1. September, 2005What IHE Delivers 1 Chris Lindop – GE Healthcare IHE Radiology Planning/Technical Committee Co-Chair IHE XDS-I: Planning for an Image Enabled EHR

2. 2 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

3. 3 Focus: Image-enabled EHR Non-imaging data  Patient data  Clinical data Laboratory resultsLaboratory results Surgery reportsSurgery reports Prescriptions, medsPrescriptions, meds Letters or notesLetters or notes Integrate with imaging data and processes Imaging data  Patient data  Images and evidence RadiologyRadiology CardiologyCardiology Nuclear MedicineNuclear Medicine Integrate with non- imaging data and processes

4. 4 Business need: share in the Care setting Radiology Reports and Images Between Care Providers:  Radiologists  Radiologists and Technologists  Radiologists and Surgeons  Radiologists and Clinicians Between Care Providers and Patients Within an enterprise Cross-enterprise in a healthcare region Cross-healthcare regions

5. 5 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 Technologist: fulfilling an imaging order Information need may include current or longitudinal evidence

6. 6 IHE - Connecting standards to care Care providers and IT professionals work with vendors to coordinate the implementation of standards to meet their needs  Care providers identify the key interoperability problems they face  Drive industry to develop and make available standards-based solutions  Implementers follow common guidelines in purchasing and integrating systems that deliver these solutions

7. 7 IHE Participants and Relationships Participants include:  Users - Clinicians, Staff, Administrators, CIOs, Governments RSNA, HIMSS, etcRSNA, HIMSS, etc  Vendors - Information Systems and Equipment e.g., imaging, Clinical Information Systems, Consultantse.g., imaging, Clinical Information Systems, Consultants Maintains formal liaison with Standards Development Organizations (SDOs):  HL7, DICOM, ISO (Liaison D) ISO TC215 (including ANSI) approved IHE Process and Profiles to be published as technical reports

8. 88 IHE Organizational Structure Contributing & Participating Vendors IHE North America USA Canada IHE Asia Japan KoreaTaiwan China ACC ACCE ACEP JAHIS JIRA JRS METI-MLHW MEDIS-DC JAMI RSNA SFR SFIL SIRM BIR EuroRec COCIR EAR-ECR DRG ESC Professional Societies / Sponsors ACP GMSI HIMSS IHE International Board Global Development Radiology Cardiology IT Infrastructure Patient Care Coordination Patient Care Devices Laboratory Pathology Eye CareRadiation Oncology Public Health, Quality and Research IHE Asia-Pacific New ZealandAustraliaMalaysia IHE Europe FranceNetherlands Spain Sweden UK Italy Germany Norway Austria Regional Deployment

9. 9 IHE: A Framework for Interoperability A common framework for harmonizing and implementing multiple standards A common framework for harmonizing and implementing multiple standards  Application-to-application  System-to-system  Setting-to-setting Enables seamless health information movement within and between enterprises, regions, nations Promotes unbiased selection and coordinated use of established healthcare and IT standards to address specific clinical needs

10. 10 IHE Technical Frameworks Implementation Guide for each Integration Profile An Integration Profile :   A Set of Actors   Exchanging Transactions Use cases Process Flows For each transaction:   Std referenced   Options specified   Mapping required Actors Transactions

11. 11 Proven Standards Adoption Process IHE Integration Profiles B IHE Integration Profile A Easy to Integrate Products IHE Demonstration User Site RFP Standards IHE Technical Framework Product IHE Integration Statement IHE Integration Profiles at the heart of IHE :  Detailed selection of standards and options each solving a specific integration problem  A growing set of effective provider/software-developer agreed solutions  Vendors can implement with ROI  Providers can deploy with stability  Process started in 1998; continuously improved IHE Connect-a-thon Product With IHE IHE Connect-a-thon Results

12. 12 Radiology Profiles Access to Radiology Information Consistent Presentation of Images Evidence Document Key Image Notes Simple Image & Numeric Reports Presentation of Grouped Procedures Post- Processing Workflow Reporting Workflow Charge Posting Patient Info. Reconciliation Scheduled Workflow Portable Data for Imaging Mammo- graphy Image Audit Trail & Node Authentication – Radiology Image Fusion Teaching Files & Clinical Export Import Reconcil- iation Workflow Cross-Enterprise Document Sharing for Imaging NM Image Card Option Radiation Exposure Monitoring Mammo- graphy Acquisition Workflow Infrastructure Presentation & Content Workflow Users Guides Radiology Departmental WorkflowMammography Workflow Trial Implementation ITI Profile(radiology option

13. 13 IHE Integration Profiles for Health Info Nets What is available and has been added in 2007 Clinical and PHR Content Health Data Exchange Patient Demographics Query Patient Identifier Cross-referencing Map patient identifiers across independent identification domains Notification of Document Availability Notification of a remote provider/ health enterprise Request Form for Data Capture External form with custom import/export scripting Patient ID Mgmt Other Final Text Approved Trial Implementation-2007 – Final Txt 2008 Cross-Enterprise Document Sharing Registration, distribution and access across health enterprises of clinical documents forming a longitudinal record Cross-Enterprise Document Pt-Pt Reliable Interchange Cross-Enterprise Document Media Interchange Cross-Community Access Security & Privacy Consistent Time Coordinate time across networked systems Audit Trail & Node Authentication Centralized privacy audit trail and node to node authentication to create a secured domain. Basic Patients Privacy Consents Establish Consents & Enable Access Control Document Digital Signature Attesting “true-copy and origin Cross-Enterprise User Assertion Provides Trusted Identity Medical Summary ( Meds, Allergies, Pbs) Format of the Document Content and associated coded vocabulary Emergency Referrals Format of the Document Content and associated coded vocabulary PHR Extracts/Updates Format of the Document Content and associated coded vocabulary ECG Report Document Format of the Document Content and associated coded vocabulary Lab Results Document Content Format of the Document Content and associated coded vocabulary Scanned Documents Format of the Document Content Imaging Information (Images & Reports) Format of the Document Content and associated coded vocabulary

14. 14 Categories of Healthcare Communication Services Security Document Sharing Patient and Provider ID Mgt Dynamic Information Access Workflow Management Source persisted and attested health records Specific info snapshot provided on demand 2 or more entities synchronize a task e.g. access to last 6 months historical labs and encounter summaries e.g. order a lab test, track status and receive results e.g. get a current list of allergies or med list from a source Hospitals HIEs and RHIOs

15. 15 Combining IHE Profiles Document Content & Modes of Document Exchange Document Exchange Integration Profiles Document Sharing XDS Sharing XDS Media Interchange XDM Reliable Pt-Pt Interchange XDR Doc Content Profiles (Semantics content) Scanned Doc XDS-SD LaboratoryXD*-Lab PHR Exchange XPHR Discharge & Referrals XDS-MS ImagingXDS-I ConsentBPPCEmergencyEDR Pre- Surgery PPHP Functional Status Assesment FSA

16. 16 Use of a shared XDS infrastructure to access Radiology Reports and Images (XDS-I) Hospital Imaging Center Physician Practice Between Radiology and : Between Radiology and : Imaging specialistsImaging specialists Non-imaging cliniciansNon-imaging clinicians PatientsPatients PACS Y PACS Z Radiology -to- Radiology Radiology -to- Physicians Same XDS Infrastructure (Registry and Repositories) for medical summaries and imaging information ! Patient Home

17. 17 Radiology Enterprise A Radiology Enterprise B Physician Office Regional Health Information Network Cross- Enterprise Registry Patient Id= 3547F45 Report 5/21/1998 : CT Head  B Study 5/21/1998 : CT Head  B Report 2/18/2005 : Chest Xray  A Study 2/18/2005 : Chest Xray  A PACS B PACS A Sharing Radiology Reports and Images in a Regional Health Information Network

18. 18 Radiology Enterprise A Radiology Enterprise B Physician Office Regional Health Information Network Query for Documents Register Imaging Information for sharing Prior imaging Reports & Studies Cross- Enterprise Registry Register Imaging Information for sharing Patient Id= 3547F45 Report 5/21/1998 : CT Head  B Study 5/21/1998 : CT Head  B Physicians and Systems within a Regional Health Network - Routine Imaging Referral

19. 19 Radiology Enterprise A Radiology Enterprise B Physician Office Regional Health Information Network Register Imaging Information for sharing Cross- Enterprise Registry Notification of Doc Availability Register Imaging Information for sharing Physicians and Systems within a Regional Health Network - Routine Imaging Referral

20. 20 Radiology Enterprise A Radiology Enterprise B Physician Office Prior Imaging Report & Study Regional Health Information Network Query for documents Imaging Report & Study Cross- Enterprise Registry Patient Id= 3547F45 Report 5/21/1998 : CT Head  B Study 5/21/1998 : CT Head  B Report 2/18/2005 : Chest Xray  A Study 2/18/2005 : Chest Xray  A Notification of Doc Availability Physicians and Systems within a Regional Health Network for a Routine Imaging Referral

21. 21 XDS-I Dependencies XDS-I depends on IT Infrastructure Cross-Enterprise Document Sharing (XDS) New Actors  Imaging Document Source  Imaging Document Consumer (should be grouped with Document Consumer) Same Actors as in XDS  Document Consumer  Document Registry  Document Repository Added extension to support imaging data (images and reports)

22. 22 Document Consumer Retrieve Document Query Documents Patient Identity Source Patient Identity Feed Imaging Document Source Document Registry Document Repository Provide & Register Document Set Register Document Set Imaging Document Consumer Retrieve Images Retrieve Presentation States Retrieve Key Image Note Retrieve Evidence Documents WADO Retrieve XDS-I Actors and Transactions

23. 23 XDS-I Transaction requirements XDS-I Actors:  Imaging Document Consumer at least one Retrieve ( [RAD-55], [RAD-16], [RAD-17], [RAD-27], [RAD-31] [RAD- 35])at least one Retrieve ( [RAD-55], [RAD-16], [RAD-17], [RAD-27], [RAD-31] [RAD- 35])  Imaging Document Source Provide and Register Document Set [RAD-54]Provide and Register Document Set [RAD-54] WADO Retrieve [RAD-55]WADO Retrieve [RAD-55] Retrieve Images [RAD-16], Retrieve Presentation States [RAD-17] Retrieve Reports [RAD-27], Retrieve Key Image Note [RAD-31], Retrieve Evidence Documents [RAD-45]Retrieve Images [RAD-16], Retrieve Presentation States [RAD-17] Retrieve Reports [RAD-27], Retrieve Key Image Note [RAD-31], Retrieve Evidence Documents [RAD-45] XDS Actors  Document Repository Provide and Register Document Set [RAD-54] Provide and Register Document Set [RAD-54]

24. 24 Options Imaging Document Source must support at least one of the following options:  Extensive Set of DICOM Instances  PDF Report  Text Report wrapped in a CDA Document

25. 25 Sharing of Extensive DICOM Instance Set

26. 26 Document Registry Document Repository Manifest Reference to image 1 DICOM Manifest Reference to image 2 Reference to image 3 Manifest Clinical Encounter Clinical IT System Query Registry Manifest Retrieve Manifest Reference to image 1 DICOM Manifest Reference to image 2 Reference to image 3 Retrieve ImagesRegister Manifest Manifest

27. 27 Sharing of Extensive DICOM Instance Set The shared Document is a manifest  a Key Object Selection DICOM Instance title : manifesttitle : manifest Imaging Document Source is required  to ensure that the referenced images from within a published manifest are available to be retrieved Imaging Document Source is responsible  for replacing a previously submitted manifest Document when a change occurs to the manifest content (eg. Change of the DICOM SOP instances referenced within the manifest)

28. 28 Sharing of Imaging Report

29. 29 Radiology system Report Source ….. Findings: Header : Report Type: OB / Gyn BPD... ….. Radiology Report Impressions : Gestational Age... Text wrapped into CDA Report PDF Report

30. 30 Radiology system Report Source Document Registry Document Repository Report Clinical Encounter Clinical IT System Query Registry Retrieve ReportRegister Report Report ….. Findings: Header : Report Type: OB / Gyn BPD... ….. Radiology Report Impressions : Gestational Age...

31. 31 Sharing of Reports The shared Report Document format is  PDF, Text wrapped in a CDA A report can  embed selected images in its PDF format  include fully resolved hyperlinks (interactively clickable) that point to the selected images Imaging Document Source is responsible  for formatting the hyperlink to reference relevant images as a DICOM WADO URI or as IHE RID Request for Document Imaging Document Source is required  to ensure that image references are valid links

32. 32 Linking Report to Complete Set of Images Document Repository Document Registry Study Manifest Report Document Entry Submission Set

33. 33 Linking Report to Complete Set of Images Document Repository Document Registry Document Entry Submission Set 1 Report Document Entry Submission Set 2 Study Manifest

34. 34 Linking Report to Prior Images and Prior Report Document Repository Document Registry Document Entry Submission Set 3 Prior Study Manifest Document Entry Submission Set 1 Prior Report Document Entry Submission Set 2 Report Document Entry Submission Set 4 Study Manifest

35. 35 Linking Report to Selected Images Radiology system Report Source ….. Findings: Header : Report Type: OB / Gyn BPD... ….. Radiology Report Relevant Image Gestational Age... WADO URI Link to image

36. 36 XDS-I Metadata Radiology specific  Acquisition Modality (e.g. CT, MR)  Anatomic Region (e.g. Arm, Elbow, Hand)  Requested procedure (e.g. MRI Knee with contrast) Query example  find all “CT of the Head” of patient John Doe for the last 2 years

37. 37 Sharing Imaging Documents (XDS-I) Document Registry Register report & image references Retrieve selected imaging report references Radiology department patient Query for re- ports Document availability Shared re- pository Onco- logist GP (follow-up) Images, report (PACS, RIS) report Longitudinal record system: across encounters Care record sys- tems: specific care delivery Retrieve

38. 38 How to Participate As a User or Vendor Committee Member Become a member of relevant Domains Planning or Technical Committees As a User, Consultant or Vendor Interested Observer Provide Public Comments on Technical Framework Supplements Attend Demonstrations, Educational Events and Workshops

39. 39 How to Use IHE As a Vendor Implementer Implement IHE Integration Profiles Test systems through Connectathon process Publish an IHE Integration Statement for products As a User Implementer or Consultant Use IHE Integration Profiles to develop interoperability strategy Use Connectathon Results and Integration Statements to evaluate vendors Demand IHE Integration Profile compliance in RFPs

40. 40 Providers and Vendors Working Together to Deliver Interoperable Health Information Systems in the Enterprise and Across Care Settings http://www.ihe.net

41. 41 More Resources - www.ihe.net www.ihe.net Frequently Asked Questions Integration Profiles in Technical Frameworks:  Cardiology  IT Infrastructure  Laboratory  Patient Care Coordination  Patient Care Devices  Radiation Oncology  Radiology Connectathon Results Vendor Products Integration Statements Participation in Committees and Connectathons

42. September, 2005What IHE Delivers 42