1. Integrating the Healthcare Enterprise (IHE)
An IHE-based Project for Image Sharing through Personal Health Records
Chris Carr
Director of Informatics, Radiological Society of North America
Secretary, IHE International Board

2. Background – Imaging
Medical imaging the most commonly ordered diagnostic procedure and fasting growing physician service in US health system
Medicare data show annual utilization increases of about 9%, three times the rate of other physician services
Value of medical imaging in providing accurate, noninvasive diagnosis is unquestioned
Costs of “overutilization” and excessive radiation exposure are growing concerns
Inaccessibility of prior studies is responsible for a significant number of duplicate studies

3. Background – Imaging
Medical images consistently standardized (DICOM) and the part of the health record most frequently provided to patients in digital form
Today most often provided on portable media (CD, DVD)
Serious limitations to exchange via physical media: inconvenience and failures for producers and consumers of images
The growth of advanced imaging techniques (eg, MRI, CT, PET, Nuclear Cardio) has led to an enormous growth in the amount of imaging data acquired—by volume the largest source of electronic health data

4. Project Overview
In Sept. 2009, RSNA was awarded two-year $4.7 million contract by the National Institute of Biomedical Imaging and Bioengineering (NIBIB)
Funding provided under provisions of ARRA
Pilot project to create “Internet-Based Network for Patient-Controlled Medical Image Sharing”
Network based on IHE XDS-I profile for sharing images and reports
Provide for patient control by incorporating access via personal health record (PHR) accounts

5. Project Goals
Demonstrate a method for sharing images and reports that improves upon portable media
Enable patients to create a medical record with access at their control
Create standards-based links to personal health record systems to enable sharing of images and reports
Establish the practice and expectation of accessibility of health records by participating patients
Enroll a growing number of patients throughout course of project
Provide data on the impact of image sharing on care
Deliver open source reference implementation of systems developed for project

6. Participating Sites Year 1: Five major medical centers
Mount Sinai, NYC
Mayo Clinic, Rochester, MN
University of California, San Francisco
University of Chicago
University of Maryland
Year 2:
Each of the five Year 1 sites recruit three additional “satellite” sites
7 additional sites begin sharing images for clinical trials

7. Overall Plan
Year 1:
Develop systems needed to enable image sharing through PHRs
Establish sharing of images and reports at five initial sites via PHR
Year 2:
Expand patient information sharing via PHR to satellite sites
Begin sharing images for clinical trials at seven additional research site
Recruit growing number of patients throughout course of trial
Gather information on patient usage and impact on radiology operations at participating sites

8. Systems Design Based on IHE XDS model
Data to be shared images (CT, MR, X-Ray) and diagnostic reports
All data access through PHR accounts
Simplified model for sharing to address policy considerations
“CD over the Wire”

9. CD Over the Wire
Participating sites create (and import) hundreds of imaging CD/DVDs daily
Physical media are time consuming to create
Physical media rely on patient maintenance and delivery to subsequent care providers
In spite of DICOM and IHE, inconsistency in formatting and viewers
Online delivery offers potential to improve incrementally upon current state of practice

10. Steps in Sharing via PHR
Site staff enroll patient and obtain consent
Site staff assemble encounter record (image and reports) and submit for sharing
Patient is provided security key (printout/ ) for retrieving record through PHR
Site staff provide patient with instructional material on creating and using PHR account
Patient creates account, logs in, uses security key to retrieve record into PHR
Patient provides subsequent care providers with access to records through PHR

11. Network Components
“Edge” Device at each site to bridge local imaging and information systems with image sharing network
Image “Clearinghouse” to temporarily store images and reports
One or more Web-based PHR providers capable of securely retrieving images and reports from clearinghouse into patient account

12. System Architecture RIS Edge PHR Device PACS PARTICIPATING SITE
DICOM
HL7
Images
&
Reports
PHR
CLEARINGHOUSE
Persistent Storage
PACS
SITE FIREWALL
PARTICIPATING SITE
Temporary Storage
Viewing by Subsequent Care Provider with Patient Authorization

13. Edge Device
Listens to HL7 messages from RIS, captures completed reports
Enables site personnel to create an encounter record by selecting one or more sets of images and reports
Retrieves image studies from PACS
Creates XDS-based payload including images, reports and manifest
Gets identifying security key from Clearinghouse and sends package

14. Clearinghouse Provides security key to Edge Devices on request
Receives and stores encounter record (image/report package) for designated period (eg, 30 days)
Responds to queries from designated PHR systems providing security key and sends requested encounter record

15. PHR Allows creation of secure patient-controlled account
Provides facility for patient to enter security key and retrieves and processes selected encounter record from Clearinghouse
Provides persistent storage for images and reports
Provides Web-based viewer for images and reports
Provides mechanism for secure download of images for viewing in local environment

16. Simplifications of IHE Model
No patient ID management or subject discovery through network
No Patient ID Cross-Reference Manager
Simplified Registry/Repository storing only security tokens and associated encounter records
Information sharing provided exclusively through PHR
Not an HIE model

17. Community Health Center
IHE XDS-I HIE Model
Care Site
Imaging Center
Community Health Center
Regional Hospital
Local
Clinic
Repository
Registry ‏
Health Information Exchange Network
Regional

18. IHE XDS-I Data Flow

19. Site Policies Behind Design
Baseline is the most restrictive policy among participants
No inbound connections to clinical systems
No export of unsecured protected health information (PHI) outside site firewall
No exchange of PHI with other care providers without business associate agreement (BAA)

20. Limitations of Project Model
No “universal coverage”
Depends on active patient to initialize sharing
Does not serve patients debilitated by trauma, age, disease
No aggregation of information for quality, outcomes analysis
Limited by capabilities and policies of PHR providers
Business model for PHRs not clear
Issuing RFI today for potential PHR partners

21. Potential Benefits of Project
Establish practice of online information sharing
Encourage patient ownership of electronic health records
Build expectation of patient-control within participating sites
Improve upon portable media for convenience and efficiency of information sharing
Show standards-based mechanism and simple infrastructure for sharing of information through PHRs

22. Summary
Medical images are a high-value use case and a relatively easy win for information sharing
Participants believe in the HIE model and the IHE approach to implementing standards for information sharing
Current business and security policies make it impossible to establish a true HIE model in performance of current contract
Information sharing through PHRs is an incremental step toward greater accessibility of health information for care providers

23. Thanks for joining us!
Find out more at ihe.net