1. Review and Update 2011 Image Sharing David S. Mendelson, M.D. Professor of Radiology Chief of Clinical Informatics The Mount Sinai Medical Center Co-chair IHE International Board

2. How are images and reports currently shared? What are some of the emerging solutions to sharing images? How might PHRs integrate sharing images –Review the NIBIB/RSNA Image Sharing Pilot Learning Objectives

3. Benefit of historical exam during interpretation Rapidly growing cost of healthcare especially growing utilization of imaging –Overutilization –Prevent duplicate exam because a recent exam is inaccessible Radiation exposure Quality –Expedites clinical care through easy availability of imaging examination Image sharing- Why?

4. What is our product? Who are our customers? What are the mechanisms of sharing? What are the impediments? –Technology –Policy Issues that govern sharing Imaging Exams

5. What is our product? Who are our customers? What are the mechanisms of sharing? What are the impediments? –Technology –Policy Issues that govern sharing Imaging Exams

6. Imaging Exam –Order –Direct patient history –Prior exams Report –Demographics Referring Clinician Reporting Team –Indication –Narrative Procedure –Impression –Structured report Our Product – Information!

7. What is our product? Who are our customers? What are the mechanisms of sharing? What are the impediments? –Technology –Policy Issues that govern sharing Imaging Exams

8. Patient Radiology Physician 2 nd Radiology Consulting Physician Clinical Trial Patient

9. Primary Clinician –Often has existing access –Not always Consulting Physician Ambulatory Imaging Center – Hospital –Either direction Second Hospital or enterprise Patient or relative Research –De-identified Who?

10. What is our product? Who are our customers? What are the mechanisms of sharing? What are the impediments? –Technology –Policy Issues that govern sharing Imaging Exams

11. Are you old enough to remember film? Still exists –Clinical offices Film

13. Today – generally regarded as the least desirable media –Expensive Medium –Limited latitude –Expensive to handle Sharing –Copying expensive, time consuming, bulky –Accessibility –Import - scanning Film

14. Portable Compact Can hold thousands of images Inexpensive ($0.50 or less) What’s wrong here? The “CD”- “better than sliced bread” or “be careful what you ask for – you may get it”

16. Different data formats –Non-Dicom Different viewers –End-user confusion Defective Discs Disc must be in your possession Patient Identity Wrong Patient on Disc Time consuming Clinician’s are confused –They share their confusion with their Radiologist CDs- Problems

17. Mayo Clinic –Unreadable Disc – 0.6% –Wrong- 0.2% Mount Sinai- estimates –5% cannot be imported –Rare wrong patient Difficult Discs-Wrong Patient/Information

18. Patient has a MRN at importing institution Patient does not have a MRN at importing institution MRN is in the DICOM header Patient Identity

19. Help!

20. Identify the patient locally Confirm the images belong to the patient Determine the name the imported exam Convert into DICOM format –Scan film –Read disc ? Dicom –Read from buffer Import and perform reconciliation –Into PACS? –Into RIS? –Into a parallel system? EMR –Is it for interpretation? –Is it to be billed? Importing an Exam- the process

21. Establish a standard viewing environment for clinicians for outside exams. Allow them to designate exams for import from this environment Import into local PACS Importing an Exam – a variant

22. Accuracy of the foreign information Compatibility Legal? –Responsibility ??? Changes to the exam or report after import –How does one become aware? Issues for exam import

23. Importing a disc provides the opportunity to correct Robust import solutions -commercial –Standard import interface Reconciliation process –Trained personnel Standards –DICOM –PDI extensions (IHE- Portable Documents for Imaging) –BIR- (IHE- Basic Image Review) Minimum requirement for review CD- Opportunities to improve

24. Mail RIS FAX E-Mail PACS –VPN Internet –EMR-Patient Portal –PHR Mechanisms of Sharing- Reports

25. When to release a Report vs. Image? The patient is entitled –Legal –Practical –Is the patient prepared for the information in the report? Immediate use to clinician May be meaningless to most patients other than a curiosity

26. Replace the CD (SneakerNet) with the Internet Convenience vs. Security New opportunities –Shared Image processing Efficiencies Network/Internet base sharing

27. Proprietary applications –Usually used within an enterprise or a limited domain with legal agreements Health Information Exchange (HIE) –Multiple enterprises with a set of legal agreements –Often have selected their own standards- not truly open standards based –Sustainability Network/Internet base sharing

28. Security/Privacy-Confidentiality HIPAA Security/ Privacy-Confidentiality HIPAA This is the networked version of the CD –More convenient –Same issues need to be addressed Network/Internet

29. VPN/Enterprise Portal –Clinical Staff –Patient –Temporary credentials Enterprise- multi-sites; proprietary solution –Multiple PACS and RIS feed one central archive –All credentialed can view that archive Point to Point networks HIE –Standards based or proprietary sharing network IHE model Patient Centric model / PHR Network/Internet

30. Who pays for an exchange infrastructure What is the persistence of the information in the exchange Are images different from other forms of healthcare data Easy secure access is good for the patient –Does it endanger the provider?- is this an impediment? –Economic adjustments and evolution are likely to occur Balance of cost control vs. Quality Reduction in Radiation exposure –Not all patients agree Challenges to exchange

31. Point to Point E-mail Cloud Computing HIE (Health Information Exchange) These are not mutually exclusive- there is overlap Methods

32. A limited number of entities establish direct connections Usually requires a direct formal relationship (legal) Can be successful to address very specific interoperability problems Doesn’t scale Point to Point

33. Requires legal relationships between participants Requires patient identity management Enables a greater number of entities to participate –May be scalable –HIE to HIE Consent issues –Commonly all or nothing rather than episode or event based –Patients may wish to only expose limited pieces of data HIE

34. Sharing Healthcare Information in the Cloud Hospital Imaging Center Primary Doctor Specialist Hospital Patient Patient Surrogate

35. Cloud Computing WHO Enterprise HIE Consumer WHAT Services Transactions Archive

36. XDS.a XDS- I.a XDS.b –?? XDS-I.b a vs. b –Related to web standards and transactions IHE-XDS (Cross-Enterprise Document Sharing)

37. XDS

38. XDS-I

39. Canada Health Infoway

40. NIBIB/RSNA IMAGE SHARING PROJECT A Standards Based Solution

42. NIBIB contract Bootstrap an IHE based network –Primary emphasis is Consumer Control through PHRs –Can be extended to other forms of sharing HIE Security and Confidentiality are drivers Replacement / Alternative to CD Goals of Contract

44. NIBIB contract summary Consumer Control Employ IHE solutions whenever possible –IHE generally has not focused on consumer driven solutions but rather on institutional and enterprise workflow 5 Academic Institutions –Mayo Clinic –Mount Sinai Medical Center –University of California San Francisco –University of Chicago –University of Maryland Establish a clearinghouse Engage PHRs 300,000 patients over 2 years

45. Edge Server –Register a patient –Listens to a Radiology Information System (RIS)- looking for a complete exam –Retrieves Image set from PACS and Report from RIS –Send both to clearinghouse PHI hidden; an RSNA ID and 2 nd factor security token are used to identify the patient Clearinghouse (XDS-I) – functions as a secure router –Transiently hold encrypted patient data PHR –Consumer controls upload and future access Must have RSNA ID available and know answer to 2 nd factor question –Develop web based viewers –Download full DICOM data set Misc Consumers Image Sharing/Elements of Solution

46. Software architecture Prepare contentPoll database, get report, get exam,prepare big fat file Background java srvlet25 days Transfer contentPoll database for transfer out, package content into xds.b Background java srvlet35 days HL7 receiverReceive HL7 A04 messages, extract reports and store them in database Mirth HL7 Channel. Let Mirth create its default database, all script work-but may have to customize per site 65 days for 5 sites Token AppCreate new tokens based on two parts, associate token with accession numbers, update database, user interface with login, get patient info,create job Ajax based web front-end,JavaServlet for CFIND using dcm4che, creating job in the RSNA database, creating tokens using kerberos – tokens generated locally 30 days DatabaseStore reports, logs, audit trails, user accounts, etc. Mirth instance for HL7 & DICOM, RSNA instance for everything else 50 days – 2 databases Management AppCreate users, monitor logs, check health Ajax gui front end, backend servlet, dicom targets etc. 45 days

48. Security is paramount –Restrictive policy –PHI is never unsecured Consumer controls the flow of information by placing it in the PHR –Diminishes the need for BAAs between enterprises Imaging Site to Clearinghouse Clearinghouse to PHR Project design assumptions

52. Image Enabled PHR

56. Report

57. Push model –No Query of PACS from outside the firewall Full DICOM data set is available –Web viewers –Download and Import to PACS Report is available Historical exams can be sent simultaneously Consumer controls flow of information –Affords the patient the ability to select what information to share Is this good? Advantages of Approach

58. Refine Workflow –Initial workflow is to replace a CD –Exam updates –Download DICOM data and archive in a local PACS Edge server as a platform –Radiation Monitoring –Peer Review –Quality Metrics Future Directions

59. CTP is a stand-alone program that provides all the processing features of a MIRC site for clinical trials in a highly configurable and extensible application. It connects to FieldCenter applications and can also connect to MIRC sites when necessary. CTP has the following key features: Single-click installation. Support for multiple pipelines. Processing pipelines supporting multiple configurable stages. Support for multiple quarantines for data objects which are rejected during processing. Pre-defined implementations for key components: –HTTP Import –DICOM Import –DICOM Anonymizer –XML Anonymizer –File Storage –Database Export –HTTP Export –DICOM Export –FTP Export Web-based monitoring of the application's status, including: –configuration –logs –quarantines –status Research CTP- The RSNA Clinical Trial Processor

60. What is our product? Who are our customers? What are the mechanisms of sharing? What are the impediments? –Technology –Policy Issues that govern sharing Imaging Exams

61. We live in a heterogeneous world needing multiple solutions CDs and portable media have both advantages and drawbacks –Compliance with standards helps We are transitioning to network/internet solutions –Security and confidentiality are even more difficult –ONC and State policies will foster these solutions –Solutions are evolving Proprietary solutions are often easier to implement Solutions based on open standards will provide the patient with greater flexibility Interoperability will require an adjustment to the way we all think of healthcare data Conclusions