1. RSNA 20021 Implementation of IHE Integration Profiles at the Cleveland Clinic Foundation Dr. David Piraino, Section Head of Radiology Informatics

2. RSNA 20022 Conflict of Interest Statement IDX Alpha PartnerIDX Alpha Partner Members of Siemens Medical Advisory BoardMembers of Siemens Medical Advisory Board No product or vendor endorsements are implied by this presentationNo product or vendor endorsements are implied by this presentation

3. RSNA 20023 About Cleveland Clinic Multispecialty academic medical center and National Referral CenterMultispecialty academic medical center and National Referral Center One of the world’s first group practices, it was formed in 1921One of the world’s first group practices, it was formed in 1921 4 Cleveland physicians came together and set forth their professional standards: “Better care of the sick, investigation of their problems, and further education of those who serve.”4 Cleveland physicians came together and set forth their professional standards: “Better care of the sick, investigation of their problems, and further education of those who serve.” 2nd largest medical group practice in the world, largest hospital in Ohio,2nd largest medical group practice in the world, largest hospital in Ohio, Nearly 73,000 outpatient visits are recorded each monthNearly 73,000 outpatient visits are recorded each month 934 staffed-bed hospital934 staffed-bed hospital –Children’s Hospital, Educational Foundation & Lerner Research Institute. In 2000, 2 million outpatient visits and 51,000 hospital admissions.In 2000, 2 million outpatient visits and 51,000 hospital admissions. More than 1,100 full-time physicians and scientistsMore than 1,100 full-time physicians and scientists 100 specialties and subspecialties.100 specialties and subspecialties.

4. RSNA 20024 About Cleveland Clinic Radiology 8 hospitals8 hospitals 15 out patient imaging centers15 out patient imaging centers Over 1 million exams per yearOver 1 million exams per year Over 700,000 digital exams archived per yearOver 700,000 digital exams archived per year Not enough radiologists and technologistsNot enough radiologists and technologists

5. RSNA 20025 In order to provide better patient care and provide an efficient operational workflow, the Cleveland Clinic Foundation has implemented the "Scheduled Workflow" and "Patient Information Reconciliation" integration profiles. These transactions are supported and are in production or in pilot mode at the Cleveland Clinic.

6. RSNA 20026 Main Benefits Time savings during patient registration - MWLTime savings during patient registration - MWL Elimination or at least significant reduction of errors during patient registration – MWLElimination or at least significant reduction of errors during patient registration – MWL Elimination of manual input at RIS terminal - MPPSElimination of manual input at RIS terminal - MPPS Elimination of manual check of archiving the images - Storage CommitmentElimination of manual check of archiving the images - Storage Commitment Reduction of incorrectly identified or “lost” studies – All of the aboveReduction of incorrectly identified or “lost” studies – All of the above

7. RSNA 20027 Prior to IHE Before the IHE implementations, the process was very paper-based and there was a great amount of data entry required. Much of the same information was being entered into different systems – the HIS, the RIS, the PACS and the Modality. This slowed down the operational workflow.Before the IHE implementations, the process was very paper-based and there was a great amount of data entry required. Much of the same information was being entered into different systems – the HIS, the RIS, the PACS and the Modality. This slowed down the operational workflow. By using the IHE Technical Framework as a guideline, much of the mapping exercises were shortened as it provided a common understanding and language between all the different information system, imaging system, and modality vendors.

8. RSNA 20028 Where are we? Patient demographics and exam information being sent from the HIS to the RIS (ADT/Order Placer and Order Filler) has been in place for the past 4 years.Patient demographics and exam information being sent from the HIS to the RIS (ADT/Order Placer and Order Filler) has been in place for the past 4 years. Implementation of Modality Worklist has been an ongoing process for the past 3 years and is currently approaching 100 integrated modalities.Implementation of Modality Worklist has been an ongoing process for the past 3 years and is currently approaching 100 integrated modalities. Storage Commitment and Modality Perform Procedure Step are in their initial implementation stage in CT.Storage Commitment and Modality Perform Procedure Step are in their initial implementation stage in CT. Ongoing process to implement IHE Integration Profiles

9. RSNA 20029 How it Works The HL7 ADT Patient Registration and Update, Filler and Order Management transactions are sent from various HIS systems to the IDXrad RIS.The HL7 ADT Patient Registration and Update, Filler and Order Management transactions are sent from various HIS systems to the IDXrad RIS. The transactions "Modality Worklist Provided" and "Modality Images Stored" are in use in the CT department at the Cleveland Clinic.The transactions "Modality Worklist Provided" and "Modality Images Stored" are in use in the CT department at the Cleveland Clinic. With the recent update of the Siemens CT Scanners these imaging modalities now support the transactions "Modality PPS in Progress", "Modality PPS Completed" and "Storage Commitment".With the recent update of the Siemens CT Scanners these imaging modalities now support the transactions "Modality PPS in Progress", "Modality PPS Completed" and "Storage Commitment". With the exception of "Storage Commitment", the IDXrad RIS also supports these transactions.With the exception of "Storage Commitment", the IDXrad RIS also supports these transactions. The Siemens image archive supports “Storage Commitment”The Siemens image archive supports “Storage Commitment”

10. RSNA 200210 Store Images Storage Commitment List of Images PACS & Archive RIS ModalityPerformed Procedure Step Performed Step: Status = Completed Performed CT Head Pat Name/ID, Dose, Accession #, Study UID Complete List of Images IHE Scheduled Workflow Modality Worklist Worklist Procedure Scheduled Patient Registration/Update Order Management Performed Step Status = begun

11. RSNA 200211 Store Images PACS & Archive RIS CCF Scheduled Workflow Manual Patient Entry Worklist Manual Prefetch Patient Registration/Update Order Management Manual Begin Exam ModalityPerformed Procedure Step Technologists manually Complete examination Technologist check archive

12. RSNA 200212 Store Images PACS & Archive RIS CCF Scheduled Workflow Modality Work-list Worklist Procedure scheduled Patient Registration/Update Order Management Performed Procedure “begin” ModalityPerformed Procedure Step Technologists manually Complete examination Storage commitment

13. RSNA 200213 Standards & Mechanisms HL7HL7 ADT Messages (A01-08, A11-13, A38, A40)ADT Messages (A01-08, A11-13, A38, A40) ORM MessagesORM Messages DICOMDICOM Modality Worklist Management (MWL)Modality Worklist Management (MWL) Modality Performed Procedure Step (MPPS)Modality Performed Procedure Step (MPPS) Storage, Storage CommitmentStorage, Storage Commitment Query/RetrieveQuery/Retrieve

14. RSNA 200214 Results CT Modality Work-listModality Work-list –Reduction in miss identified studies –Reduction in time between exam completion and dictation because of fewer miss identified studies

15. RSNA 200215 Results CT Modality Perform Procedure StepModality Perform Procedure Step –Currently in pilot –Provides more accurate begin exam time –Questions remain about completion Billing requirementsBilling requirements Group procedures give that we have not implemented the Grouped Procedure ProfileGroup procedures give that we have not implemented the Grouped Procedure Profile

16. RSNA 200216 Results Orthopedic Out Patient Clinic Completion to Dictation Analog films120 hoursAnalog films120 hours CR60 hoursCR60 hours Modality work-list40 hoursModality work-list40 hours Work flow change20 hoursWork flow change20 hours Large portion of the delay is “lost” images from film or incorrectly identified studiesLarge portion of the delay is “lost” images from film or incorrectly identified studies

17. RSNA 200217 Test Implementation Issue The challenge of managing each vendor's update to their software was overcome by creating a fully-functional test environment. This approach enables Cleveland Clinic to effectively simulate their production environment. Production

18. RSNA 200218 Customer/Vendor Collaboration Step 1. Following a controlled change management process, each vendor installs their latest update into the test environment. Step 2. Extensive testing occurs until all vendors and Cleveland Clinic approve the update; then it is scheduled to be placed into production.

19. RSNA 200219 Thinking about the Workflow Need to manage the business processes and workflow changes Need to manage the business processes and workflow changes Business process re-engineering requires an intense user education process which includes user feedback. Business process re-engineering requires an intense user education process which includes user feedback. For successful integration, it is critical to work closely with all users of the solution. For successful integration, it is critical to work closely with all users of the solution.

20. RSNA 200220 Questions Dr. David Piraino – piraind@ccf.org