Integrating the Healthcare Enterprise

Integrating the Healthcare Enterprise
Improving Clinical Care: IHE Integration Profiles in Detail

Co-authors and Presenters
Charles Parisot Member IHE Technical and Planning Committees GE Medical Systems – Information Technologies Sanjay Jain Co-Chair IHE Planning Committee Cerner Corporation, Radiology and Clinical Imaging Andrei Leontiev Co-Chair IHE Technical Committee IDX Systems Beya Aich Siemens Medical Solutions John Paganini

IT/Imaging Integration Challenge IHE, A Novel Approach
An RSNA & HIMSS Initiative promoting and supporting the integration of systems in a healthcare enterprise To improve efficiency and quality of clinical practice Serious Integration Challenges: Systems need info that other systems have Systems communicate poorly or not at all Result in tedious inefficient workflows and data inconsistent Understanding the Clinical Benefits ……the IHE Integration Profiles RSNA 2002

Integration Profiles Scheduled Workflow
Presentation of Grouped Procedures Subset a single acquisition Patient Information Reconciliation Unknown patients and unscheduled orders Post- Processing Workflow Schedule, perform, & notify image processing & CAD steps Charge Posting Collection of billable procedure details Admit, order, schedule, acquire images, notify of completed steps Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Key Image Notes Flag significant images Simple Image and Numeric Reports Simple reports with image links and, optionally, measurements 3 profiles added in year 4. Basic Security, Charge Posting, and Post Processing workflow. Access to Radiology Information Consistent access to images and reports Basic Security Audit Trail Consolidation & Node Authentication RSNA 2002

IHE Workflow Concepts IHE identifies four fundemental workflow information units. ORDER : A request for radiologic service REQUESTED PROCEDURE : A Unit of Reporting Work with associated codified, billable acts Procedure Steps : The smallest unit of work in the workflow: SCHEDULED PROCEDURE STEP: ‘A unit of work to do’ PERFORMED PROCEDURE STEP: ‘A unit of work done’ Representation includes: healthcare providers, information systems vendors, imaging systems vendors, and standards groups participating "Assisted Acquisition Protocol Setting" option operates at the Scheduled and Performed Procedure Step Level RSNA 2002

IHE Workflow is User Driven
Information Unit has its Prime User ORDER: A request for imaging service (Accession Number) CLINICIAN OR REFERING DOC: The Imaging Dept Customer REQUESTED PROCEDURE : Units of work resulting in one Report with associated codified, billable acts (Requested Procedure ID) RADIOLOGIST : In Charge of producing the Report TECHNOLOGIST (and RADIOLOGIST) In charge of acquiring images, etc. PROCEDURE STEP : The smallest unit of work in the workflow (modality worklist entry) Representation includes: healthcare providers, information systems vendors, imaging systems vendors, and standards groups participating RSNA 2002

Problems Before the Technologist performs the acquisition, how do I make sure the correct info is used ? Paper based workflow with data re-entry Risk of error AND Inefficient Stale information Changes between time of print and time of data entry Cancel orders, Generic Order / Order Changes After the Technologist completes acquisition, how do I let all systems know ? When are things ready to be read (PACS) When can things be deleted (Modality) How do I know what to bill (RIS) When do I wake up the referring physician The solution is…… RSNA 2002

IHE Scheduled Workflow
Patient Registration/Update Order Management Order Protocolized IHE Scheduled Workflow Modality Worklist Procedure Scheduled Proposed Protocols Loaded and Reviewed Worklist Pt A, …, SPS=P1, P4 Pt C, …, SPS=P1, P5 Pt B, …, SPS=P2 Pt E, …, SPS=P4 RIS Modality Performed Procedure Step With Performed Acquisition Protocols Performed Step: Status = Completed Performed Procedure: CT Head Performed Protocol Code=P1 Pat Name/ID, Dose, Accession #, Study UID Complete List of Images Scheduled Protocol Code=P1, P5 Storage Commitment List of Images Store Images PACS & Archive As Performed Procedure Step, the most recent of the four Service Classes become available, a fully integrated solution for the modalities is on the horizon. Implementing Modality Worklist is the first step and can be done today with most recent modality products. Closing this loop delivers many benefits to the overall operation efficiency of the radiology department in the context of the overall hospital. A Closed Loop Update IS Scheduling Match Procedure with Order Support Billing Based on MPPS Avoid Reading incomplete Procedures RSNA 2002

Examples of Protocol Codes
A Scheduled Procedure Step may contain a single Protocol Code: “Standard Chest X-ray” Protocol Code. This implies PA and Lateral views. “Screening Mammography” Protocol Code. This implies RMLO and LMLO, RCC and LCC views.  Assisted Protocols provide a New Level of efficiency RSNA 2002

Examples of Protocol Codes
A Scheduled Procedure Step may also contain multiple Protocol Codes for more complex SPS with several acquisition or image processing tasks be performed in a sequential manner, for example: “MRI Acquisition” Prot. Code followed by an “MRA Acquisition” Prot. Code. “CT Head without contrast” Prot. Code followed by a “CT with contrast” Prot. Code. “CT Lumbar Spine” Prot. Code followed by a “Reformation of the discs” Prot. Code. “CT Thorax” prot. Code followed by a “Recon with lung kernel” Prot. Code.  Assisted Protocols provide a New Level of efficiency RSNA 2002

Multiple Modality Steps
DICOM Modality Worklist Radiology Department ORDER A request for Radiologic Service Scheduled Procedure Step A Acquisition Modality One or more series of images Performed Procedure Step P1 Report Set of Codifiable, Billable, Acts Requested Procedure 1 DICOM Modality Worklist Scheduled Procedure Step B Acquisition Modality One or more series of images Performed Procedure Step P2 Representation includes: healthcare providers, information systems vendors, imaging systems vendors, and standards groups participating RSNA 2002

Discontinued Procedure Step
DICOM Modality Worklist Radiology Department ORDER A request for Radiologic Service Report Set of Codifiable, Billable, Acts Requested Procedure 2 Scheduled Procedure Step C 1 Step A Acquisition Modality One or more series of images Performed Procedure Step P1 Representation includes: healthcare providers, information systems vendors, imaging systems vendors, and standards groups participating DICOM Modality Worklist No Performed Procedure Step Discontinue RSNA 2002

IHE Scheduled Workflow with Exception Management
Modality Worklist Worklist Procedure Scheduled RIS Modality Performed Procedure Step Performed Step: Status = Completed Performed CT Head Pat Name/ID, Dose, Accession #, Study UID Complete List of Images Storage Commitment List of Images Store Images If Wrong Worklist Images "removed“ and Step "undone" PACS & Archive Step Discontinued With Reason As Performed Procedure Step, the most recent of the four Service Classes become available, a fully integrated solution for the modalities is on the horizon. Implementing Modality Worklist is the first step and can be done today with most recent modality products. Closing this loop delivers many benefits to the overall operation efficiency of the radiology department in the context of the overall hospital. A Closed Loop Update IS Scheduling Match Procedure with Order Support Billing Based on MPPS Avoid Reading incomplete Procedures RSNA 2002

Problems John Doe Trauma Clean-Up Recovering After Systems Are Down
Error in manual entry at modality VIP Privacy The solution is…… RSNA 2002

Patient Information Reconciliation Unknown patients and unscheduled orders Admit, order, schedule, acquire images, notify of completed steps 3 profiles added in year 4. Basic Security, Charge Posting, and Post Processing workflow. RSNA 2002

IHE Scheduled Workflow + IHE Patient Information Reconciliation
PACS is synchronized with all patient registration and order information updates through Dept Scheduler. ADT Patient Registration Order Placer When Institution Policy assumes pre-registration of ER patients (John/Jane Doe), IHE supports 3 possible cases: Unidentified Patient registered at ADT and order placed at Order Placer Unidentified Patient registered at ADT and order placed at Department Scheduler/Order Filler Unidentified Patient registered at ADT but acquisition completed at Modality prior to Order Dept Scheduler Modality Image Manager/Archive RSNA 2002

IHE Scheduled Workflow + IHE Patient Information Reconciliation
ADT Patient Registration When Institution Policy allows departments to register ER patients, IHE supports 2 possible cases: Unidentified Patient assigned Temporary Departmental ID and Scheduled at Dept Scheduler/Order Filler Image Acquisition Completed Without Scheduling at Dept Scheduler/Order Filler (Patient ID entered at Modality) Supports cases when ADT or Dept Scheduler is down Order Placer Dept Scheduler Modality Image Manager/Archive RSNA 2002

Problems Schedule and track post-processing workflow steps for accuracy of work Share workload among workstations, chain workflow steps to avoid redundancy Store and Query/Retrieve of Evidence Documents for CAD, Image Processing etc. The solution is…… RSNA 2002

Patient Information Reconciliation Unknown patients and unscheduled orders Post- Processing Workflow Schedule, perform, & notify image processing & CAD steps Admit, order, schedule, acquire images, notify of completed steps 3 profiles added in year 4. Basic Security, Charge Posting, and Post Processing workflow. RSNA 2002

Post-Processing Workflow Profile
Acquisition Modality PACS System Source Data Post-Proc. Workflow Manager 3-D *Workstation Worklist Workstation Work Status Work Status CAD *Workstation Results Report Repository … Results RSNA 2002

Modality and Post-Processing Steps
DICOM Modality Worklist Radiology Department ORDER A request for Radiological Service Scheduled Procedure Step B Step A Acquisition Modality One or more series of images M-Perf. Procedure Step P1 Report Set of Codifiable, Billable Acts Requested Procedure 1 DICOM Post-Processing Worklist Post-Processing One or more series of images PP-Perf. Procedure Step P2 Representation includes: healthcare providers, information systems vendors, imaging systems vendors, and standards groups participating RSNA 2002

Worklist Provided Modality finds out what post-processing tasks have been scheduled by the Post-Processing Manager (RIS or PACS) Worklist is provided for workitem codes: Image Processing, Computer Aided Diagnosis, and Computer Aided Detection. Modality includes received information in the resulting instances RSNA 2002

Evidence Document Stored
Acquisition Modality stores an Evidence Document to PACS Non-image evidence for diagnostic interpretation DICOM Structured Reporting documents or Waveforms, e.g. Mammography CAD SR, Basic Text SR, Enhanced SR, Comprehensive SR RSNA 2002

Problems How to standardize the Charge Posting and billing for work performed How to Reduce System Interface Installation Time between Clinical Systems and the Charge Processors How to avoid Billing System needing to know the Radiology Internals We have a problem. When a referring physician orders a study, it typically consists of more than one radiologic procedure. In this case a CT Chest Abdomen and Pelvis corresponds to three radiologic acts. Most radiology groups will bill 3 CPT codes. Some departments will then generate one report that is copied three times and some departments generate three separate reports. Similarly, some departments will have one radiologist read all three components and some will have them read by different radiologists. We have one spiral CT study. If we send the data set to the PACS, where will it go? Will all the images go into the Chest folder and no images into the abdomen or pelvis folder??! How will the reports match up with the images??!! We don’t want to send the same images to the PACS three times! If this patient then comes back just for an abdomen/pelvis study, how do I “fetch” the old study if it is stored in a Chest folder? How do I automatically display the old abdomen images with the new abdomen images??!! The solution is…… RSNA 2002

Patient Information Reconciliation Unknown patients and unscheduled orders Post- Processing Workflow Schedule, perform, & notify image processing & CAD steps Charge Posting Collection of billable procedure details Admit, order, schedule, acquire images, notify of completed steps 3 profiles added in year 4. Basic Security, Charge Posting, and Post Processing workflow. RSNA 2002

Charge Posting Profile
ADT Terminal Account Management Post Charges *Billing System Charge Poster Study Performed Report Generated / Signed 3-D Performed CAD Performed / Materials Used Report Repository Acquisition Modality Facilitates Collection of Procedure Details for Billing Performed Procedure Technical Fees Materials Usage Reporting Professional Fees Etc. Maintains Correspondence of Account Details in Procedure Records 3-D *Workstation CAD *Workstation … RSNA 2002

Workflow RIS indicates to the Billing System that procedures are available for Technical and/or Professional billing – maintain accuracy Charge Posted Transaction may be sent at various times in the workflow - flexibility Regulations and site policies determine when a procedure is eligible for Charge Posting RSNA 2002

IHE Integration Profiles in Detail II
John Paganini Member IHE Technical and Planning Committees IDX Systems

Problems Ensuring print quality outside of the department
Radiologist discussing images with remote physicians Capture image manipulation to avoid redundant work (coronal CT, MR reading, etc.) The solution is…… RSNA 2002

Patient Information Reconciliation Unknown patients and unscheduled orders Post- Processing Workflow Schedule, perform, & notify image processing & CAD steps Charge Posting Collection of billable procedure details Admit, order, schedule, acquire images, notify of completed steps Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state 3 profiles added in year 4. Basic Security, Charge Posting, and Post Processing workflow. RSNA 2002

The Radiologist’s Transformations With Presentation State
The Radiologist Saves a New Presentation State: What the Reviewing Physician Sees: +Zoom Area Of Interest +Annotation Area Of Interest The Radiologist’s Transformations Are Saved With Presentation State Consistent Presentation of Images On a Calibrated Display Original Image Original Image +Windowing Original Image Supprimé libellé 3ème message All the Transformations Are Completely Lost No Presentation State Inconsistent Presentation On an Uncalibrated Display Radiologist Views Images

Grayscale Standard Display Function (GSDF)
6 modalities  4 cameras, 26 workstations The current way = 180 calibrations The IHE way = only 36 calibrations Soft Copy Review Barten Curve Just Noticeable Differences Luminance DICOM Standard Display Function Acquisition This is good news. Indeed the increase in the number of image sources and of image rendering devices (workstations and hardcopy) is making the traditional pair-wise callibration an unpractical solution. The solution is in sight with products in the Year time frame with the completion of the standardization work in late 1999. Film Review Independent device calibration delivers consistency with simplicity RSNA 2002

Consistent Presentation of Images
With films, image quality was the imaging department problem…. Softcopy image distribution across the healthcare enterprise Enabled by digital radiology Avoids lost films, reduce delays Decreases utilization of staff and equipment But …need to ensure quality and consistency ! This IHE Integration Profile is the cost effective and technically correct solution. RSNA 2002

Problems An hematologist/oncologist orders:
“CT CAP, Lymphoma, R/O disease” We do “CT CHEST, ABDOMEN, PELVIS w/CON” 3 orders in RIS, 3 accession numbers, 3 CPTs, 3 reports Chest radiologist will read chest Body Imager will read abdomen and pelvis With One Spiral CT Exam what do we do ? We have a problem. When a referring physician orders a study, it typically consists of more than one radiologic procedure. In this case a CT Chest Abdomen and Pelvis corresponds to three radiologic acts. Most radiology groups will bill 3 CPT codes. Some departments will then generate one report that is copied three times and some departments generate three separate reports. Similarly, some departments will have one radiologist read all three components and some will have them read by different radiologists. We have one spiral CT study. If we send the data set to the PACS, where will it go? Will all the images go into the Chest folder and no images into the abdomen or pelvis folder??! How will the reports match up with the images??!! We don’t want to send the same images to the PACS three times! If this patient then comes back just for an abdomen/pelvis study, how do I “fetch” the old study if it is stored in a Chest folder? How do I automatically display the old abdomen images with the new abdomen images??!! The solution is…… RSNA 2002

Presentation of Grouped Procedures Subset a single acquisition Patient Information Reconciliation Unknown patients and unscheduled orders Post- Processing Workflow Schedule, perform, & notify image processing & CAD steps Charge Posting Collection of billable procedure details Admit, order, schedule, acquire images, notify of completed steps Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state 3 profiles added in year 4. Basic Security, Charge Posting, and Post Processing workflow. RSNA 2002

IHE – Presentation of Grouped Procedures
Requested Procedure: CHEST Report: CHEST Report: ABDOMEN Requested Procedure: ABDOMEN Chest View Abdomen View RIS / PACS MODALITY Performs a single exam Operator groups 2 procedures Chest View Abdomen View RSNA 2002

Presentation of Grouped Procedures
PGP maintains the link back to each one of the grouped procedures: without breaking the acquisition apart Without duplicating images PGP ensures that each image subset related to a requested procedure is identified and ready to be presented.  This is key for quick display of new and prior studies. RSNA 2002

Other Group/Split cases…
CT: Head bone / brain separation CR: Foot/ankle - hand/wrist E.g., lateral image of foot shared between AP of ankle and AP of foot DR: Trauma patient AP / Lat re-grouping I.e., do all the Aps then rotate the patient once then do Lats MR: MRI/MRA To be viewed and billed separately IR: Diagnostic run and therapeutic run Performed contemporaneously, viewed/billed separately US: Abdomen and kidneys/ retroperitoneum The solution is…… RSNA 2002

Problems Will you ask your technologist to push Mr. Smith’s study and report to our Radiation Therapy planning system?” “No.” Pushing images from modalities to all the potential users of the studies is not feasible or manageable. I have 50 imaging modalities and 24 workstations. Technologists should be scanning patients on the modalities. Isn’t there some way to have users in need of studies ‘pull’ them from my system? What about reports? What about Presentation states? What about Key Image Notes? HELP!! The solution is…… RSNA 2002

Presentation of Grouped Procedures Subset a single acquisition Patient Information Reconciliation Unknown patients and unscheduled orders Post- Processing Workflow Schedule, perform, & notify image processing & CAD steps Charge Posting Collection of billable procedure details Admit, order, schedule, acquire images, notify of completed steps Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state 3 profiles added in year 4. Basic Security, Charge Posting, and Post Processing workflow. Access to Radiology Information Consistent access to images and reports RSNA 2002

Access to Radiology Information
Referring Physician Emergency Department Radiology Department Images and Reports Remote Clinics Other Departments: - Oncology - Surgery - Neurology - Pediatrics - etc. Supprimé libellé 3ème message Electronic Medical Record RSNA 2002

Problems “Dave, you read that 3000 slice MR study last night. Can you highlight the 5 most important images for me” “Sure” “Dr., I just reviewed 40 cases and marked my questions on yellow stickies. Can you review those” Tech to radiologist: “The patient wouldn’t hold still” Is there a way to associate a few choice words with an image? How about a way to associate one comment with a bunch of images? Can I tag images for QA purposes? Can technologists tag images in order to explain why images have artifacts The solution is…… RSNA 2002

Presentation of Grouped Procedures Subset a single acquisition Patient Information Reconciliation Unknown patients and unscheduled orders Post- Processing Workflow Schedule, perform, & notify image processing & CAD steps Charge Posting Collection of billable procedure details Admit, order, schedule, acquire images, notify of completed steps Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Key Image Notes Flag significant images 3 profiles added in year 4. Basic Security, Charge Posting, and Post Processing workflow. Access to Radiology Information Consistent access to images and reports RSNA 2002

The radiologist selects Key Images, and creates appropriate Notes.
The referring physician views the Key Image Note prepared by radiologist. for refering physician In this image you can see the renal rupture. Note 1: for refering physician In this image you can see the renal rupture. Note 1: In this image you can see the hematoma. Note 2: Results in improved communication between the radiologist and the referring physician for refering physician In this image you can see the hematoma. Note 2: RSNA 2002

The radiologist selects Key Images, and creates appropriate Notes.
The referring physician views the Key Image Note prepared by radiologist. for refering physician In this image you can see the hematoma. Note 3: for refering physician Hematoma everywhere Note 3: Results in improved communication between the radiologist and the referring physician RSNA 2002

Key Image Notes There is more to teamwork than images and reports
With IHE, it is possible to attach « electronic post-it™ » to images to increase informal but critical communication between: The Technologist and the Radiologist about specific examination events The Radiologist and the Technologist about image quality issues The Radiologist and other department clinicians (surgeon, orthopedist,..) The Radiologist and collegues about selecting images for conferences The Radiologist to the Referring Provider, …..etc. This IHE Integration Profile is the cost effective solution (increases radiology and overall efficiency). RSNA 2002

Can You Make A Report Like This?
Institution Identification Patient Identification Study Identification Technique Identification Discussion The liver is normal. There is a focal area of decreased attenuation adjacent to the falciform ligt., likely representing focal fat (image 22). The spleen, both kidneys, the … are normal. Impression CT of the abdomen within normal limits Signature I should be able click on anything that is underlined or in color and get more info or images (green). The solution is…… RSNA 2002

Or Like That ? Discussion
Comparison is made to the prior study of 4/11/99. The left paratracheal lymph node (image 8, image 11) now measures 2.5x2.7x3.1 cm increasing from 2.0x2.1x2.6 previously. No other mediastinal, upper abdominal or axillary adenopathy is identified. No focal pulmonary lesions are seen. The…………… are normal. Impression Worsening L Paratracheal adenopathy. Signature RSNA 2002

Presentation of Grouped Procedures Subset a single acquisition Patient Information Reconciliation Unknown patients and unscheduled orders Post- Processing Workflow Schedule, perform, & notify image processing & CAD steps Charge Posting Collection of billable procedure details Admit, order, schedule, acquire images, notify of completed steps Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Key Image Notes Flag significant images Simple Image and Numeric Reports Simple reports with image links and, optionally, measurements 3 profiles added in year 4. Basic Security, Charge Posting, and Post Processing workflow. Access to Radiology Information Consistent access to images and reports RSNA 2002

Simple Image & Numeric Reports
Based on DICOM SR Allows to include without transcription: - measurements - Image links - structured content Integrated with the imaging workflow Friendly to XML implementations Easy to export to the CPR (HL7) RSNA 2002

Simple Image and Numeric Report
Report content is more than words….. With IHE, it is possible to add value to reporting with input from modalities and image processing applications (e.g. Measurements). This IHE Integration Profile is the cost effective solution for sharing reports and inclusion of image enabled reports into the Electronic Patient Record. RSNA 2002

Problems How did Person X view MVP’s ankle images?
How to maintain Clinical Use and Privacy authorized persons must have access to medical data of patients, and the information must not be disclosed otherwise. How to guarantee: Confidentiality Integrity Availability Authenticity Is there a way to associate a few choice words with an image? How about a way to associate one comment with a bunch of images? Can I tag images for QA purposes? Can technologists tag images in order to explain why images have artifacts The solution is…… RSNA 2002

Basic Security Profile
Audit Record Repository … … “Images Queried / Retrieved” “Reports Retrieved” “Reports Printed” Image Manager & Archive Report & Image Review “Images Printed” “Reports Stored” “Reports Queried / Retrieved” Report Repository Diagnostic Workstation RSNA 2002

IHE Basic Security HIPAA-Readiness
IHE Year 4 has a proposal for a basic set of Security functions defined User Log-on Node Authentication Audit Trail This targets the HIPAA requirement for Accountability and Access control Is this sufficient for HIPAA in the Radiology imaging domain? Who decides? RSNA 2002

See IHE actually implemented….
See the 30 min presentation to see these IHE Integration Profiles actually implemented Demonstrated by more than 30 vendors with more than 70 products You check on the commercial exhibit, availability of IHE Integration Profile in products you may own or intend to acquire IHE is HERE and NOW ! RSNA 2002

Where is More Information Available?
IHE Technical framework for year 4 – V5.4 Non-Technical Brochures : IHE Primer and IHE FAQ IHE Integration Profiles: Guidelines for Buyers IHE Connectathon Results IHE Integration Statements from Vendors RSNA 2002

Integrating the Healthcare Enterprise

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