1. RADIOLOGY & IT Merger or Collision ? David P. Mayer, MD,MS,FACR
Clinical Professor of Radiology
Drexel University College of Medicine

2. RADIOLOGY & IT OUTLINE What is Radiology?
Connectivity & Image Management
Alphabet Soup: DICOM;PACS and IHE et al.
The Future of IT & Radiology
Summary

3. Diagnostic Radiology
Re-Defined: The use of various imaging tools to examine the body
in order to guide patient treatment
There is an information chain that
connects the patient and referring
Doctor to the Radiology Department
which responds with useful diagnostic
information

4. “Radiology is an applied IT field”
Diagnosis? r
Digital Image:
A Dx Puzzle
“You’ve got Questions,
We’ve got answers!”
& Fax
Results

5. Radiology: “Information Steps”
The Radiologist Works HERE!

6. Imaging Tools: CT Scanning (CAT Scan) MRI (Magnetic Resonance Imaging)
Ultrasound
Angiography & Interventional
X-ray & Fluoroscopy
Mammography & etc.
MRI
CT Scanning
Ultrasound

7. Diagnostic Radiology: IT Issues
Imaging Challenges:
Xs Digital Data (225K Cases/yr=3Tb/yr)
Future = Video Display (Film is “dead”)
Digital transmission via Inter and IntraNet
Disseminated Access is Required
Demands  Xs Bandwidth; Redundancy; 3-5 Megapixel >500:1 contrast; Long term Image & Data Archival; Rapid Access with report info & Demographics; Standardized format- i.e. DICOM; Image Manipulation tools; etc.

8. Computer Data Byte = 8 bits or 256 shades of gray
Kilobyte = 1024 Bytes
Megabyte = 1024 Kbytes (KB)
Gigabyte = 1024 Mbytes (MB)
Terabyte = 1024 Gbytes (GB)
Average Word processing Doc < 100KB
Average (Digital) Radiology Exam =25MB
Single Digital X-Ray = 10 MB

9. Network Standards PACS data loads are huge
Requires high speed/high capacity network
@ 100 – 1000Mb/sec
MHS data volume/year ~ 3TBytes/yr
Data Multiplication: exams move many times across the network

10. Diagnostic Radiology: IT Issues
Read-to-write ratio: In healthcare because many different medical professionals repeatedly access the same data.
Data lifecycle: Process by which you can move data from online storage, to near online, to tape, to archive—is specific to healthcare.
Recall data: Captured years earlier & Accessed very quickly.
Disparate data: Generated, captured, and stored in different locations & different applications, with different Dx modalities.
Requirement: Link the images with the patient's chart, pharmacy records, billing information, etc..
Health Insurance Portability and Accountability Act (HIPAA):
Providers must communicate information between different stakeholders in the system including doctors, hospitals, insurance companies, and the Federal government
Information must be secure at every step in the process.

11. “Radiology is an applied IT field”
Diagnostic Radiology
PACS: “Picture Archival & Communication System”
DICOM: A Digital Communication Standard between Diagnostic Modalities & PACS
IHE: “Integrating the Healthcare
Enterprise”
“Radiology is an applied IT field”

12. PACS & Diagnostic Radiology
PACS: “Picture Archival & Communication System”
Provides a means to move, display and store images generated by radiology or other hospital depts.
Radiology “product”: The interpretation of an image
Interpretations MUST be timely!

13. PACS “Any image, anywhere, anytime – and fast”
Northwestern Memorial Hospital, Chicago, Illinois

14. PACS Key Components: Modality Interfaces Clinical Workstations
Network Backbone
Database Management System
Image Management System
Long term Archive
Diagnostic Workstations
Clinical Workstations
Web server Access to images

15. PACS
Advantages: Redundant Archives; Cost savings: Film, Chemicals, Storage Space; Manpower, & Time !!!
Potential Increased productivity
Reduced Turnaround time
Reduced Retakes & Lost Films
Easier consultation & Stat reporting
Disadvantages: Large Capital $ outlay; Requires new work paradigm; Clinician cooperation?; Reinvestment are required
Cultural shift: Age and Medical Specialty dependent

16. PACS: 2006-7 Hospitals w/o PACS:
The question shifts from “if” to “when”
Approx. 50% of US Hospitals
Hospitals w/ PACS:
Upgraded systems:
IHE Networking
Upgraded data handling capabilities
Upgraded computers & monitors to LCD’s

17. PACS: 2006-7 Upgraded systems: 99.99% Network & PACS Uptime:
Redundancy; “self healing”
99% uptime = 1 failed day/100d
Requirements:
HL7; DICOM; IHE standards
HIS+RIS+PACS:
“seamless” & “bidirectional”
Modality “worklist” (MWL) etc.
Wireless systems??

18. PACS: 2006-7 Upgraded systems: PACS is “Not just for Radiology”:
Cardiology & Pathology E.M.A.
[“-ologies” : common data storage]
Data Storage requirements:
e.g. MD-CT: 64+ slices; Digital Mammo;
ultrasound video clips; High res. MRI;
Faster Spinning media archive access
3D renderings

19. PACS:

20. PACS: 2006-7 Upgraded systems: “Off the shelf” hardware
“Software only” solutions
Mergers:
Images with Voice Recognition generated reports
Hospital-wide Image & Data
Clinical Data w/ Images
Surgical templates w/ images

21. Healthcare IT Issues IT Government Oversight:
HIPAA: Audit trails required
FDA
State & Local Health Regulations
HIPAA:
1. Electronic Data format standards:
2. Privacy: Integrity & Confidentiality of patient info. Flexibility vs. privacy
3. Security: Storage, Transmission and Display Data protection.
*PHI (Protected Health Information) requires User Authentication
*Every data access must be logged
*Secure Storage & Transmission

22. PACS: 2006-7 Upgraded systems: HIPAA Compliant security systems
Site requirements:
PACS administrator
Voice recognition Administrator
Teamwork:

23. Securing clinical Information systems
Healthcare IT Dilemma
Securing clinical Information systems
“CIA Triad”: Confidentiality; Integrity & Availability
Confidentiality: Staff & Pt. Data must be protected
Integrity: Correct & Complete data; Legal & HIPAA: sanctions
Availability: Timely and secure access; Mission criticality: 24/7/365
Tradeoff:
Protected Info. vs. Ease-of-use

24. HIPAA – Its Impact on Radiology
Cost estimates: $2B-43B
Security for Radiology Reports & Images
Digital environment:
Authentication: “Who are you” ?
Encryption: “Encode the data”
Access: “Need to know” basis

25. DICOM (Digital Image Communication in Medicine):
A standard for image communication in the medical field, that is supported by most vendors of digital imaging devices (CT, MR, digital X-Ray, ultrasound, etc.).
DICOM standard includes a detailed description of the patient information with the images and the way the images are sent between different devices:
e.g. between a CT scanner and a PACS (Picture Archival and Communication System)

26. DICOM 3 (Current level):
ACR & NEMA: Formed joint committee to develop Digital Imaging standards
Other participating organizations: IEEE, HL7, ANSI, JIRA, etc.
Allows Gateway to HL7, www

27. HIS/RIS – PACS Communication:
Optimal: Bidirectional interface between HIS/RIS & PACS
Minimizes data entry errors
Est. 15% of medical data entries have errors !!!
Faster reporting and image availability
Pre-fetching of old reports & exams
Modality Work List: Data   Scanner

28. DICOM
Note: “ ”
Gary Wendt, MD
i.e. The devil is in the details !

29. DICOM http://medical.nema.org/
Many Capabilities are included under the “DICOM” name [e.g. 12 DICOM “Classes”]
DICOM Verification Service Class
DICOM Storage Service Class
DICOM Query/Retrieve Service Class
DICOM Study Content Notification Service Class
DICOM Patient Management Service Class
DICOM Study Management Service Class
DICOM Results Management Service Class
DICOM Print Management Service Class
DICOM Media Storage Service Class
DICOM Storage Commitment Service Class
DICOM Basic Worklist Management Service Class
DICOM Queue Management Service Class

30. Radiology Information System
RIS
Radiology Information System
Patient registration order entry
Data analysis
Management reporting
Scheduling & Billing data
Exam & Patient tracking (incl. Mammo)
Transcription
Integration: IHE; HIPAA; PACS

31. Radiology Information System
RIS
Radiology Information System
8. Patient info merges w/ Images:
Allergies; lab values & Hx
Internet linkage
Mammography: (Unfunded federal mandate) MQSA Regulations

32. DICOM
Note:
All new imaging modalities (e.g. CT, Ultrasound, MRI, Digital X-Ray etc.) are available with DICOM compatibility
Older imaging equipment require ($$$) upgrades or interfaces to the DICOM std.
There are numerous “levels” or “classes” to DICOM compatibility
DICOM continues to evolve  IHE

33. What is IHE? "Integrating the Healthcare Enterprise" (IHE), is a multi-year initiative, sponsored by the Radiological Society of North America (RSNA) and the Healthcare Information and Management Systems Society (HIMSS), whose single purpose is to bring together medical equipment and information products from different manufacturers for developing an efficient and seamless workflow between multiple products from multiple vendors while improving the clinical and economic efficiencies of hospital-wide connectivity.

34. Note that the IHE is not a Standards organization
Note that the IHE is not a Standards organization. The IHE uses existing standards, such as DICOM and HL-7, for developing workflow solutions for the healthcare enterprise

35. Partners
Supporting organizations providing expertise, technology and guidance
American College of Physicians
Centers for Disease Control & Prevention
CDISC
Duke University Medical Center
Food & Drug Administration
OASIS
Massachusetts Medical Society
National Institute for Standards & Technology
UC David, Medical Informatics

36. Participants

37. IHE Integrating the Healthcare Enterprise
Multi-year initiative
Creates framework for seamless passage of health information
Provides framework for implementing relevant standards: e.g. “Connectathon”
1998: RSNA & HIMSS provides leadership
Drives the adoption of standards to address specific clinical needs
Does NOT create new standards
Ensures higher level of practical interoperability
Clinical Domain Expansion: Cardiology, Medication Mgnt. And Clinical Engineering

38. From Continuity of Care scenario
Imaging Integration, Tumor Reporting, Claims Processing
Imaging
RIS
Workstation
Dictation
Server
Payer
Repository
Broker
EMR
Broker
PCP
eForms
Registry
Tumor Registry
Pathology
Hospital
Surgery
Brokered Claim; Registry Discovery
For patient chart and Tumor Registry; CCR back to PCP

39. Continuity of Care (e.g. Tumors)
Imaging Integration, Tumor Reporting, Claims Processing
EMR
Imaging
Virtual EHR
eForms
PCP
Transform
Tumor Registry/repository
Virtual EHR
EMR
Hospital
Secure transport
Dictation
EMR
Lab
Imaging

40. Highlights Firsts: Annotated Electro-cardiogram, submissions
CDA College of American Pathology tumor report,
CDA Continuity of Care Record (CCR)
Clinical Document Architecture Release 2 (ballot draft)
Distributed, standards-based decision support
Document-based HIPAA claims attachments
End-to-end, standards-based electronic clinical trial data submission
End-user Authentication profile
Hyperlink between electronic document and PACS image
Nationally Notifiable Disease report
Open-source metadata registry for ubiquitous access to distributed information
Patient Information Cross-reference profile
Patient Synchronized Applications
Retrieve Information for Display profile
Re-use of electronic clinical documents to support a claim
Structured Product Labeling
Third-party brokered claims attachments
Version 3/CDA Templates

41. The HL7-IHE Demo…
Creates the future of machine interoperability through human interoperability
We identify barriers to Interoperability and
And we engineer breakthroughs.

42. IHE INTEGRATION PROFILES

43. IHE Components (1)
Scheduled Workflow : flow of information for the key steps (registration, ordering, scheduling, acquisition, distribution and storage)
Patient Information Reconciliation method for reconciliation of information for unidentified or mistakenly identified patients
Consistent Presentation of Images ensures a consistent view of images and annotations across different displays and media
Presentation of Grouped Procedures management of images for multiple procedures in a single acquisition step (e.g. spiral CT: chest & abdomen)
Access to Radiology Information mechanism for sharing radiological images and information across department boundaries

44. IHE Components (2)
Key Image Note addition of textual notes and pointers to key images in a series
Simple Image and Numeric Reports standard way of creating, managing, storing and viewing reports that include images, text and numerical values
Charge Posting information about procedures available to billing systems allows consistent and timely billing of technical and professional charges
Basic Security establishes enterprise-wide security infrastructure for meeting privacy requirements (such as HIPAA)
Post-processing Workflow supports workflow steps such as Computer-Aided Detection (CAD), Imaging Processing, and Image Reconstruction

45. Teleradiology
Teleradiology programs allow the sending of pictures between different stations in different locations.
MR Image from the brain

46. Teleradiology
Teleradiology programs allow the sending of pictures between different stations in different locations. CT
MRI
X-Ray

47. Productivity in Radiology: Why?
Procedure volume increasing by 3.5-5%/yr
Supply of radiologists increasing by 2%/yr
Between
MRI Exams increased by 19%:
CT Exams increased by 10%:
Case complexity & Slices: 64 slice CT !!!
Clinical expectations are also increasing !!

48. Diagnostic Radiology SUMMARY: The Future of Medicine
Digital based image acquisition, interpretation and distribution Continued integration of imaging with demographic & clinical data
Computer Assisted Diagnosis (CAD):
[the real “Tricorder”]

49. Diagnostic Radiology SUMMARY: The Future of Medicine
Computer Assisted Diagnosis (CAD):
[the first real “Tricorder”??]
Working CAD systems:
Mammography
Clinical Trials:
CT Scanning: Chest
Chest X-Rays
The Tricorder Site, 2001,

50. Questions ???? Office: 610-237-4353 Pager: 888-966-9716