1. The Operating Room and the need for an IT Infrastructure and Standards
IGT Workshop
Rockville, MD, 20th September 2006
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

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

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

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

7. acquisition completed acquisition in-progress acquisition completed
Scheduled Workflow Profile
Report
Repository
Registration
report
Diagnostic
Workstation
Film
Lightbox
HIS
PACS
Orders Placed
Image Manager
& Archive
Film
Folder
Orders Filled
Specifies transactions that function to maintain the integrity of patient, image, and order information across systems
Integrates modalities with information and imaging systems
Biggest Value of IHE
Smooth flow of patient, image and order information across systems
Status updates of orders
Acquisition Modality
acquisition completed
Film
RIS
acquisition in-progress
acquisition completed
images printed
Modality

8. WG 24 “DICOM in Surgery“ Project Groups
PG1 WF/MI Neurosurgery
PG2 WF/MI ENT and CMF Surgery
PG3 WF/MI Orthopaedic Surgery
PG4 WF/MI Cardiovascular Surgery
PG5 WF/MI Thoraco-abdominal Surgery
PG6 WF/MI Interventional Radiology
PG7 WF/MI Anaesthesia
PG8 S-PACS Functions
PG9 WFMS Tools
PG10 Image Processing and Display
PG11 Ultrasound in Surgery

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

10. Workflow for Ablation Procedure
DICOM Workgroup 24
Workflow for Ablation Procedure

12. DICOM Workgroup 24

13. DICOM Workgroup 24
Pre-procedure Planning

14. Functional Categories
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
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

15. Table 1
IOD
Related IOD
Functional
Categories
COMPUTED RADIOGRAPHY IMAGE 1
COMPUTED TOMOGRAPHY IMAGE
1,2 3
ENHANCED COMPUTED TOMOGRAPHY
MAGNETIC RESONANCE IMAGE
ENHANCED MR
MR Spectroscopy
NUCLEAR MEDICINE IMAGE
ULTRASOUND IMAGE
ULTRASOUND MULTI-FRAME IMAGE
Ultrasound (IVUS)
2,3
DIGITAL X-RAY IMAGE
Overlay Plane Module 3
POSITRON EMISSION TOMOGRAPHY IMAGE
STANDALONE PET CURVE
ENHANCED XA [X-RAY ANGIOGRAPHIC] IMAGE
ENHANCED XRF [X-RAY RF] IMAGE

16. Content Motivation, interfaces, workflow and standards
Interfacing examples
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. Source: K. Radermacher, RWTH Aachen
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. Integration of Planning, Imaging, Navigation and Treatment
Postoperative
Monitoring, e.g.. MRI
Preoperative Planning
OR IT Integration
Intraoperative Imaging and Navigation
OR Integration:
Dräger Siemens Storz
Source: C. Bulitta, SIEMENS

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

24. Source: C. Bulitta, SIEMENS
Concept of levels
Consolidation of frontend-exchange or integration on screenlevel
Data 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 Bus
HIS
System 1
web-service
enabled
System 2
System 3
System N
conncector
Frontend-1
(KVM switch/RDP)
Source: C. Bulitta, SIEMENS

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

27. Diagnostic Image-Centric World View
PACS
Modalities
(X-ray,
CT, US, MR,
SPECT, PET)
DICOM
DICOM
Archive
Images
(CAD etc.)
Identification
(name, SS #,
exam code,
date, …)
At the present, this is a model of imaging informatics in radiology.
Acquisition
Parameters
Query:
name? date?
exam type?

28. Future-PACS based on DICOM-X
Integrated Patient Care
Omics
EMR
EBM
Workflow
IHE
Mechatronics
(Navigation,
ablation, …)
Modalities
(X-ray,CT, US,
MR,SPECT,
PET,OI)
Integration
and Diagnosis
(Data fusion,
CAD, …)
Modelling and
Intervention
(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-X
Image-Centric World View
Model-Centric World View
H. U. Lemke, CARS 2006

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

30. DICOM RT Modules PS 3.3-2006 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

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

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 …

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

35. Surgical DICOM Model of the real world (exemplary, incomplete…)
Patient
conducts
Physician
makes
Is subject of
makes
Visit
prepares
has
includes
Intervention
Study
defines
Repository
Plan
Comprised of
contains
Bases on / uses / contains
Modality performed procedure steps
Data Library
includes
contains
creates
Workflow
Tools
Diagnosis
Someone…
defines
Series
references
creates
Frame of Reference
contains
Equipment
Image
Waveform
Report
Workflow
Tools
Diagnosis
Image Processing
Ontologies
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
UPnP
Registration
Presentation State RT
Conf. Mgmt
Img. Processing
Hanging Protocols
Visible Light
Images, WF…
Segmentation
Patient Model
Navigation
Geometric Models
Library, Repository
Augmented Reality
Video based Nav.
Intervention
Ontologies
Simulation
Manipulator
Workflows

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

39. Informatic Portals for Data Mining
Data Repositories

40. P2P „Best Practice“ Workflow Repository
Repository of workflow
reference models (WFs, SIPs)
for medical techniques,
operating instructions,
etc.
Generic models and
patient-spec. models
Peer Expert I
Peer Expert II
Peer Expert III
Peer Expert IV
Reference expert knowledge
WF graph
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 Data Grid for PACS Image Data Backup: The DICOM Data GRID
HCC2 PACS
Server
HCC2
PACS WS
HCC2 SAN P1
SJHC
PACS WS
SJHC PACS
Server
DICOM
Data Grid
SJHC SAN P1 P2 P2
SJHC
IPI SAN
PACS
IPI
Simulator

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. Therapy Imaging and Model Management System (TIMMS)
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. Therapy Imaging and Model Management System (TIMMS)
Interventional Cockpit/SAS modules
Data Exch.
Repo-
sitory
Engine
IT Model-Centric World View
Control
Therapy Imaging and Model Management System (TIMMS)
© H.U. Lemke, August 2006
Images
and
signals
Modelling
tools
Computing
WF and
K+D
Rep.
Devices/
Mechatr.
Validation
IO Imaging
and
Biosensors
Modelling
Simulation
Kernel for
WF and K+D
Management
Visualisation
Rep. Manager
Intervention
Validation
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
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.
Models
(Simulated
Objects)
WF`s, EBM,
”cases”
Models and
intervention
records
Data and
information

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

47. WG 24 “DICOM in Surgery“ Project Groups
PG1 WF/MI Neurosurgery
PG2 WF/MI ENT and CMF Surgery
PG3 WF/MI Orthopaedic Surgery
PG4 WF/MI Cardiovascular Surgery
PG5 WF/MI Thoraco-abdominal Surgery
PG6 WF/MI Interventional Radiology
PG7 WF/MI Anaesthesia
PG8 S-PACS Functions
PG9 WFMS Tools
PG10 Image Processing and Display
PG11 Ultrasound 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. Rockville, MD, 20th September 2006
IGT Workshop
Rockville, MD, 20th September 2006
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).

51. Rockville, MD, 20th September 2006
IGT Workshop
Rockville, MD, 20th September 2006
(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.

52. CARS 2007 Computer Assisted Radiology and Surgery
CARS / SPIE 7th Joint Workshop on Surgical PACS and the DOR Berlin, 30 June, 2007
9th Meeting of the
DICOM Working Group WG 24 “DICOM in Surgery“
30 June 2007