1. Integrating the Healthcare Enterprise: Building the Electronic Health Record
Cor Loef – Co-chair IHE Rad TC
Acknowledgement for presentation input to:
Christoph Dickmann – Member IHE Rad TC
Charles Parisot – Co-chair IHE IT-I PC

2. Business need: share in the Care setting Radiology Reports and Images
Between Radiology and
imaging specialists
non-imaging professionals
Within an enterprise
Cross-enterprise in a healthcare region
By network or media

3. Care Cycle Definition
The array of health services and care settings that address:
health promotion
disease prevention
diagnosis, treatment, management, and rehabilitation
of a disease, injury, and/or disability…. Source: CDC, US government

4. The Care Cycle Approach
Set of tools to identify:
Different paths someone may follow through the care cycle
Disciplines and roles
Sites of care
Technology requirements
Social and political changes required
Costs
Potential future care cycles

5. Deriving Care Cycles PCP office ED Cardiol- ogist ICU/CCU Non- imaging
testing
Home
Floor
OR /
Cath Lab
invasive
Imaging
Rehab
Clinical guidelines
Observations
Industry leaders
Literature

6. Pragmatic definition of EHR
Integrated data and workflow
Multimedia data access
text, image, waveform, …
Communication among stakeholders in the care cycle
clinicians, caregivers, consumers, …
Support different views of data
Clinical records
Details: episode, visit, study
Longitudinal records
Summaries: episode, visit
cross-department and cross-enterprise users
Linking summaries and clinical details

7. EHR goals in IHE (compatible with U.S. NHII goals)
Informed Clinical Practice
IHE integrates clinical data and functions for an EHR
Interconnected Clinicians
Beyond the department: community or regional scope
Personalized Care
Web-based data access and summary data
Support for higher-level goals
Better outcomes
Increased patient safety
More efficient healthcare operations

8. EHR complexity Business dilemmas Coordination and cooperation
Significant, long-term investment
Investors may not be main beneficiaries
Coordination and cooperation
Active collaboration among multiple stakeholders
Identify and work out commonalities and barriers
Integration and interoperability
Implement existing standards
Develop additional standards
 Evolutionary system specification (system of systems)

9. Focus: Image-enabled EHR (connect two “worlds”)
Non-imaging data
Patient data
Clinical data
Laboratory results
Surgery reports
Prescriptions, meds
Letters or notes
Integrate with imaging data and processes
Imaging data
Patient data
Images and evidence
Radiology
Cardiology
Nuclear Medicine
Integrate with non-imaging data and processes
Departmental/ clinical information system world compared to imaging system world: both complement each other from an EHR viewpoint

10. Potential use cases of an image-enabled EHR
Using images
Neurologist: reviewing stroke patient transfer to ward
Nurse: preparing GI ward round for Dr. X
GP: seeing a post-MI patient after hospital discharge
Patient: be prepared for an obstetric visit
Producing images/ evidence
Cardiologist: during catheter intervention
Radiologist: starting an abdomen CT
Physician: counseling at diabetes outpatient clinic
Oncologist: planning radiotherapy
The left column describes use cases from the image usage point of view.
The right column describes use cases from the image production or specific service point of view.
Information need may include current or longitudinal evidence

11. Image-enabled EHR Pregnancy outpatient clinics encounter
evaluate
acquire
Image/ Report Repository
store new data
Ultrasound report and images
index
Document Registry
register
(XDS architecture)
The next 2 slides show use cases from 2 encounters of the same patient in different care institutions. The example is taken from pregnancy care before and for childbirth.
The flow of information illustrates the primary IHE mechanism of document sharing.

12. Image-enabled EHR Childbirth inpatient stay
evaluate
Document Registry
Image/ Report/ Document Repositories
index
Document Repository
store new data
Report, letters (incl. images)
retrieve
index
query
register
(XDS architecture)

13. Sharing Imaging Documents (XDS-I)
Radiology department
patient
Onco- logist
GP (follow-up)
Document availability
Images, report (PACS, RIS)
report
Longitudinal record system: across encounters
Care record sys-tems: specific care delivery
Retrieve
Shared re- pository
Query
for re-
ports
Retrieve selected imaging report references
Document Registry
Register report & image references
Your local imaging systems keep their DICOM objects, these are not copied to the shared information network.
Shared repositories are not imaging-specific, a general “infrastructure” can be used.
Imaging Information via native DICOM (imaging specialists) or WADO (general-purpose, web-based).
You can learn more about XDS-I in the presentation “What is new in IHE” right here in the infoRAD classroom (please mention day/time).

14. IHE contributions to EHR implementation
EHR realization
IHE IT Infrastructure 7 Int. Profiles
IHE Radiology 7 Int. Profiles
IHE Laboratory 1 Int. Profile
IHE Cardiology 3 Int. Profiles
IHE Pat. Care Coord. 3 Int. Profile
IHE Rad and Card are the major existing imaging-related Technical Frameworks (TF) – and are likely to be needed in a combined way in many scenarios.
IHE IT-I Profiles provide common services for EHR system implementation.
IHE PCC can be assumed to specify a majority of document contents
IHE plans for the coming years include missing integration profiles to cover most EHR services.
Each TF can contribute to EHR scenarios with Integration Profiles for
Data access
Workflow

15. Basic requirements of EMR/EHR systems
Integrated healthcare provider systems
EHR sources/ users, user interaction
Document handling
Storage and retrieval of EHR documents
Infrastructure services
Basic data and application integration
Network
EHR storage, inquiry, and retrieval path

16. EMR/EHR interoperability examples
Backend integration (services, data)
Source 1
Source 2
Desktop
Integration
as an EHR enabler
Appl. 1
Appl. 2
Appl. 3
Patient identifier matching
Single sign on
Same patient selected
Patient demographics
Personnel/ staff data
Any user
Applications may be for
specific purposes (e.g. department / specialist focus),
for wider purpose (e.g. enterprise / distribution focus), or
for general access/ creation/ viewing purpose (e.g. RHIO/ community-wide document viewing focus)
Common person data or services

17. IHE - Radiology images and reports for an EMR/EHR system
Access to Radiology (Rad ARI) Retrieve diagnostic quality images, evidence, reports
Simple Image and Numeric Reports (Rad SINR) Access or export reports and related images
Key Image Notes (Rad KIN) Mark, annotate, retrieve selected imaging evidence
Portable Data for Imaging (Rad PDI) Export/ import/ view media data
Nuclear Medicine Image (Rad NM Image) Capture and use complex NM result screens
Mammography Image (Rad Mammo Image) Capture and use complex Mammography screens
Consistent Presentation of Images (Rad CPI) Consistent image viewing on all review stations

18. IHE – Cardiology images and reports for an EMR/EHR system
Cardiac Catheterization / Echo Workflow (Card CATH, ECHO) Retrieve catheterization and echocardiography imaging evidence
Retrieve ECG for Display (Card ECG) Retrieve ECG summaries and results
Displayable Reports (Card DRPT) Create and access reports for viewing

19. IHE - common interoperability services
Common patient identification (ITI PIX)
Common patient demographics (ITI PDQ)
Desktop integration (ITI PSA) Running applications work on the same patient
Single sign on (ITI EUA, XUA) Enterprise-wide or cross-enterprise user handling
Security and privacy (ITI/ RAD ATNA, Accountability, document integrity DSG)
Common staff data (ITI PWP) Health professionals are commonly recognized
Now, a comprehensive overview is given on all these aspects of EHR systems that can be enabled or realized by IHE Integration Profiles.
You will see, IHE provides many steps in the gradual evolution of your IT system landscape to a comprehensive patient record system. The IHE Integration Profiles provide interoperability added value independently – however, if combined, they can complete the picture of an intra- or cross-enterprise EHR system.
Fundamental enablers of cross-system health record system functions. Gradual enhancement and combination is the key.

20. IHE – documents for general purpose EHR functions
Cross-Enterprise Document Sharing for Imaging (Rad XDS-I) Share DICOM instances via web or DICOM connection; share imaging information via web
Cross-Enterprise Document Sharing (ITI XDS) Store & retrieve documents and summaries (focus: longitudinal data)
Notification of Document Availability (ITI NAV) Send notification/ reference to new shared documents
Retrieve Information for Display (ITI RID) Query and retrieve documents and summaries/ lists
Needs common services as a basis (e.g. security, patient identification)

21. IHE - clinical/ textual information for an EMR/EHR system
Simple Image and Numeric Reports (Rad SINR) Access original or exported reports
Cross-Enterprise Document Sharing (ITI XDS) Cross-Enterprise Doc. Sharing for Imaging (Rad XDS-I) Store & retrieve documents, summaries or reports with longitudinal data
Retrieve Information for Display (ITI RID) Access documents and summaries (e.g. imaging, lab, discharge, medications, prescriptions)
Sharing Laboratory report (Lab XD*-LAB) Access to laboratory results

22. IHE - workflow / patient management support
Workflow integration (Rad, Card, Lab)
Scheduled Workflow
Ordering, scheduling and tracking of image acquisition steps
Appointment tracking to order placer
Reporting Workflow
Scheduling and tracking of report creation tasks
Patient data integration (Rad, Card, ITI)
Patient Information Reconciliation
Modification and matching of patient data and imaging evidence
Patient Administration Management
Creating and changing patient identifiers and encounter data
Overall concept (Rad whitepaper)
Departmental workflow and interfaces to the enterprise

23. Envisaged IHE development
Extend XDS’ document content
Harmonize IHE domain-specific workflow and document content
Realize overall workflow concept
Link departmental documents, in particular diagnostic reports, to the enterprise EMR
Code sets and master files
Configuration support
Security details, e.g. access control

24. Image-enabled EHR – IHE progress and plans
IHE Integration Profiles from different domains can be combined
Combinations of current profiles can cover many EHR scenarios
Information integration (imaging, textual)
Enhanced functionality beyond one department
Intra- and cross enterprise communication
Scenarios enable system evolution (organizational change management not to be forgotten)
IHE ensures integration testing and future Integration Profile development
IHE knows that it does not provide specifications to completely realize image-enabled EHR systems yet. But it has clear plans how to get there within the next few years.