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The Operating Room and the need for an IT Infrastructure and Standards Heinz U. Lemke, PhD Research Professor of Radiology University of Southern California,

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Presentation on theme: "The Operating Room and the need for an IT Infrastructure and Standards Heinz U. Lemke, PhD Research Professor of Radiology University of Southern California,"— Presentation transcript:

1 The Operating Room and the need for an IT Infrastructure and Standards Heinz U. Lemke, PhD Research Professor of Radiology University of Southern California, Los Angeles, USA Senior Advisor for Research Strategies Innovation Center Computer Assisted Surgery University of Leipzig, Germany IGT Workshop Rockville, MD, 20 th September 2006

2 Content 1.Motivation, interfaces, workflow and standards 2.Interfacing examples 3.Patient model-guided therapy and DICOM in Surgery

3 IT Model-Centric World View Interventional Cockpit/SAS modules Modelling Models (Simulated Objects) © H.U. Lemke, August 2006 Therapy Imaging and Model Management System (TIMMS) ICT infrastructure (based on DICOM-X) for data, image, model and tool communication for patient model-guided therapy Simulation Kernel for WF and K+D Management Visualisation Rep. Manager InterventionValidation Repo- sitory Engine Data Exch. Control IO Imaging and Biosensors Images and signals Modelling tools Computing tools WF and K+D tools Rep. tools Devices/ Mechatr. tools Validation tools WF`s, EBM, ”cases” Data and information Models and intervention records Therapy Imaging and Model Management System (TIMMS)

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 n

6 Presentation of Grouped Procedures Subset a single acquisition 10 IHE Integration Profiles Patient Information Reconciliation Unknown patients and unscheduled orders Consistent Presentation of Images Hardcopy and softcopy grayscale and presentation state Access to Radiology Information Consistent access to images and reports Key Image Notes Exchange flagging significant images Simple Image and Numeric Reports Exchange simple reports with image links and, optionally, measurements Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps Postprocessing Work Flow Schedule, perform, notify image processing & CAD steps Basic Security Audid Trail Consolidation & Node Authentication Charge Posting Collection of billable procedure details

7 RIS HIS PACS Scheduled Workflow Profile Registration Orders Placed Orders Filled Film Folder Image Manager & Archive Film Lightbox report Report Repository Diagnostic Workstation Modality acquisition in-progress acquisition completed images printed Acquisition Modality

8 WG 24 “DICOM in Surgery“ Project Groups PG1WF/MI Neurosurgery PG2WF/MI ENT and CMF Surgery PG3WF/MI Orthopaedic Surgery PG4WF/MI Cardiovascular Surgery PG5WF/MI Thoraco-abdominal Surgery PG6WF/MI Interventional Radiology PG7WF/MI Anaesthesia PG8S-PACS Functions PG9WFMS Tools PG10Image Processing and Display PG11Ultrasound in Surgery

9 End of operative phase Result Processing of instantaneous section Neck dissection Disinfection of the neck Aseptic dressing Prepare for contralateral neck dissection Induction of narcosis Suturation Transfer to pathology Lymph Node Biopsy Classificatio n with TNM Remove skin graft Aseptic dressing Marking on forearm skin Disinfection of skin Team waits for skin graft from abdominal wall Skin graft into resection situ Suturation Remove skin graft Disinfection of abdominal skin Aseptic dressing Vessel anastomosis Suturation using OP- microscope End of narcosis and transfer End of neck dissection Bilateral neck dis complet e End of operative phase (surgery) Transplantation of skin graft onto forearm yes no Start of operating phase Resection of tumor and staging Start of operating phase (surgery) Partial and condensed workflow of “Resection of Tonsillar Carcinoma”

10 DICOM Workgroup 24 Workflow for Ablation Procedure

11

12 DICOM Workgroup 24

13 Pre-procedure Planning

14 1. Basic Imaging (Image-centric) a. Pre-procedure evaluation i. Review of previous imaging studies b. Post-Procedure i. Review of the performed Interventional Procedure ii. Follow-up to evaluate the outcome of the procedure 2. Real-Time Imaging (Image-centric) a. Intra-procedural Imaging 3. 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 pathology ii. Targeting – plan and determine access and trajectory of needles/probes iii. Image guidance – final plans and measurements for probe placement iv. Navigation v. Monitoring 4. Physiologic Monitoring (Model-centric) Functional Categories

15 Table 1 IODRelated IODFunctional Categories COMPUTED RADIOGRAPHY IMAGE1 COMPUTED TOMOGRAPHY IMAGE1,2 3 ENHANCED COMPUTED TOMOGRAPHY 1,2 3 MAGNETIC RESONANCE IMAGE1,2 3 ENHANCED MR1,2 3 MR Spectroscopy1,2 3 NUCLEAR MEDICINE IMAGE ULTRASOUND IMAGE1,2 3 ULTRASOUND MULTI- FRAME IMAGE 1,2 3 Ultrasound (IVUS)2,3 DIGITAL X-RAY IMAGE1 Overlay Plane Module3 POSITRON EMISSION TOMOGRAPHY IMAGE 1 STANDALONE PET CURVE1 ENHANCED XA [X-RAY ANGIOGRAPHIC] IMAGE 2,3 ENHANCED XRF [X-RAY RF] IMAGE2,3

16 Content 1.Motivation, interfaces, workflow and standards 2.Interfacing examples 3.Patient model-guided therapy and DICOM in Surgery

17 SOMIT Project: Minimal Invasive Orthopaedic Surgery Project timing: 2005 – 2010 Partner institutions: 25 Grant volume: 12,5 Mio €

18 Source: K. Radermacher, RWTH Aachen

19 Integrated Workstation –Integrated and consistent user interface –Context specific dialogue and coordinated system access –Modular design with standardised interfaces Source: K. Radermacher, RWTH Aachen

20 State of the Art Source: 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 levels Usability of devices integrated as well as stand- alone Communication between devices (bus system,…) Workflow-management Integration of standard conforming modules without renewed safety tests (MPG, etc.) Source: K. Radermacher, RWTH Aachen

22 OR Integration: Dräger Siemens Storz Intraoperative Imaging and Navigation OR IT Integration Preoperative Planning Postoperative Monitoring, e.g.. MRI Integration of Planning, Imaging, Navigation and Treatment Source: C. Bulitta, SIEMENS

23 Integration-server Pre-/intraop. Imaging Link H-IT Applications (Endonavigation) Backend - Integration Therapy- Planning KARL STORZ SIEMENS Dräger Frontend-Integration FlatscreenTouchscreen Technology-Integration: OR-Cockpit / OR-Anaesthesia Themes, e.g. : Visualisation Device-Control Context Information RFID triggert Events Application specifice Data- and Event- Synchronisation (Workflow-controlled) Source: C. Bulitta, SIEMENS

24 Concept of levels 1)Consolidation of frontend- exchange or integration on screenlevel 2)Data exchange via existing interfaces and ESB integration via inubit IS. 3)Connecting to external systems (HIS etc.). 4)Frontend integration via portlets (patient-oriented/ case oriented optimised visualisation). Source: C. Bulitta, SIEMENS

25 System 2 System 3 System N Frontend-1 (KVM switch/RDP) System 1 Frontend-2 ( anesthesia cockpit) Frontend-3 ( surgery cockpit) Frontend-4 ( image viewer) Enterprise Service Bus web-service enabled conncector HIS Source: C. Bulitta, SIEMENS

26 Content 1.Motivation, interfaces, workflow and standards 2.Interfacing examples 3.Patient model-guided therapy and DICOM in Surgery

27 Archive Modalities (X-ray, CT, US, MR, SPECT, PET) Images (CAD etc.) Acquisition Parameters Identification (name, SS #, exam code, date, …) DICOM Diagnostic Image-Centric World View PACS

28 Biosensors (physiology, metabolism, serum, tissue, …) Omics EMR Modalities (X-ray,CT, US, MR,SPECT, PET,OI) Model-Centric World View Integrated Patient Care EBM Workflow IHE Image-Centric World View Integration and Diagnosis (Data fusion, CAD, …) Modelling and Intervention (Simulation, decision support, validation, …) Data bases (Atlas, P2P repositories, data grids,...) Mechatronics (Navigation, ablation, …) H. U. Lemke, CARS 2006 Future-PACS based on DICOM-X

29 IT Model-Centric World View Interventional Cockpit/SAS modules Modelling Models (Simulated Objects) © H.U. Lemke, August 2006 Therapy Imaging and Model Management System (TIMMS) ICT infrastructure (based on DICOM-X) for data, image, model and tool communication for patient model-guided therapy Simulation Kernel for WF and K+D Management Visualisation Rep. Manager InterventionValidation Repo- sitory Engine Data Exch. Control IO Imaging and Biosensors Images and signals Modelling tools Computing tools WF and K+D tools Rep. tools Devices/ Mechatr. tools Validation tools WF`s, EBM, ”cases” Data and information Models and intervention records Therapy Imaging and Model Management System (TIMMS)

30 DICOM RT Modules PS Annex A, Composite IOD RT Dose ROI Contour Structure Set RT General Treatment Record RT General Plan RT Tolerance Tables RT Brachy Application Setups …

31 Generic and patient specific modelling tools Geometric modelling Prosthesis modelling Properties of cells and tissue Segmentation and reconstruction Biomechanics and damage Tissue growth Tissue shift Properties of biomaterials Modelling tools

32 Generic and patient specific modelling tools Atlas-based anatomic modelling FEM of medical devices and anatomic tissue Collision response strategies for constraint deformable objects Variety of virtual human models Lifelike physiology and anatomy Fabrication model for custom prosthesis Template modelling Modelling tools

33 Generic and patient specific modelling tools Animated models Multi-scale modelling (BC) Fusion/integration of data/images Registration between different models incl. Patient, equipment and OR Modelling of the biologic continuum Modelling of workflows … Modelling tools

34 Some steps towards a surgical DICOM IOD surface mesh... Michael Gessat, Oliver Burgert ICCAS, Leipzig ICCAS Project timing: 2005 – 2010 Grant volume: 8,5 Mio €

35 Surgical DICOM Model of the real world (exemplary, incomplete…) Patient makes Visit includes Study Comprise d of Modality performed procedure steps includescontains Series creates Equipment defines Frame of Reference has Repository Data Library contains creates Someone… Is subject of Intervention Plan Physician Diagnosis Report reference s conducts defines prepares Bases on / uses / contains Image contains makes Waveform Image Processing Tools Ontologies Workflow DiagnosisTools Navigation …

36 Information Model for Surgical DICOM ER-Diagram shows the complexity of the surgical environment Multiple 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 Model Organization of data will become a primary task

37 IODs for Surgical DICOM Actual DICOM Presentation StateRegistrationRT Conf. Mgmt Segmentation Visible LightHanging ProtocolsImages, WF… Navigation Augmented Reality Video based Nav. Simulation Geometric Models Manipulator Patient Model Ontologies Library, Repository Workflows UPnP Img. Processing Intervention

38 IOD Entity-Relationship Model Patient Is the subject of 1 Study contains 1 1…n contains 1 Registration Frame of reference 1…n 0…1 Series 0…n Presentation StateFiducialsImage 0…n WaveformSurface Mesh defines 0…n creates Equipment 0…n Algorithm Surface Mesh Presentation State spatially or temporarily defines 0…n uses 0…n

39 Informatic Portals for Data Mining Data Repositories

40 Repository of workflow reference models (WFs, SIPs) for medical techniques, operating instructions, etc. Generic models and patient-spec. models etc. Peer Expert I Peer Expert II Peer Expert III Peer Expert IV Reference expert knowledge P2P „Best Practice“ Workflow Repository WF graph

41 Data Grid Provide 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 SAN DICOM Data Grid P2 SJHC PACS Server SJHC PACS WS SJHC SAN P1 SJHC HCC2 PACS Server HCC2 PACS WS HCC2 SAN P1 HCC2 IPI PACS Simulator IPI Data Grid for PACS Image Data Backup: The DICOM Data GRID

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 Control –Location Tracking and Verification System (LTVS) for Access Control –Lossless Digital Signature Embedding (LDSE) method for Image Integrity assurance

44 Conclusion 1. 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 an IT infrastructure such as a TIMMS Therapy Imaging and Model Management System (TIMMS)

45 IT Model-Centric World View Interventional Cockpit/SAS modules Modelling Models (Simulated Objects) © H.U. Lemke, August 2006 Therapy Imaging and Model Management System (TIMMS) ICT infrastructure (based on DICOM-X) for data, image, model and tool communication for patient model-guided therapy Simulation Kernel for WF and K+D Management Visualisation Rep. Manager InterventionValidation Repo- sitory Engine Data Exch. Control IO Imaging and Biosensors Images and signals Modelling tools Computing tools WF and K+D tools Rep. tools Devices/ Mechatr. tools Validation tools WF`s, EBM, ”cases” Data and information Models and intervention records Therapy Imaging and Model Management System (TIMMS)

46 Conclusion Therapy Imaging and Model Management System (TIMMS) 3. Derive S-DICOM services and IOD`s from TIMMS functionalities

47 WG 24 “DICOM in Surgery“ Project Groups PG1WF/MI Neurosurgery PG2WF/MI ENT and CMF Surgery PG3WF/MI Orthopaedic Surgery PG4WF/MI Cardiovascular Surgery PG5WF/MI Thoraco-abdominal Surgery PG6WF/MI Interventional Radiology PG7WF/MI Anaesthesia PG8S-PACS Functions PG9WFMS Tools PG10Image Processing and Display PG11Ultrasound in Surgery

48 WG24 “DICOM in Surgery” Secretariat: Howard Clark, NEMA Secretary: Franziska Schweikert, CARS/CURAC Office General Chair: Heinz U. Lemke, ISCAS, Germany Co-Chair: Ferenc Jolesz, Harvard Medical School, Boston (Surgery/Radiology) Co-Chair: tbd (Industry)

49 S-DICOM Cooperation Partners CARS Institute/Foundation SPIE University of Geneva ICCAS, University of Leipzig (ENT, Cardio, Neuro) Technical University of Berlin (CG and CAM) University of Southern California (IPI) University of Rennes Japan Institute of CARS Industry (Agfa, Siemens, Philips,...) CURAC (AG S-WF and S-PACS) University of Pisa, EndoCAS The Interventional Centre, Oslo Georgetown University, Washington University of Chicago ISCAS …

50 (a)What 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). IGT Workshop Rockville, MD, 20 th September 2006

51 (b) How do you think that we at NCIGT (National Center for Image-Guided Therapy) can help address these challenges 1. 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. IGT Workshop Rockville, MD, 20 th September 2006

52 CARS / SPIE 7 th Joint Workshop on Surgical PACS and the DOR Berlin, 30 June, th Meeting of the DICOM Working Group WG 24 “DICOM in Surgery“ 30 June 2007 CARS 2007 Computer Assisted Radiology and Surgery


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