1. RSNA 2007 – Informatics ClassroomWhat IHE Delivers 1 Kevin ODonnell, Toshiba Medical Systems Chris Lindop, GE Healthcare Your Problems; IHE Solutions

2. RSNA 2007 – Informatics Classroom 2 Learning Objectives Review well-known sources of pain still commonly afflicting radiologists, department managers, PACS administrators and referring physicians in practice today Enumerate some of the specific ways the quality, speed, cost and efficiency of the care you provide may be being degraded Understand how you should be benefiting from new electronic infrastructure and integrated systems Learn which IHE Integration Profiles would be good first steps for each problem

3. RSNA 2007 – Informatics Classroom 3 Images on CDs Scenario: A referred patient arrives with relevant prior imaging on a CD And then the fun starts…

4. RSNA 2007 – Informatics Classroom 4 Your Problems with CDs I plug the CD into my workstation and nothing happens The CD format is not compatible with my workstation The images are not in DICOM The images are DICOM but are not properly encoded The CD tries to auto-launch a viewer that collides with the one on my workstation Impact Time is wasted Relevant clinical data is inaccessible

5. RSNA 2007 – Informatics Classroom 5 Your Problems with CDs Every CD seems to have a different viewer It costs me time trying to learn them all I dont work as quickly when I dont know how to use them The viewers lack specific features I need The viewers require additional software that I do not have My IT group has security concerns about running unknown software from CDs Impact More wasted time Less effective review of data

6. RSNA 2007 – Informatics Classroom 6 Your Problems with CDs The Images are in the PACS but are messed up The patient ID is wrong, it doesnt come up in a query I cant display the new images with the old The unknown procedure codes mess up my hanging protocols Impact: More lost time More drags on effectiveness

7. RSNA 2007 – Informatics Classroom 7 How It Should Work I insert the CD into my workstation The DICOM Viewer installed on my workstation displays the CD contents my way I decide to import the data into my PACS The CD content is retrieved from the disk The content is reconciled and automatically prepared for importation into the patients electronic medical record The images and reports are reviewed on PACS in the context of the current patient encounter I insert the CD into a random PC (uncommon) CD may have a DICOM viewer CD may have Browser versions of images and report

8. RSNA 2007 – Informatics Classroom 8 IHE Solution Two relevant Integration Profiles (PDI) - Portable Data for Imaging Uses only the most common, most compatible DICOM CD format Adds requirements to remove common sources of problems Based on cross-testing between vendors (IRWF) – Import Reconciliation Workflow During image import, the details are fixed to match (or not conflict with) local values Patient IDs, Name Procedure Codes, Accession Numbers, etc.

9. RSNA 2007 – Informatics Classroom 9 Acquisition Workflow Scenario: I order an imaging procedure for my patient. Really, what could be simpler?

10. RSNA 2007 – Informatics Classroom 10 Your Problems with Workflow Why are my techs entering patient and procedure information on all the systems? Why is this a manual task? My techs should be doing scans, not duplicating data entry All too often, data entry mistakes are made Patient records get fragmented Priors are not always available at time of reading Impact Degraded care, reduced productivity

11. RSNA 2007 – Informatics Classroom 11 Your Problems with Workflow Why is it so hard to close an order? Somewhere in the process of getting the images and distributing the reports, the accession # keeps getting messed up Studies get disconnected and go unread Billing details dont match what was actually performed (so the payor doesnt want to pay) Impact Delayed care, reduced productivity, lost revenues

12. RSNA 2007 – Informatics Classroom 12 Your Problems with Workflow Why arent my images showing up on PACS? If patient info was mistyped at acquisition, the query wont match Someone spends time searching or we re-scan Network failure; modality didnt know they werent on PACS and deleted them We make techs manually confirm all images are on the PACS It only takes a couple minutes At 100,000 studies per year, thats only 416 8-hour shifts of work Impact Delayed care, increased dose, reduced productivity

13. RSNA 2007 – Informatics Classroom 13 Your Problems with Workflow When a name needs to be fixed I never know when/if the patient record will be properly reassembled. John Does get scanned and identified later images/report needs to be reintegrated Patients get incorrectly entered (or mis-selected in a worklist) Peoples names change (e.g. marriage) People are changing things on the modality, in the PACS, in the RIS, sometimes inconsistently, or at different times So their clinical history is missing, or their images have been moved and I cant find them, or both Impact Delayed care, incomplete information, reduced productivity

14. RSNA 2007 – Informatics Classroom 14 How It Should Work Registration feeds the Scheduling System Patient demographics are entered once at registration & centrally managed Modalities download Worklists Patient demographics & Procedure detail entry is automatic, fast, accurate & up-to-the-minute Relevant clinical and protocol information details are included Procedure code in worklist can optionally trigger protocol selection PACS is notified of scheduled procedures Relevant priors can be automatically pre-fetched Modalities report procedure progress to RIS and PACS Accession # consistently replicated in Images and Reports Better tracking/closure of orders, better billing PACS receipt of Images is automatically confirmed by Modality Fewer Lost Studies

15. RSNA 2007 – Informatics Classroom 15 IHE Solution Two relevant IHE Integration Profiles (SWF) – Scheduled Workflow Integrates Registration, Scheduling, Acquisition Workflow and Image Content Bridges HL7 and DICOM spaces properly Most current products support it (but ask for it to be sure) (PIR) – Patient Information Reconciliation Facilitates coordinated reconciliation between PACS, RIS and HIS Handles John Does, fixing mistakes and back-filling orders for unscheduled exams

16. RSNA 2007 – Informatics Classroom 16 Cross-Enterprise Image Sharing Scenario An ER patient with abdominal pain has a lesion on their x-ray. The H&P noted an earlier x-ray (in another state) with an abnormal finding. I need the prior images STAT! OK, no one expects this to be easy…

17. RSNA 2007 – Informatics Classroom 17 Your Image Sharing Problems How do I even find out who has the images? Patient said it was an imaging center in downtown LA How many imaging centers are there in downtown LA? Patient was not sure of the name of the PCP Impact Time wasted trying to track down and obtain the images Potentially unnecessary procedures (imaging, surgery)

18. RSNA 2007 – Informatics Classroom 18 Your Image Sharing Problems How do I find the matching Patient Record at the other institution? Patient doesnt know their patient ID from the other site I only have the Patient ID for my institution The other site doesnt really want to let me go browsing their patient database Impact More delays and uncertainty

19. RSNA 2007 – Informatics Classroom 19 Your Image Sharing Problems How do I get the Images? Mail? No - need images STAT Fax? Not good for sending images E-mail? Do we both have secured e-mail systems? How do I view them? Their web viewer? No account on their system - No experience with their product Impact Delayed care or incomplete information

20. RSNA 2007 – Informatics Classroom 20 Your Image Sharing Problems What about security and privacy policies? I dont have privileges at the other hospital. Who do I have to talk to to get access to the data? Isnt there some way to get emergency access? Im just trying to treat the patient. Impact Delayed care and/or incomplete information

21. RSNA 2007 – Informatics Classroom 21 How It Should Work My EHR Terminal handles everything: I select my patient on my system I select the RHIO that supported my patients care My system automatically matches the patient and lets me confirm (either by ID cross-reference table or demographics matching) I ask for a list of relevant priors. Success! We have no BAA with the other site so I click Break Glass. My ID and access of the data is logged for later security review. My system pulls the images and reports electronically from the other system for my review I determine there is no change in the lesion & diagnose an Aortic Transsection, avoiding unnecessary surgery

22. RSNA 2007 – Informatics Classroom 22 IHE Solution (XDS-I) Cross-Enterprise Document Sharing for Imaging Shares images, diagnostic reports and related information between healthcare enterprises (PIX) Patient ID Cross-referencing Cross-index patient IDs across multiple sites (PDQ) Patient Demographics Query Query and retrieve a patients demographic and visit information (ATNA) Audit Trail and Node Authentication Systems Authentication PHI-related audit events management (BPPC) Basic Patient Privacy and Consent Patient privacy consents & enforcement

23. RSNA 2007 – Informatics Classroom 23 Teaching Files or Clinical Trials Scenario: This study Im reading would make a good case for my/our teaching files or This study should be included in a clinical trial we are participating in It seems so simple…

24. RSNA 2007 – Informatics Classroom 24 Your Teaching/Clinical Trial Problems Where did I put my notes? Why am I the one digging through PACS for the studies? Tracking down images after the fact is a pain Impact Inefficient use of time Cant find study later Lower participation in clinical trial No cool images to share

25. RSNA 2007 – Informatics Classroom 25 Your Teaching/Clinical Trial Problems How am I supposed to get the images to the clinical trial, or to my teaching file account? The images are raw material; I need to get them to a system where I can work up a proper teaching file Were in 5 clincal trials, each with their own file server; I need to get the images to the right one. Impact Inefficient use of time Becomes more trouble than its worth

26. RSNA 2007 – Informatics Classroom 26 Your Teaching/Clinical Trial Problems De-identifying the data for HIPAA is painful What are DICOM Attributes and why is PHI hiding in so many of them? The tools provided require an IT savvy that I do not have PACS Admin says I screwed up the images when I edited them Impact Inefficient use of time Becomes more trouble than its worth Might fail to protect patient privacy

27. RSNA 2007 – Informatics Classroom 27 How should it work? I flag the image(s) of interest I identify the clinical trial and/or add a few notes about the clinical context (optional) Images are de-identified automatically Images and supporting information are bundled and automatically routed to the appropriate destination Teaching File Authoring System; Clinical Trial Export Node Later, I login to my Teaching File account: My images and notes are waiting for me I finalize the teaching case and put it in our repository

28. RSNA 2007 – Informatics Classroom 28 IHE Solution (TCE) – Teaching File & Clinical Trial Export Automatic De-identification Automatic Routing Can include brief notes Compatible with free RSNA MIRC tools Teaching File Server Teaching File Authoring Tool Clinical Trial Node mirc.rsna.org

29. RSNA 2007 – Informatics Classroom 29 Integration Challenge Notice the pattern? Scenario: I want to do something that requires some of the (literally) dozens/hundreds of systems in my department to collaborate…

30. RSNA 2007 – Informatics Classroom 30 Your Integration Problem My systems claim to be standards-based, but they still cant integrate to do what I want. Some of my systems use different parts of the same standard Some of my systems use the same standard in different ways Some of my systems use multiple standards Some of my systems use the enhanced proprietary standard preferred by the vendor My vendors have different ideas about what each other should do Many of my vendors products have never been directly tested together Impact Lack of interoperability Costly point-to-point integration Long install & deployment cycle Have to do it over again with each new system

31. RSNA 2007 – Informatics Classroom 31 IHE Solution Working with vendors, care providers and standards organizations, IHE: Distills a clear description of the problem Determines the right way to solve it using standards (IHE Profile) Documents the solution in an implementation guide (IHE Technical Framework) Coordinates cross-vendor testing of the solution (IHE Connectathon) Go see the rest of the profiles

32. RSNA 2007 – Informatics Classroom 32 IHE in Action Visit IHE Demonstrations at RSNA 2007 Cross-Enterprise Document Sharing for Imaging [XDS-I] Teaching File & Clinical Trial Export [TCE] IHE Product Showcase and participating Vendor Booths Visit IHE Demonstrations at HIMSS 2008 Integration Showcase Covers IT, Radiology, Cardiology, …. Visit www.ihe.net/profileswww.ihe.net/profiles There are MANY more Profiles Start learning about them and IHE

33. RSNA 2007 – Informatics Classroom 33 Summary Become familiar with the IHE Profiles that address your pain points Make IHE Profiles part of your purchase and upgrade requirements; List them in your RFP

34. RSNA 2007 – Informatics Classroom 34