1. IHE Cardiology Image Enabled Office Harry Solomon

2. IHE Cardiology Page 2 Image Enabled Office Problem Statement An increasing number of clinicians have both imaging equipment and electronic medical records in their offices. The prevalence of imaging equipment is increasing as lower cost systems are being brought to market, and the universal deployment of EMRs is an explicit goal of the U.S. government. Note: The draft U.S. “meaningful use criteria” for 2015 would require EMRs to handle medical imaging objects, although the extent and nature of such support is undetermined. This equipment needs to be integrated into the office environment workflow, and the imaging results need to be seamlessly integrated into the EMR. Note that the systems in an office environment must in may ways be more technically sophisticated than in an in-patient environment, as they must operate with less IT-savvy human supervision, and combine features that would otherwise be distributed across multiple systems.

3. Profile Scope The Image-Enabled Office (IEO) Profile specifies the integration of an imaging suite (modalities, storage server, and workstations) with an electronic health record system in an ambulatory office setting. This is a fully bi-directional integration, including ordering/scheduling of an imaging exam, status reporting for that exam, report creation, and web-based imaging exam review integration. It also addresses import of referral image exams from exchange media into the integrated office environment. Out of Scope: Exchange with other entities (supported by XDS and XDS-I functionality), except for image import from media IHE Cardiology Page 3

4. Use Case 1 Andy Carditis, a patient, is referred to Belle Plummer, a cardiologist, for consultation regarding a fever and associated heart murmur (potential infective endocarditis). Dr. Plummer orders blood labs and an echo study, which the patient elects to have performed in Dr. Plummer’s cardiology office. The patient and the cardiology office manager schedule the echo for later that day. At the scheduled time, Sue Skann, the sonographer in the office, preps Mr. Carditis. She uses the ultrasound machine to query for the scheduled exams, and selects Mr. Carditis from the list. She performs the echo study, and makes preliminary measurements on the ultrasound machine. The images and measurements are sent to a local mini-PACS image server. On an imaging workstation, Dr. Plummer reviews the images and measurements, and notes the vegetation on the mitral valve. She selects a representative image, and saves a reference to it in a note that is stored on the mini-PACS. She defers creating a report until the lab results will have been returned. The next morning, the lab results are returned electronically and recorded in the office EMR. On the EMR workstation, Dr. Plummer reviews both the lab results and the echo measurements, and creates a report with findings, selected measurements, and the representative image selected the previous day. She orders a two week regimen of intravenous antibiotics, which will be administered by her nurse practitioner. The report is stored in the EMR, and is also sent to the referring primary care physician. IHE Cardiology Page 4

5. Approach Reuse capabilities from existing IHE Profiles: Radiology Scheduled Workflow Radiology Import Reconciliation Workflow Radiology/Cardiology Evidence Documents Cardiology Displayable Reports IT Infrastructure Patient Demographics Query IT Infrastructure Consistent Time IHE Cardiology Page 5

6. IHE Cardiology Page 6 In-patient Scheduled Workflow Diagram    Pt. Registration [RAD-1]  Patient Update [RAD-12] Pt. Registration [RAD-1]  Patient Update [RAD-12]   Placer Order Management [RAD-2]  Filler Order Management [RAD-3] ADT  Query Images [RAD-14]  Retrieve Images [CARD-4] Image Display Modality Image/Evidence Stored [CARD-2] Storage Commitment [CARD-3]  Procedure Scheduled [RAD-4]  Procedure Updated [RAD-13]  Query Modality Worklist [RAD-5] Performed Procedure Step Manager  Modality PS in Progress [CARD-1]  Modality PS Completed [RAD-7]  Modality PS in Progress [CARD-1]  Modality PS Completed [RAD-7]  Modality PS in Progress [CARD-1]  Modality PS Completed [RAD-7] Order Placer Acquisition Modality Image Manager Image Archive DSS/ Order Filler  Patient Update [RAD-12] Evidence Creator Modality Image/Evidence Stored [CARD-2] 

7. IHE Cardiology Page 7 IEO Functional Features Equivalent to in-patient “top half” systems should be a single actor incorporating both practice management and EMR Image Manager/Archive should be an actor separate from PM/EMR Modality, Image Display, and Evidence Creator actors should operate with no changes from Scheduled Workflow / ED Modality worklist, MPPS, image/evidence storage Reports should be creatable on either an imaging workstation, or at an EMR workstation Report Creator actor should operate with no changes from Displayable Reports Destination of Encapsulated Report is EHRS Image Manager/Archive shall support a web-based viewer interface Usable from EMR workstation Upon MPPS complete (Storage Commitment?), the IM/IA shall send a link to the web viewer for the study to the EHRS

8. System Actors (top level) Acquisition Modality Importer Image Manager / Image Archive Retrieve Images/Evidence Image Display Images /Evidence Stored Modality Worklist Procedure Step in Progress/Completed Report Submission Procedure Scheduled / Update Patient Update Patient Demographics Access DICOM Study for Display Storage Commitment Report Storage EHR-S

9. IEO Issues Should EHRS DICOM interface be broken out to a separate actor (as not typically included in EHRS)? No – it is responsibility of EHRS vendor to integrate with an interface engine if needed. Existing IHE transactions specified with a variety of end point actor definitions Modality Worklist transaction to Department System Scheduler / Order Filler actor; Patient Demographics Query transaction to Patient Demographics Consumer actor Need to group these formal actor definitions with our desired actors Transcoding of DICOM Structured Report measurements into CDA observations is non-trivial No transcoding functional requirements included in Profile – left to implementation IHE Cardiology Page 9

10. Refined Actor / Transaction Diagram Report Manager Display Patient Demographics Supplier DSS / OF Acquisition Modality Importer Performed Procedure Step Manager Image Manager / Image Archive Query Images/Evidence […] Retrieve Images/Evidence […] Image Display Image /Evidence Stored […] Query Modality Worklist [RAD-5] Procedure Step in Progress […] Procedure Step Completed […] Report Creator Encapsulated Report Submission [CARD-7] Procedure Scheduled [RAD-4] Procedure Updated [RAD-13] Patient Update [RAD-12] Notify Study Access [CARD-y] Patient Demographics Query [ITI-21] Evidence Creator Access DICOM Study for Display [CARD-z] Storage Commitment [RAD-10] Encapsulated Report Storage [CARD-9] Report Display Report Repository Encapsulated Report Retrieve [CARD-11] Encapsulated Report Query [CARD-10] EHR-S Patient Demographics Consumer

11. Dynamic Model – Process Flow 1 IHE Cardiology Page 11

12. Dynamic Model – Process Flow 2 IHE Cardiology Page 12

13. IHE Cardiology Page 13 New Transactions Notify Study Access HL7 ORU^R01 Trigger Event – availability of study images at Image Manager OBX segment with Study Unique ID Alternate under consideration – ORI^O24 Access DICOM Study for Display Web service over HTTP Uses Study UID from Notify Study Access transaction Returns top level web page for navigation / viewing study in standard web browser

14. Notify Study Access - OBX OBX-2 Value Type : “HD” (Hierarchical Designator) OBX-3 Observation Identifier : “113014^DICOM Study^DCM” OBX-5 Observation Value : DICOM Study Instance UID as an ISO OID OBX-11 Observation Result Status : “R” (Results entered -- not verified) OBX-14 Date/Time of the Observation : date and time of the most recent update made to the study content (e.g., most recent addition, deletion or modification of images or objects within the study). IHE Cardiology Page 14 SEQLENDTUsageCard.TBL#ITEM#ELEMENT NAME 14SIR00569Set ID – OBX 23IDR012500570Value Type = HD 3705CWER00571Observation Identifier 570HDR00573Observation Value 111IDR008500579Observation Result Status = R 1424DTMR200582Date/Time of the Observation

15. Access DICOM Study for Display Follows model of IHE ITI Retrieve Info for Display web services http:// /IHERetrieveDICOMInfo?requestType=DICOM- STUDY&studyUID= Display actor (in EHRS) must be configured with web access port of Image Manager ( ) Alternatively (not part of IEO profile), EHRS can be configured with (thick) client app from Image Manager vendor, and invoke it with the Study UID IHE Cardiology Page 15