1. Sept 13-15, 2004IHE Interoperability Workshop 1 Integrating the Healthcare Enterprise Echocardiography Profile Cameron Brackett, Cerner Echo Profile co-editor, IHE Cardiology Technical & Planning Committee

2. Sept 13-15, 2004IHE Interoperability Workshop 2 Introduction The Echocardiography Workflow Integration Profile describes the workflow associated with digital echocardiography, specifically that of transthoracic echo (TTE), transesophageal echo (TEE), and stress echo. As does the Cath Workflow Integration Profile, this profile deals with patient identifiers, orders, scheduling, status reporting, multi-stage exams (especially stress echo), and data storage. It also specifically addresses the issues of acquisition modality devices that are only intermittently connected to the network, such as portable echo machines, and addresses echo-specific data requirements. Intravascular ultrasound (IVUS) and intracardiac echocardiography (ICE) are used in cardiac catheterization procedures, and are supported as modalities in the Cath Workflow, and not in the Echo Workflow.

3. Sept 13-15, 2004IHE Interoperability Workshop 3 High ROI—value added problem solutions Standards in place (DICOM & HL-7) No “political” challenges – just technical Restricted scope for a “quick win” Reuse successful Radiology profiles to meet similar needs Goal for Year 1

4. Sept 13-15, 2004IHE Interoperability Workshop 4 Reuse of similar IHE-Radiology Profiles  Scheduled Workflow (IHE-R SWF)  Patient Information Reconciliation (IHE-R PIR) Intermittently Connected Modality  Workflow  Acquisition Modality storage Stress Echo  Workflow  Staged Protocol Acquisition Modality (optional) Image Display (required) Year 1 Scope: Imaging Workflow

5. Sept 13-15, 2004IHE Interoperability Workshop 5 Echo – Out of scope year 1 Documentation/Reporting  Nursing (e.g. TEE)  Sonographer (e.g. measurements via DICOM SR)  Cardiologist (final report)  Medication administration Counter-indication/clinical decision support Fetal and pediatric echo Combined echo/ECG stress acquisition workflow

6. Sept 13-15, 2004IHE Interoperability Workshop 6 Echo Actors & Transactions    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] ADT  Query Images [Rad-14]  Retrieve Images [Card-4] Image Display Modality Image/Evidence Stored [Card-2] Storage Commitment [Card-3]  Procedure Scheduled [Rad-4]  Procedure Updated [Rad-13]  Query Modality Worklist [Rad-5] Performed Procedure Step Manager  Modality PS in Progress [Card-1]  Modality PS Completed [Rad-7]  Modality PS in Progress [Card-1]  Modality PS Completed [Rad-7]  Modality PS in Progress [Card-1]  Modality PS Completed [Rad-7] Order Placer Acquisition Modality Image Manager Image Archive DSS/ Order Filler  Patient Update [Rad-12]

7. Sept 13-15, 2004IHE Interoperability Workshop 7 Actors No new Actors Actors Using Cardiology Specific Transactions  Department System Scheduler/Order Filler (DSS/OF)  Performed Procedure Step Manager  Image Archive  Image Manager  Acquisition Modality  Image Display

8. Sept 13-15, 2004IHE Interoperability Workshop 8 Transactions Modality Procedure Step In Progress – An Acquisition Modality notifies the Performed Procedure Step Manager of the start of a new Procedure Step and the PPS Manager informs the Department System Scheduler/Order Filler and Image Manager. [CARD-1, derived from RAD-6]  Intermittently connected workflows may send the MPPS “In Progress” immediately preceding the MPPS “Complete”

9. Sept 13-15, 2004IHE Interoperability Workshop 9Transactions Modality Images/Evidence Stored – An Acquisition Modality sends acquired or generated images, waveforms, or other evidence documents to the Image Archive. [CARD-2, derived from RAD-8 and RAD-43]  Echocardiography Option Image Archives supporting the ECHOCARDIOGRAPHY 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 Multi-Frame True Color Secondary Capture images, and shall support the YBR_FULL_422 photometric interpretation. Acquisition Modalities supporting the ECHOCARDIOGRAPHY option are required to support Ultrasound Multi-frame Image Storage SOP Class UIDSOP Class Name 1.2.840.10008.5.1.4.1.1.7Secondary Capture Image Storage 1.2.840.10008.5.1.4.1.1.6.1Ultrasound Image Storage 1.2.840.10008.5.1.4.1.1.3.1Ultrasound Multi-frame Image Storage 1.2.840.10008.5.1.4.1.1.88.59Key Object Selection 1.2.840.10008.5.1.4.1.1.88.11Basic Text SR 1.2.840.10008.5.1.4.1.1.88.22Enhanced SR 1.2.840.10008.5.1.4.1.1.88.33Comprehensive SR

10. Sept 13-15, 2004IHE Interoperability Workshop 10Transactions Modality Images/Evidence Stored – cont’d  Stress Echo Option Acquisition 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 Attribute NameTagRequirement Performed Procedure Step Description(0040,0254)R+ Protocol Name(0018,1030)R+ Performed Protocol Code Sequence(0040,0260)R+ Number of Stages(0008,2124)R+ Number of Views in Stage(0008,212A)R+ Stage Code Sequence(0040,000A)R+ (note 2) Stage Number(0008,2122)R+ View Number(0008,2128)R+ (note 1) View Code Sequence(0054,0220)R+ (note 2)

11. Sept 13-15, 2004IHE Interoperability Workshop 11Transactions Modality Images/Evidence Stored – cont’d  Stress Echo Option Numbers: Stage Number & View Number Code Sequences: Stage Code Sequence & View Code Sequence Coding Scheme Designator (0008,0102) Code Value (0008,0100) Code Meaning (0008,0104) SRTP5-01201Image acquisition at baseline SRTP5-01202Pre-stress image acquisition SRTP5-01203Mid-stress image acquisition SRTP5-01204Peak-stress image acquisition SRTP5-01205Image acquisition during recovery Stage

12. Sept 13-15, 2004IHE Interoperability Workshop 12Transactions Modality Images/Evidence Stored – cont’d Coding Scheme Designator Code ValueCode Meaning SRTG-A19BApical two chamber SRTG-A19CApical four chamber SRTG-0395Apical long axis SRTG-0396Parasternal long axis SRTG-0397Parasternal short axis SRTG-0398Parasternal short axis at the aortic valve level SRTG-0399Parasternal short axis at the level of the mitral chords SRTG-039AParasternal short axis at the Mitral Valve level SRTG-039BParasternal short axis at the Papillary Muscle level SRTG-039CRight Ventricular Inflow Tract View SRTG-039DRight Ventricular Outflow Tract View SRTG-039ESubcostal long axis SRTG-039FSubcostal short axis SRTG-03A0Suprasternal long axis SRTG-03A1Suprasternal short axis View

13. Sept 13-15, 2004IHE Interoperability Workshop 13 Transactions Storage Commitment – A requestor (Acquisition Modality) requests that the Image Manager confirm ownership for the specified DICOM objects (images, waveforms, evidence documents, or any combination thereof) that the requestor stored in the Image Archive, thus allowing the sender to delete those objects now owned by the Image Manager. [CARD-3, derived from RAD-10]  This option requires the Image Manager to send the N-Event Report message to the mobile modality at the time that reconnects to the Image Manager.

14. Sept 13-15, 2004IHE Interoperability Workshop 14 Transactions Retrieve Images – An Image Display requests and retrieves a particular image or set of images from the Image Archive. [CARD-4, derived from RAD- 16]  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.

15. Sept 13-15, 2004IHE Interoperability Workshop 15 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

16. Sept 13-15, 2004IHE Interoperability Workshop 16 Use Case E2 Query Modality Worklist [RAD-5] ADT Order Placer RegisterJ.Doe Acquisition Modality Placer Order Management– New [RAD-2] Patient Reconciliation Department System Scheduler/ Order Filler Schedule Procedure Scheduled [RAD-4] Modality Procedure Step Completed [RAD-7] J.Doe-> J.Smith Patient Update/ Merge [RAD-12] Modality Procedure Step Completed [RAD-7] Patient Registration [RAD-1] Patient Update/ Merge [RAD-12] Modality Procedure Step In Progress [CARD-1]- Modality Procedure Step In Progress [CARD-1]- Perform Acquisition Filler Order Mgmt-Status Update [RAD-3] Filler Order Mgmt-Status Update [RAD-3] Image Manager/ PPS Manager Filler Order Management- New [RAD-3] One or the other methods of creating an order is used Query Modality Worklist [RAD-5] ADT Order Placer RegisterJ.Doe Acquisition Modality Placer Order Management– New [RAD-2] Patient Reconciliation Department System Scheduler/ Order Filler Schedule Procedure Scheduled [RAD-4] Modality Procedure Step Completed [RAD-7] J.Doe-> J.Smith Patient Update/ Merge [RAD-12] Modality Procedure Step Completed [RAD-7] Patient Registration [RAD-1] Patient Update/ Merge [RAD-12] Modality Procedure Step In Progress - Modality Procedure Step In Progress Perform Acquisition Filler Order Mgmt-Status Update [RAD-3] Filler Order Mgmt-Status Update [RAD-3] Image Manager/ PPS Manager Filler Order Management- New [RAD-3] One or the other methods of creating an order is used [CARD-3]- Storage Commitment - MPPS In Progress [Card-1] Storage Commitment [Card-3]

17. Sept 13-15, 2004IHE Interoperability Workshop 17 More information…. IHE Web sites: http://www.himss.org/IHE http://www.rsna.org/IHE http://www.acc.org/quality/ihe.htmhttp://www.acc.org/quality/ihe.htm. Technical Frameworks: ITI V1.0, RAD V5.5, LAB V1.0 Technical Framework Supplements - Trial Implementation May 2004: Radiology August 2004: Cardiology, IT Infrastructure Non-Technical Brochures : Calls for Participation IHE Fact Sheet and FAQ IHE Integration Profiles: Guidelines for Buyers IHE Connect-a-thon Results Vendor Products Integration Statements