2. WHIT Conference 10-13 October 2006 What IHE Delivers 1 Peter Künecke / Dr. Nikolaus Wirsz SIEMENS Medical Solutions IHE Radiology – Overview

3. WHIT Conference 10-13 October 2006 2 Integration Solutions Available Today from Medical Systems Vendors – BUT... Common Problems of Modern Healthcare Enterprises: (In Spite of IT Standards and Advanced Technology) Lack of Access to Complete Medical Information Inconsistent Medical Information Across Departments and Institutions Inadequate Communicating of Medical Data Across Multiple Systems from Different Vendors Risky Investments in Proprietary Solutions Challenges of Integration

4. WHIT Conference 10-13 October 2006 3 An Incremental Multi-Year Project Launched in 1998 by RSNA & HIMSS Enhance the Access to Clinical Information Ensure Continuity and Integrity of Patient Information Speed Up the Integration in Healthcare Environments Foster Communication Between Vendors of Medical Information Technology Prove that Integration is Attainable Based on Standards Participants: Representatives of Healthcare Providers Information Systems Vendors Imaging Systems Vendors Standardization Groups The IHE Initiative

5. WHIT Conference 10-13 October 2006 4 Evolution of IHE Domains Radiology IT Infrastructure for Healthcare Cardiology Laboratory Radiation Oncology Patient Care Coordination Patient Care Devices Pathology Pharmacy IHE Global Developments Integration Profiles – Solutions to Real-World Needs & Problems: Within Clinical Departments e.g.: o oRadiology o oCardiology o oLab o o... Across Departmental & Institutional Boundaries – XDS o oRHIOs (Regional Healthcare Information Organizations) o oEHR Enablers Veterinarian Endoscopy Eye Care / Ophthalmology Year 1 (1999)Year 2 (2000)Year 3 (2001)Year 4 (2002)Year 5 (2003)Year 6 (2004) Year 7 (2005) Year 8 (2006)

6. WHIT Conference 10-13 October 2006 5 report Examination Ordered Patient Registration initial capture of patient demographic information Patient Information HIS Orders Placed physician orders desired procedure RIS Orders Filled Break down entered order: specific radiology procedure steps to be performed procedure scheduled Prefetch any relevant prior studies PACS Image Manager and Archive modality worklist Patient and procedure information retrieved by the modality Position patient and acquire images storage commitment print images Printer Film Folder acquisition completed acquisition completed Diagnostic image and demographic info stored for network access query/ retrieve images Light Box Diagnostic image and demographic info for radiologist Report Repository report Radiologist report stored for network access Modality * IHE = Integrating the Healthcare Enterprise Workstation IHE & the Radiology Workflow

7. WHIT Conference 10-13 October 2006 6 ADT Patient Registration Image Archive Image Manager Image Display Image Creator Acquisition Modality Department System Scheduler – Order Filler – Order Placer Modality Worklist Patient Registration Patient Update Procedure Scheduled Images Availability Query Storage Commit Storage Commit PPS In-Progress / Completed Filler Order Management Placer Order Management Patient Update Procedure Update Performed Procedure Step Manager PPS In-Progress / Completed PPS In-Progress / Completed Q /R Key Image Note Q /R Presentation Sates Q /R Images Stored Key Image Note Stored Present. State Stored Images Stored Present. State Stored Key Image Note Stored IHE Systems Transactions Overview

8. WHIT Conference 10-13 October 2006 7 ADT Patient Registration Image Archive Image Manager Image Display Image Creator Acquisition Modality Department System Scheduler – Order Filler – Order Placer Modality Worklist Patient Registration Patient Update Procedure Scheduled Images Availability Query Storage Commit Storage Commit PPS In-Progress / Completed Filler Order Management Placer Order Management Patient Update Procedure Update Performed Procedure Step Manager PPS In-Progress / Completed PPS In-Progress / Completed Q /R Key Image Note Q /R Presentation Sates Q /R Images Stored Key Image Note Stored Present. State Stored Images Stored Present. State Stored Key Image Note Stored IHE Systems Transactions Overview HIS RIS IMAGING: PACS Workstations Modalities

9. WHIT Conference 10-13 October 2006 8 IHE Goes Beyond Standards IHE = + Multi-Vendor + Workflow-Driven + INTEGRATION based on established medical IT Standards IHE = A Standards Harmonization Approach

10. WHIT Conference 10-13 October 2006 9 Integration Profiles Q Actors Q Transactions Q Standards User Focus: Solutions to Clinical Problems Transaction TransactionTransactionTransaction TransactionTransaction TransactionTransactionTransaction Implementation: Technical Details (Standards)

11. WHIT Conference 10-13 October 2006 10 Integration Profiles - Group related transactions and associate them with real-world functions Integration Profiles allow the customer to focus on high-level integration while vendor products handle the details Reduce Ambiguities Manage Customer Expectations IHE Integration Profiles:http://www.ihe.net/resources/ihe_integration_profiles.cfm IHE FAQ:http://www.ihe.net/About/ihe_faq.cfm IHE Users Handbook:http://www.ihe.net/Resources/upload/ihe_radiology_users_handbook_2005edition.pdf

12. WHIT Conference 10-13 October 2006 11 IHE Radiology Integration Profiles – Solutions to Real-World Problems in Radiology Patient Information Reconciliat ion Reconcile worklists, status, and data objects for unknown patients and demographics changes Access to Radiology Information - Consistent access to images and reports Consistent Presentation of Images Manage, retrieve & use objects for hardcopy and softcopy grayscale presentation states Key Image Notes Create, store, manage, retrieve & use objects to flag significant images Simple Image and Numeric Reports Manage simple diagnostic reports with optional images, measurements Scheduled Workflow Presentation of Grouped Procs Manage individual procedure image subsets from a multi-procedure acquisition for viewing & reporting Charge Posting Collect and post timely billable procedure details ITI ATNA – Radiology Option (Replaces Basic Security) Reporting Workflow Manage worklists, track status, perform & notify diagnostic reporting steps Evidence Documents Manage, retrieve & use objects to record study evidence Manage worklists, track status, perform & notify image processing & CAD steps Post- Processing Workflow Manage worklists, track status, perform & notify acquisition related step, create, store, manage, retrieve & use images NM Image Create, store, manage, retrieve & use NM image objects Portable Data for Imaging - Consistent access to images and reports on CD Media Admit, Order, Schedule Teaching Files & Clinical Trials Export Standardize Clinical Trial Data and Anonymization XDS for Imaging - Sharing of Imaging Information across health enterprises WorkflowsBilling Teaching/ Research Contents & DisplayCommon Infrastructure

13. WHIT Conference 10-13 October 2006 12 Contents – Consistency – Presentation Consistent Presentation of Images Evidence Documents Key Image Notes Simple Image & Numeric Reports NM Image IHE Radiology – Integration Profiles Workflow Support: Scheduled Workflow Patient Information Reconciliation Post-Processing Workflow Reporting Workflow Presentation of Grouped Procedure Common IT Infrastructure & Data Sharing Access to Radiology Information Portable Data for Imaging Cross-Enterprise Data & Image Sharing Security: Audit Trails & Node Authentication Others: Billing / Charge Posting Teaching Files & Clinical Trials

14. WHIT Conference 10-13 October 2006 13 Access to Radiology Information - Consistent access to images and reports Key Image Notes Create, store, manage, retrieve & use objects to flag significant images Simple Image and Numeric Reports Manage simple diagnostic reports with optional images, measurements Presentation of Grouped Procs Manage individual procedure image subsets from a multi-procedure acquisition for viewing & reporting Charge Posting Collect and post timely billable procedure details ITI ATNA – Radiology Option (Replaces Basic Security) Reporting Workflow Manage worklists, track status, perform & notify diagnostic reporting steps Evidence Documents Manage, retrieve & use objects to record study evidence Manage worklists, track status, perform & notify image processing & CAD steps Post- Processing Workflow NM Image Create, store, manage, retrieve & use NM image objects Portable Data for Imaging - Consistent access to images and reports on CD Media Teaching Files & Clinical Trials Export Standardize Clinical Trial Data and Anonymization XDS for Imaging - Sharing of Imaging Information across health enterprises Consistent Presentation of Images Manage, retrieve & use objects for hardcopy and softcopy grayscale presentation states Scheduled Workflow Charge Posting Manage worklists, track status, perform & notify acquisition related step, create, store, manage, retrieve & use images Admit, Order, Schedule Scheduled Workflow (SWF) Patient Information Reconciliat ion Reconcile worklists, status, and data objects for unknown patients and demographics changes

15. WHIT Conference 10-13 October 2006 14 ADT Patient Registration Image Archive Image Manager Image Display Image Creator Acquisition Modality Department System Scheduler – Order Filler – Order Placer Modality Worklist Patient Registration Patient Update Procedure Scheduled Images Availability Query Storage Commit Storage Commit PPS In-Progress / Completed Filler Order Management Placer Order Management Patient Update Procedure Update Performed Procedure Step Manager PPS In-Progress / Completed PPS In-Progress / Completed Q /R Key Image Note Q /R Presentation Sates Q /R Images Stored Key Image Note Stored Present. State Stored Images Stored Present. State Stored Key Image Note Stored The IHE Benefits: Data Consistency & Process Optimization Scheduled Workflow (SWF)

16. WHIT Conference 10-13 October 2006 15 Scheduled Workflow Charge Posting Manage worklists, track status, perform & notify acquisition related step, create, store, manage, retrieve & use images Admit, Order, Schedule Patient Information Reconciliat ion Reconcile worklists, status, and data objects for unknown patients and demographics changes Access to Radiology Information - Consistent access to images and reports Key Image Notes Create, store, manage, retrieve & use objects to flag significant images Simple Image and Numeric Reports Manage simple diagnostic reports with optional images, measurements Presentation of Grouped Procs Manage individual procedure image subsets from a multi-procedure acquisition for viewing & reporting Charge Posting Collect and post timely billable procedure details ITI ATNA – Radiology Option (Replaces Basic Security) Evidence Documents Manage, retrieve & use objects to record study evidence Manage worklists, track status, perform & notify image processing & CAD steps Post- Processing Workflow NM Image Create, store, manage, retrieve & use NM image objects Portable Data for Imaging - Consistent access to images and reports on CD Media Teaching Files & Clinical Trials Export Standardize Clinical Trial Data and Anonymization XDS for Imaging - Sharing of Imaging Information across health enterprises Consistent Presentation of Images Manage, retrieve & use objects for hardcopy and softcopy grayscale presentation states Reporting Workflow (RWF) Reporting Workflow Manage worklists, track status, perform & notify diagnostic reporting steps

17. WHIT Conference 10-13 October 2006 16 Reporting Worklist Work Item Claimed Reporting Procedure Step STARTED Reporting Procedure Step STARTED Store Reports Reporting Procedure Step COMPLETED Reporting Procedure Step COMPLETED Report Manager RIS Image Manager/ Archive PACS & Archive Report Reader/Creator Retrieve Images & Evidence Documents Measurements CAD Reports ………………… Released (Completed) Reporting Workflow (RWF) The IHE Benefits: Manage Reporting Tasks & Improve Workflow Efficiency

18. WHIT Conference 10-13 October 2006 17 Reporting Workflow Manage worklists, track status, perform & notify diagnostic reporting steps Scheduled Workflow Charge Posting Manage worklists, track status, perform & notify acquisition related step, create, store, manage, retrieve & use images Admit, Order, Schedule Patient Information Reconciliat ion Reconcile worklists, status, and data objects for unknown patients and demographics changes Access to Radiology Information - Consistent access to images and reports Key Image Notes Create, store, manage, retrieve & use objects to flag significant images Simple Image and Numeric Reports Manage simple diagnostic reports with optional images, measurements Presentation of Grouped Procs Manage individual procedure image subsets from a multi-procedure acquisition for viewing & reporting Charge Posting Collect and post timely billable procedure details ITI ATNA – Radiology Option (Replaces Basic Security) Evidence Documents Manage, retrieve & use objects to record study evidence Manage worklists, track status, perform & notify image processing & CAD steps Post- Processing Workflow NM Image Create, store, manage, retrieve & use NM image objects Portable Data for Imaging - Consistent access to images and reports on CD Media Teaching Files & Clinical Trials Export Standardize Clinical Trial Data and Anonymization XDS for Imaging - Sharing of Imaging Information across health enterprises Consistent Presentation of Images (CPI) Consistent Presentation of Images Manage, retrieve & use objects for hardcopy and softcopy grayscale presentation states

19. WHIT Conference 10-13 October 2006 18 Reporting Radiologist Referring Physician or Reviewing Radiologist Original ImageWindow LevelFlip Without Consistent Presentation Area Of Interest Achieving Consistent Presentation Presentation State Presentation LUT Grayscale Standard Zoom Area Of Interest Annotate The IHE Benefits: Enhancing & Preserving Image Quality Consistent Presentation of Images (CPI)

20. WHIT Conference 10-13 October 2006 19 XDS for Imaging - Sharing of Imaging Information across health enterprises Consistent Presentation of Images Manage, retrieve & use objects for hardcopy and softcopy grayscale presentation states Reporting Workflow Manage worklists, track status, perform & notify diagnostic reporting steps Scheduled Workflow Charge Posting Manage worklists, track status, perform & notify acquisition related step, create, store, manage, retrieve & use images Admit, Order, Schedule Patient Information Reconciliat ion Reconcile worklists, status, and data objects for unknown patients and demographics changes Access to Radiology Information - Consistent access to images and reports Simple Image and Numeric Reports Manage simple diagnostic reports with optional images, measurements Presentation of Grouped Procs Manage individual procedure image subsets from a multi-procedure acquisition for viewing & reporting Charge Posting Collect and post timely billable procedure details ITI ATNA – Radiology Option (Replaces Basic Security) Evidence Documents Manage, retrieve & use objects to record study evidence Manage worklists, track status, perform & notify image processing & CAD steps Post- Processing Workflow NM Image Create, store, manage, retrieve & use NM image objects Portable Data for Imaging - Consistent access to images and reports on CD Media Teaching Files & Clinical Trials Export Standardize Clinical Trial Data and Anonymization Key Image Notes (KIN) Key Image Notes Create, store, manage, retrieve & use objects to flag significant images

21. WHIT Conference 10-13 October 2006 20 Radiologist Flags Images: Referring Physician Sees Key Images First: Study Including Key Image Notes Note 1 For referring physician: This image shows the renal rupture. Key Image Notes (KIN) Note 2 For referring physician: This image has the hematoma. Note 1 For referring physician: This image shows the renal rupture. Note 2 For referring physician: This image has the hematoma. Note 1 For referring physician: This image shows the renal rupture. Note 2 For referring physician: This image has the hematoma. The IHE Benefits: Enhancing Communication Among Medical Specialties

22. WHIT Conference 10-13 October 2006 21 ITI ATNA – Radiology Option (Replaces Basic Security) XDS for Imaging - Sharing of Imaging Information across health enterprises Consistent Presentation of Images Manage, retrieve & use objects for hardcopy and softcopy grayscale presentation states Reporting Workflow Manage worklists, track status, perform & notify diagnostic reporting steps Scheduled Workflow Charge Posting Manage worklists, track status, perform & notify acquisition related step, create, store, manage, retrieve & use images Admit, Order, Schedule Patient Information Reconciliat ion Reconcile worklists, status, and data objects for unknown patients and demographics changes Access to Radiology Information - Consistent access to images and reports Key Image Notes Create, store, manage, retrieve & use objects to flag significant images Simple Image and Numeric Reports Manage simple diagnostic reports with optional images, measurements Presentation of Grouped Procs Manage individual procedure image subsets from a multi-procedure acquisition for viewing & reporting Charge Posting Collect and post timely billable procedure details Evidence Documents Manage, retrieve & use objects to record study evidence Manage worklists, track status, perform & notify image processing & CAD steps Post- Processing Workflow NM Image Create, store, manage, retrieve & use NM image objects Teaching Files & Clinical Trials Export Standardize Clinical Trial Data and Anonymization Portable Data for Imaging (PDI) Portable Data for Imaging - Consistent access to images and reports on CD Media

23. WHIT Conference 10-13 October 2006 22 What Is the IHE PDI Integration Profile? Images Evidence Objects Diagnostic Reports for: Import Storage Display Printing Enables the Reliable Interchange of Patient Records on CD including: CDs that Work !

24. WHIT Conference 10-13 October 2006 23 Distribution of Imaging Information on CD Media CD Creator Printer Image / Report Display Media Importer John Doe CD For use in other departments, e.g. surgery For enterprise data interchange For referral For printing For patient personal records

25. WHIT Conference 10-13 October 2006 24 IHE PDI – Media Creator Create DICOM Compliant CDROM media Create web content (optional) DICOMDIR INDEX.HTM README.TXT Directory of DICOM files IHE_PDI Directory of web files Other optional content Web content (optional) CDROM Structure:

26. WHIT Conference 10-13 October 2006 25 IHE PDI – Value Proposition Get CDs that can be Created and Read Anywhere Media Interoperability Validation: – Eliminate Sources of Problems & Incompatibilities Support for Exchange of DICOM Data Optional Support for Web Data: – View of Images and Reports in a Browser Allow Import of Patient Data into the Local Information Base

27. WHIT Conference 10-13 October 2006 26 Consistent Presentation of Images Manage, retrieve & use objects for hardcopy and softcopy grayscale presentation states Reporting Workflow Manage worklists, track status, perform & notify diagnostic reporting steps Scheduled Workflow Charge Posting Manage worklists, track status, perform & notify acquisition related step, create, store, manage, retrieve & use images Admit, Order, Schedule Patient Information Reconciliat ion Reconcile worklists, status, and data objects for unknown patients and demographics changes Access to Radiology Information - Consistent access to images and reports Key Image Notes Create, store, manage, retrieve & use objects to flag significant images Simple Image and Numeric Reports Manage simple diagnostic reports with optional images, measurements Presentation of Grouped Procs Manage individual procedure image subsets from a multi-procedure acquisition for viewing & reporting Charge Posting Collect and post timely billable procedure details ITI ATNA – Radiology Option (Replaces Basic Security) Evidence Documents Manage, retrieve & use objects to record study evidence Manage worklists, track status, perform & notify image processing & CAD steps Post- Processing Workflow NM Image Create, store, manage, retrieve & use NM image objects Portable Data for Imaging - Consistent access to images and reports on CD Media Teaching Files & Clinical Trials Export Standardize Clinical Trial Data and Anonymization Cross-Enterprise Image & Data Sharing (XDS-I) XDS for Imaging - Sharing of Imaging Information across health enterprises

28. WHIT Conference 10-13 October 2006 27 Enterprise A Enterprise B Physician Office Between Radiology and o o Imaging Specialists o o Non-imaging Professionals Between Enterprises PACS B PACS A Radiology -to- Radiology Radiology -to- Physicians PACS C Within an Enterprise Cross-Enterprise Image & Data Sharing (XDS-I) Business Need: Share Radiology Reports & Image

29. WHIT Conference 10-13 October 2006 28 Image-Enabled EHR Pregnancy Outpatient Clinics Encounter acquire evaluate index Image/ Report Repository store new data Ultrasound report and images Document Registry register (XDS architecture)

30. WHIT Conference 10-13 October 2006 29 register index evaluate Document Registry Image/ Report/ Document Repositories index query retrieve Document Repository store new data Report, letters (incl. images) (XDS architecture) Image-Enabled EHR Childbirth Inpatient Stay

31. WHIT Conference 10-13 October 2006 30 IHE Radiology – Integration Profiles Newest Additions in 2006 Workflow Extensions Import Reconciliation Workflow (IRWF) Describes workflow details for the import of external data: Evidence Objects e.g. DICOM images (on a CD) and Non-Digital Data e.g. scanned films, documents into the Enterprise Extends the PDI profile (interchange of CDs) with workflow integration capabilities Content Profiles Nuclear Medicine Image with Cardiac Option Addition of a Cardiac NM option to the existing NM Image Profile – improve functionality for nuclear medicine cardiac image viewing synchronous viewing of gated images or projections of tomographic images ability to display myocardial perfusion data

32. WHIT Conference 10-13 October 2006 31 IHE Radiology – Integration Profiles Newest Additions in 2006 (continued) Content Profiles (continued) Image Fusion (FUS) Specifies communications between systems creating and registering image sets and systems displaying fused images Defines how DICOM objects for spatial registration, blended presentation and the images themselves are created, stored, queried, retrieved, processed and displayed Mammography Image (MAMMO) Specifies how DICOM Mammography images & evidence objects are created, exchanged & used Full Field Digital Mammography (FFDM) Images on Acquisition Modalities CAD Systems acting as Evidence Creators Attributes & Capabilities for Image Displays IHE Brochure Going Digital: An IHE Guide for Mammography http://www.ihe.net/Mammo/going_digital_mammography.cfm

33. WHIT Conference 10-13 October 2006 32 IHE Radiology – Integration Profiles An Outlook for 2007 (Year 9) Incremental Developments ~2 New Integration Profiles / Year Work Item Proposals for 2007 Mammography Workflow Enhanced CT / MR Image Reporting Strategy / Improvements / Workflow Considerations DICOM SR HL7 CDA PDF Multi-Study Acquisition Local hard split on Acquisition Modalities an easy entry alternative to PGP (Presentation of Grouped Procedures) … others … Selection / priorities to be determined in October 2006

34. WHIT Conference 10-13 October 2006 33 International Adoption of IHE Year 1 (1999)Year 2 (2000)Year 3 (2001)Year 4 (2002)Year 5 (2003)Year 6 (2004)Year 7 (2005) France Local Deployment National Extensions (Local Adaptions) Promotional & Live Demonstration Events Funding USAGermanyItalyJapanUKCanadaKoreaTaiwanNorwayHollandSpainChina

35. WHIT Conference 10-13 October 2006 34 IHE Organizational Structure ACC HIMSS RSNA JAHIS JIRA JRS METI-MLHW MEDIS-DC JAMI GMSIH SFR SFIL SIRM BIR EuroRec COCIR EAR-ECR DRG ESC Professional Societies / Sponsors Contributing & Participating Vendors IHE (International) Strategic Development Committee Global Development Radiology Cardiology IT Infrastructure Patient Care Coordination Patient Care Devices Laboratory Pathology Pharmacy / Medication Admin Radiation Oncology New IHE Europe IHE North America France USA Canada IHE Asia-Oceania Japan KoreaTaiwan Netherlands Spain Sweden UK ItalyGermany Norway Regional Deployment China New

36. WHIT Conference 10-13 October 2006 35 IHE Europe:http://www.IHE-Europe.org IHE Main Web Site:http://www.IHE.net Questions ?