Presentation on theme: "The Operating Room and the need for an IT Infrastructure and Standards"— Presentation transcript:
1 The Operating Room and the need for an IT Infrastructure and Standards IGT WorkshopRockville, MD, 20th September 2006Heinz U. Lemke, PhDResearch Professor of RadiologyUniversity of Southern California, Los Angeles, USASenior Advisor for Research StrategiesInnovation Center Computer Assisted SurgeryUniversity of Leipzig, Germany
2 Content Motivation, interfaces, workflow and standards Interfacing examplesPatient model-guided therapy and DICOM in Surgery
4 Workplace in a cardiac surgery OR with several monitors that can be seen from various positions.
5 Standards for Medical Technology Source: K. Radermacher, RWTH Aachen
6 10 IHE Integration Profiles Scheduled WorkflowAdmit, order, schedule, acquire images, notify of completed stepsPatient Information ReconciliationUnknown patients and unscheduled ordersAccess to Radiology InformationConsistent access to images and reportsPostprocessingWork FlowSchedule, perform,notify image processing& CAD stepsConsistent Presentation of ImagesHardcopy and softcopy grayscale and presentation statePresentation of Grouped ProceduresSubset a single acquisitionBasic SecurityAudid Trail Consolidation& Node AuthenticationCharge PostingCollection of billableprocedure detailsSimple Image and Numeric ReportsExchange simple reports with imagelinks and, optionally,measurementsKey Image NotesExchange flagging significant images
7 acquisition completed acquisition in-progress acquisition completed Scheduled Workflow ProfileReportRepositoryRegistrationreportDiagnosticWorkstationFilmLightboxHISPACSOrders PlacedImage Manager& ArchiveFilmFolderOrders FilledSpecifies transactions that function to maintain the integrity of patient, image, and order information across systemsIntegrates modalities with information and imaging systemsBiggest Value of IHESmooth flow of patient, image and order information across systemsStatus updates of ordersAcquisition Modalityacquisition completedFilmRISacquisition in-progressacquisition completedimages printedModality
8 WG 24 “DICOM in Surgery“ Project Groups PG1 WF/MI NeurosurgeryPG2 WF/MI ENT and CMF SurgeryPG3 WF/MI Orthopaedic SurgeryPG4 WF/MI Cardiovascular SurgeryPG5 WF/MI Thoraco-abdominal SurgeryPG6 WF/MI Interventional RadiologyPG7 WF/MI AnaesthesiaPG8 S-PACS FunctionsPG9 WFMS ToolsPG10 Image Processing and DisplayPG11 Ultrasound in Surgery
9 Partial and condensed workflow of “Resection of Tonsillar Carcinoma” Induction of narcosisResection of tumor and stagingStart of operating phaseStart of operating phase (surgery)Marking on forearm skinLymph Node BiopsyDisinfection of the neckDisinfection of skinDisinfection of abdominal skinClassification with TNMAseptic dressingPrepare for contralateral neck dissectionAseptic dressingAseptic dressingTransfer to pathologyNeck dissectionRemove skin graftRemove skin graftSuturationBilateral neck dis completeTeam waits for skin graft from abdominal wallnoSuturationyesTransplantation of skin graft onto forearmSuturation using OP-microscopeResult Processing of instantaneous sectionSkin graft into resection situVessel anastomosisEnd of narcosis and transferEnd of neck dissectionEnd of operative phase (surgery)End of operative phase
10 Workflow for Ablation Procedure DICOM Workgroup 24Workflow for Ablation Procedure
14 Functional Categories 1. Basic Imaging(Image-centric)a. Pre-procedure evaluationi. Review of previous imaging studiesb. Post-Procedurei. Review of the performed Interventional Procedureii. Follow-up to evaluate the outcome of the procedure2. Real-Time Imaginga. Intra-procedural Imaging3. Pre-Procedural and Intra-Procedural image manipulation(Model-centric)a. In the case of tumor biopsy or ablation:i. Localization – evaluation of location and characteristics of pathologyii. Targeting – plan and determine access and trajectory of needles/probesiii. Image guidance – final plans and measurements for probe placementiv. Navigationv. Monitoring4. Physiologic Monitoring
19 Integrated Workstation Integrated and consistent user interfaceContext specific dialogue and coordinated system accessModular design with standardised interfacesSource: K. Radermacher, RWTH Aachen
20 Source: K. Radermacher, RWTH Aachen State of the ArtSource: K. Radermacher, RWTH Aachen
21 OrthoMIT, Concept of an Integrated Workstation Modular Design („Plug and Play“)Open standard and inclusion of present standards (DICOM, HL7, future S-DICOM)Different integrations levelsUsability of devices integrated as well as stand-aloneCommunication between devices (bus system,…)Workflow-managementIntegration of standard conforming modules without renewed safety tests (MPG, etc.)Source: K. Radermacher, RWTH Aachen
22 Integration of Planning, Imaging, Navigation and Treatment PostoperativeMonitoring, e.g.. MRIPreoperative PlanningOR IT IntegrationIntraoperative Imaging and NavigationOR Integration:Dräger Siemens StorzSource: C. Bulitta, SIEMENS
23 Technology-Integration: OR-Cockpit / OR-Anaesthesia Frontend-IntegrationFlatscreenTouchscreenThemes, e.g. :VisualisationDevice-ControlContext InformationRFID triggert EventsSIEMENSIntegration-serverPre-/intraop. ImagingLink H-ITApplications(Endonavigation)Therapy-PlanningKARL STORZDrägerBackend - IntegrationApplication specifice Data- and Event- Synchronisation (Workflow-controlled)Source: C. Bulitta, SIEMENS
24 Source: C. Bulitta, SIEMENS Concept of levelsConsolidation of frontend-exchange or integration on screenlevelData exchange via existing interfaces and ESB integration via inubit IS.Connecting to external systems (HIS etc.).Frontend integration via portlets (patient-oriented/ case oriented optimised visualisation).Source: C. Bulitta, SIEMENS
25 Enterprise Service Bus Frontend-3(surgery cockpit)Frontend-2(anesthesia cockpit)Frontend-4(image viewer)Enterprise Service BusHISSystem 1web-serviceenabledSystem 2System 3System NconncectorFrontend-1(KVM switch/RDP)Source: C. Bulitta, SIEMENS
26 Content Motivation, interfaces, workflow and standards Interfacing examplesPatient model-guided therapy and DICOM in Surgery
27 Diagnostic Image-Centric World View PACSModalities(X-ray,CT, US, MR,SPECT, PET)DICOMDICOMArchiveImages(CAD etc.)Identification(name, SS #,exam code,date, …)At the present, this is a model of imaging informatics in radiology.AcquisitionParametersQuery:name? date?exam type?
28 Future-PACS based on DICOM-X Integrated Patient CareOmicsEMREBMWorkflowIHEMechatronics(Navigation,ablation, …)Modalities(X-ray,CT, US,MR,SPECT,PET,OI)Integrationand Diagnosis(Data fusion,CAD, …)Modelling andIntervention(Simulation,decision support,validation, …)Biosensors(physiology,metabolism,serum, tissue, …)Data bases(Atlas,P2P repositories,data grids, ...)We actually need a better integrated and more comprehensive view of current and previously collected information, as well as the cumulative experience with diagnosis and treatment.Future-PACS based on DICOM-XImage-Centric World ViewModel-Centric World ViewH. U. Lemke, CARS 2006
30 DICOM RT Modules PS 3.3-2006 Annex A, Composite IOD RT DoseROI ContourStructure SetRT General Treatment RecordRT General PlanRT Tolerance TablesRT Brachy Application Setups…
31 Generic and patient specific modelling tools Geometric modellingProsthesis modellingProperties of cells and tissueSegmentation and reconstructionBiomechanics and damageTissue growthTissue shiftProperties of biomaterials
32 Generic and patient specific modelling tools Atlas-based anatomic modellingFEM of medical devices and anatomic tissueCollision response strategies for constraint deformable objectsVariety of virtual human modelsLifelike physiology and anatomyFabrication model for custom prosthesisTemplate modelling
33 Generic and patient specific modelling tools Animated modelsMulti-scale modelling (BC)Fusion/integration of data/imagesRegistration between different models incl. Patient, equipment and ORModelling of the biologic continuumModelling of workflows…
34 Some steps towards a surgical DICOM Michael Gessat, Oliver Burgert ICCAS, LeipzigICCAS Project timing:2005 – 2010Grant volume:8,5 Mio €IOD surface mesh...
35 Surgical DICOM Model of the real world (exemplary, incomplete…) PatientconductsPhysicianmakesIs subject ofmakesVisitprepareshasincludesInterventionStudydefinesRepositoryPlanComprised ofcontainsBases on / uses / containsModality performed procedure stepsData LibraryincludescontainscreatesWorkflowToolsDiagnosisSomeone…definesSeriesreferencescreatesFrame of ReferencecontainsEquipmentImageWaveformReportWorkflowToolsDiagnosisImage ProcessingOntologiesNavigation…
36 Information Model for Surgical DICOM ER-Diagram shows the complexity of the surgical environmentMultiple objects from different origins act together in contexts given by patients, interventions… (the column-like World Model has turned into a web of entities)Representation of all necessary meta data with each frame is no longer feasible (Overhead!)Normative IODs reflecting patient, study, series, repository,… will be necessary Patient ModelOrganization of data will become a primary task
37 IODs for Surgical DICOM Actual DICOMUPnPRegistrationPresentation StateRTConf. MgmtImg. ProcessingHanging ProtocolsVisible LightImages, WF…SegmentationPatient ModelNavigationGeometric ModelsLibrary, RepositoryAugmented RealityVideo based Nav.InterventionOntologiesSimulationManipulatorWorkflows
38 IOD Entity-Relationship Model Patient1Is the subject of1…nStudy1contains0…nuses0…n0…nspatially or temporarily defines1…n0…nSeriescreates0…n0…11containsEquipmentAlgorithmFrame of reference0…ndefines0…nRegistrationFiducialsPresentation StateImageWaveformSurface MeshSurface Mesh Presentation State
39 Informatic Portals for Data Mining Data Repositories
41 Data GridProvide a distributed fault-tolerant data services for large data, eg, TeraGrid (100 GB ~ 10 TB)Data services include storage, share, distribution, and metadata management.IPI (USC) Data Grid: an integration of DICOM information object model with general data services for clinical image applications.
42 IPI Data Grid for PACS Image Data Backup: The DICOM Data GRID HCC2 PACSServerHCC2PACS WSHCC2 SANP1SJHCPACS WSSJHC PACSServerDICOMData GridSJHC SANP1P2P2SJHCIPI SANPACSIPISimulator
43 Methods for HIPAA Security in PACS To make current PACS HIPAA compliant in Access Control, Audit Control, and Integrity.IPI has developed:HIPAA compliant auditing system (HCAS) for Audit ControlLocation Tracking and Verification System (LTVS) for Access ControlLossless Digital Signature Embedding (LDSE) method for Image Integrity assurance
44 Therapy Imaging and Model Management System (TIMMS) Conclusion1. S-WF definitions (on an appropriate granulation level) and visualizations allow surgeons, interventionists and associated disciplines to better understand IT requirements for information guided intervention (IGI)2. Selected S-WFs defined by some standard method may be entered into a repository, providing a reference base for the development of anIT infrastructure such as a TIMMSTherapy Imaging and Model Management System (TIMMS)
46 Therapy Imaging and Model Management System (TIMMS) Conclusion3. Derive S-DICOM services and IOD`s from TIMMS functionalitiesTherapy Imaging and Model Management System (TIMMS)
47 WG 24 “DICOM in Surgery“ Project Groups PG1 WF/MI NeurosurgeryPG2 WF/MI ENT and CMF SurgeryPG3 WF/MI Orthopaedic SurgeryPG4 WF/MI Cardiovascular SurgeryPG5 WF/MI Thoraco-abdominal SurgeryPG6 WF/MI Interventional RadiologyPG7 WF/MI AnaesthesiaPG8 S-PACS FunctionsPG9 WFMS ToolsPG10 Image Processing and DisplayPG11 Ultrasound in Surgery
48 WG24 “DICOM in Surgery” Secretariat: Howard Clark, NEMA Secretary: Franziska Schweikert, CARS/CURAC OfficeGeneral Chair: Heinz U. Lemke, ISCAS, GermanyCo-Chair: Ferenc Jolesz, Harvard Medical School, Boston (Surgery/Radiology)Co-Chair: tbd(Industry)
49 S-DICOM Cooperation Partners CARS Institute/FoundationSPIEUniversity of GenevaICCAS, University of Leipzig (ENT, Cardio, Neuro)Technical University of Berlin (CG and CAM)University of Southern California (IPI)University of RennesJapan Institute of CARSIndustry (Agfa, Siemens, Philips, ...)CURAC (AG S-WF and S-PACS)University of Pisa, EndoCASThe Interventional Centre, OsloGeorgetown University, WashingtonUniversity of ChicagoISCAS…
50 Rockville, MD, 20th September 2006 IGT WorkshopRockville, MD, 20th September 2006What do you believe are three important challenges facing the engineering of IGT systems:1. Development of appropriate standards for interfacing software engines and repositories in IGI.2. To specify and design an IGT system based on best practice surgical workflows.3. To complement the paradigm of Image Guided Therapy (IGT) with Model Guided Therapy (MGT) and to proceed towards Information Guided Intervention (IGI).
51 Rockville, MD, 20th September 2006 IGT WorkshopRockville, MD, 20th September 2006(b) How do you think that we at NCIGT (National Center for Image-Guided Therapy) can help address these challenges1. To participate in DICOM Working Group 24 "DICOM in Surgery".2. To participate in building a repository of a representative set of best practice surgical workflows.3. To participate in raising awareness of information guided intervention (IGI) through workshops, think tanks, etc.
52 CARS 2007 Computer Assisted Radiology and Surgery CARS / SPIE 7th Joint Workshop on Surgical PACS and the DOR Berlin, 30 June, 20079th Meeting of theDICOM Working Group WG 24 “DICOM in Surgery“30 June 2007