS DICOM interface be broken out to a separate actor (as not typically included in EHRS)?
No – it is responsibility of EHRS vendor to integrate with an interface engine if needed.
Existing IHE transactions specified with a variety of end point actor definitions
Modality Worklist transaction to Department System Scheduler / Order Filler actor; Patient Demographics Query transaction to Patient Demographics Consumer actor
Need to group these formal actor definitions with our desired actors
Transcoding of DICOM Structured Report measurements into CDA observations is non-trivial
No transcoding functional requirements included in Profile – left to implementation
IHE Cardiology

10. Refined Actor / Transaction Diagram
EHR-S
Encapsulated Report Submission [CARD-7]
Report Manager
Notify Study Access [CARD-y]
Display
Access DICOM Study for Display [CARD-z]
Patient Demographics Supplier
Procedure Scheduled [RAD-4]
Patient Update [RAD-12]
DSS / OF
Procedure Updated [RAD-13]
Report Creator
Encapsulated Report Storage [CARD-9]
Encapsulated Report Query [CARD-10]
Encapsulated Report Retrieve [CARD-11]
Report Repository
Report Display
Performed Procedure Step Manager
Image Manager / Image Archive
Image Display
Patient Demographics Query [ITI-21]
Query Images/Evidence […]
Retrieve Images/Evidence […]
Query Modality Worklist [RAD-5]
Procedure Step in Progress […]
Procedure Step Completed […]
Evidence Creator
Acquisition Modality
Image /Evidence Stored […]
Storage Commitment [RAD-10]
Patient Demographics Consumer
Importer
Patient Demographics Consumer
Portable Media Importer

11. Dynamic Model – Process Flow 1
IHE Cardiology

12. Dynamic Model – Process Flow 2
IHE Cardiology

13. New Transactions Notify Study Access Access DICOM Study for Display
HL7 ORU^R01
Trigger Event – availability of study images at Image Manager
OBX segment with Study Unique ID
Alternate under consideration – ORI^O24
Access DICOM Study for Display
Web service over HTTP
Uses Study UID from Notify Study Access transaction
Returns top level web page for navigation / viewing study in standard web browser
IHE Cardiology

14. Notify Study Access - OBX
SEQ
LEN DT
Usage
Card.
TBL#
ITEM#
ELEMENT NAME 1 4 SI R
00569
Set ID – OBX 2 3 ID
0125
00570
Value Type = HD
705
CWE
00571
Observation Identifier 5 70 HD
00573
Observation Value 11
0085
00579
Observation Result Status = R 14 24
DTM R2
00582
Date/Time of the Observation
OBX-2 Value Type : “HD” (Hierarchical Designator)
OBX-3 Observation Identifier : “113014^DICOM Study^DCM”
OBX-5 Observation Value : DICOM Study Instance UID as an ISO OID
OBX-11 Observation Result Status : “R” (Results entered -- not verified)
OBX-14 Date/Time of the Observation : date and time of the most recent update made to the study content (e.g., most recent addition, deletion or modification of images or objects within the study).
IHE Cardiology

15. Access DICOM Study for Display
Follows model of IHE ITI Retrieve Info for Display web services
Display actor (in EHRS) must be configured with web access port of Image Manager (<location>)
Alternatively (not part of IEO profile), EHRS can be configured with (thick) client app from Image Manager vendor, and invoke it with the Study UID
IHE Cardiology