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September, 2005What IHE Delivers 1 Cardiology Workflow & Display Requirements ACCA IHE Workshop 2007 Bob Baumgartner, BSN, MBA McKesson Corporation IHE-Cardiology.

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Presentation on theme: "September, 2005What IHE Delivers 1 Cardiology Workflow & Display Requirements ACCA IHE Workshop 2007 Bob Baumgartner, BSN, MBA McKesson Corporation IHE-Cardiology."— Presentation transcript:

1 September, 2005What IHE Delivers 1 Cardiology Workflow & Display Requirements ACCA IHE Workshop 2007 Bob Baumgartner, BSN, MBA McKesson Corporation IHE-Cardiology Planning Committee Administrative Co-Chair

2 2 Agenda Cardiology Workflows General Cath Workflow Cath Workflow Echo Workflow Echo Workflow Stress Workflow Stress Workflow Content Display Requirements Stress Echo Stress Echo Stress Stress

3 3 Cardiology Workflows Cardiology : the study of the heart heart its action its action and diseases and diseases

4 4 The Problem This is an example of a cardiology workflow. Any questions! Workflow is the linchpin to data integrity

5 5 General Workflow

6 6 Agenda Cardiology Workflows General Cath Workflow Cath Workflow Echo Workflow Echo Workflow Stress Workflow Stress Workflow Content Display Requirements Stress Echo Stress Echo Stress Stress

7 7 Cath Lab Multiple re-entry of Patient ID Error prone Results fragmented across systems Results inconsistently time-tagged 1 2 3 4 5 6 7 8 9 10 11

8 8 Administrative Process Flow ADT Order Placer Image Manager Acquisition Modality Placer Order Mgmt - New [Rad-2] Department System Scheduler/ Order Filler Procedure Scheduled [Rad-4] Register/ Admit Patient Create Order Schedule Procedure Patient Registration [Rad-1] Select Patient Query Modality Worklist [Rad-5] Start Procedure

9 9 Procedure Performance Process Flow Image Manager/ Image Archive Acquisition Modality Department System Scheduler/ Order Filler Modality Procedure Perform Acquisition Modality Images/ Evidence Stored [Card-2] Storage Commitment [Card-3] Modality Procedure Step In Progress [Card-1] Modality Procedure Step Completed [Rad-7] Modality Procedure Step In Progress [Card-1] Order Placer Order Status Update [Rad-3] Update Schedule Acquisition Modality n Query Modality Worklist [Rad-5] Modality Procedure Step In Progress [Card-1] Modality Procedure Step In Progress [Card-1] Perform Acquisition Modality Images/Evidence Stored [Card-2] Step Completed [Rad-7]

10 10 Use Cases Case C1: Patient Registered at ADT and Procedure Ordered at the Order Placer Case C1: Patient Registered at ADT and Procedure Ordered at the Order Placer Case C2: Patient Registered at ADT and Procedure Ordered at DSS/OF Case C2: Patient Registered at ADT and Procedure Ordered at DSS/OF Case C3: Patient Registered at ADT and Procedure Not Ordered Case C3: Patient Registered at ADT and Procedure Not Ordered Case C4: Patient Registered at DSS/OF and Procedure Ordered Case C4: Patient Registered at DSS/OF and Procedure Ordered Case C5: Patient Not Registered Case C5: Patient Not Registered Case C6: Patient Updated During Procedure Case C6: Patient Updated During Procedure Case C7: Change Rooms During Procedure Case C7: Change Rooms During Procedure Case C8: Cancel Procedure Case C8: Cancel Procedure Case C9: Post-Procedure Evidence Creation Case C9: Post-Procedure Evidence Creation Case C10: EP Ablation / Implantation Lab Case C10: EP Ablation / Implantation Lab

11 11 Case C1: Patient Registered at ADT and Procedure Ordered at the Order Placer Clinical Context Corresponds to traditional Radiology workflow Corresponds to traditional Radiology workflow Order placed in central system Order placed in central system Also deals with case where emergency identifier has been created Also deals with case where emergency identifier has been created Common identifiers known ahead of time Common identifiers known ahead of time IHE Context MPPS in Progress from first modality used to update worklists for others MPPS in Progress from first modality used to update worklists for others

12 12 Case C2: Patient Registered at ADT and Procedure Ordered at DSS/OF Clinical Context Slight difference to Case 1 Slight difference to Case 1 Order placed NOT in central system but in department Order placed NOT in central system but in department Department system provides info to Central ordering system Department system provides info to Central ordering system Typical of many institutes, relieves need for HIS terminal in lab Typical of many institutes, relieves need for HIS terminal in lab IHE Context Filler Order Management (New Order) transaction [RAD-3] is sent from Department System Scheduler/Order Filler to the Order Placer. Filler Order Management (New Order) transaction [RAD-3] is sent from Department System Scheduler/Order Filler to the Order Placer.

13 13 Case C3: Patient Registered at ADT and Procedure Not Ordered Clinical Context Slight difference to Case 2 Slight difference to Case 2 Procedural information is NOT entered at the departmental system Procedural information is NOT entered at the departmental system The first modality must initiate the process of creating common procedure identifiers (usually hemo) The first modality must initiate the process of creating common procedure identifiers (usually hemo) The common procedure identifiers are created by the departmental system based on the information available from the first modality The common procedure identifiers are created by the departmental system based on the information available from the first modality Can generate a generic cath procedure if no coded procedural type is available Can generate a generic cath procedure if no coded procedural type is available IHE Context Upon receiving the first MPPS the DSS/OF will auto generate a Requested Procedure and its associated Scheduled Procedure Steps utilizing the Study UID provided in the first MPPS. All other modalities use the Query Modality Worklist transaction. Upon receiving the first MPPS the DSS/OF will auto generate a Requested Procedure and its associated Scheduled Procedure Steps utilizing the Study UID provided in the first MPPS. All other modalities use the Query Modality Worklist transaction.

14 14 Case C4: Patient Registered at DSS/OF and Procedure Ordered Clinical Context This case accommodates the emergency case where there is not enough time to register the patient on ADT system This case accommodates the emergency case where there is not enough time to register the patient on ADT system A temporary patient identifier is created at the department level A temporary patient identifier is created at the department level The order placer is notified only after the patient is registered and manually reconciled on the department system The order placer is notified only after the patient is registered and manually reconciled on the department system IHE Context The DSS/OF assigns a temporary Patient ID with a temporary name and schedules the required procedures The DSS/OF assigns a temporary Patient ID with a temporary name and schedules the required procedures The DSS/OF does not send the Filler Order Management (New Order) transaction to the Order Placer until the patient is registered on the ADT system and reconciliation occurs on the DSS/OF. The DSS/OF does not send the Filler Order Management (New Order) transaction to the Order Placer until the patient is registered on the ADT system and reconciliation occurs on the DSS/OF.

15 15 Case C5: Patient Not Registered Clinical Context This is the Emergent Case where the patient information is not known or there is not enough time to enter the information This is the Emergent Case where the patient information is not known or there is not enough time to enter the information A temporary ID is assigned by the department and entered at the first modality and forwards that information to the departmental system to be shared with the other modalities A temporary ID is assigned by the department and entered at the first modality and forwards that information to the departmental system to be shared with the other modalities Like in C4 information is sent to the Order Placer post patient registration and reconciliation on the departmental system Like in C4 information is sent to the Order Placer post patient registration and reconciliation on the departmental system IHE Context Patient ID and name are selected based upon locally (usually department) base rules Patient ID and name are selected based upon locally (usually department) base rules The first modality will send an MPPS with the appropriate information to the DSS/OF which will in turn generate the appropriate requested procedure(s) using the Study UID assigned by the first modality The first modality will send an MPPS with the appropriate information to the DSS/OF which will in turn generate the appropriate requested procedure(s) using the Study UID assigned by the first modality

16 16 Case C6: Patient Updated During Procedure Clinical Context An unidentified patient may have been registered at the ADT and brought into the cath lab with the temporary ID An unidentified patient may have been registered at the ADT and brought into the cath lab with the temporary ID During the procedure the patient information is updated on the ADT which sends the patient update information During the procedure the patient information is updated on the ADT which sends the patient update information This can results is some of the information been associated with the temp ID and the rest with the permanent ID This can results is some of the information been associated with the temp ID and the rest with the permanent ID The case defines how the reconciliation occurs. The case defines how the reconciliation occurs. IHE Context The modality may have requested information from the DSS/OF prior the patient update The modality may have requested information from the DSS/OF prior the patient update The Image Manager needs to update the items stored to Image Archive as well as any subsequent items received. The Image Manager needs to update the items stored to Image Archive as well as any subsequent items received.

17 17 Case C7: Change Rooms During Procedure Clinical Context This is the case when the patient is moved due to any of the following reasons: The change from a diagnostic to interventional procedure The change from a diagnostic to interventional procedure The need to use the current room for another patient The need to use the current room for another patient Equipment failure Equipment failure NOTE: This case does not cover the scenario where a patient is moved to the holding area from a procedure room. IHE Context Each modality will issue a MPS (Completed or Discontinued) Each modality will issue a MPS (Completed or Discontinued) The DSS/OF will reassign the requested procedure to the new room The DSS/OF will reassign the requested procedure to the new room In the event the DSS/OF does not reassign, each modality in the new room would use the broad Modality Worklist Query In the event the DSS/OF does not reassign, each modality in the new room would use the broad Modality Worklist Query This insures consistency of the Study UID for all information This insures consistency of the Study UID for all information

18 18 Image Manager Acquisition Modality Room 1 Department System Scheduler/ Order Filler Modality Procedure Step Discontinued [Rad-7] Modality Procedure Step Discontinued [Rad-7] Modality Procedure Step In Progress [Card-1] Modality Procedure Step In Progress [Card-1] Acquisition Modality n Room 1 Query Modality Worklist [Rad-5] Perform Acquisition Perform Acquisition Modality Room 2 Acquisition Modality n Room 2 Query Modality Worklist [Rad-5] Modality Procedure Step In Progress [Card-1] Modality Procedure Step In Progress [Card-1] Modality Procedure Step In Progress [Card-1] Modality Procedure Step In Progress [Card-1] Query Modality Worklist [Rad-5] Perform Acquisition Perform Acquisition Query Modality Worklist [Rad-5] Modality Procedure Step In Progress [Card-1] Modality Procedure Step In Progress [Card-1] Reassign Procedure Update Schedule Case 7: Change Rooms During Procedure

19 19 Case C8: Cancel Procedure Clinical Context This case allows for the information systems to keep track of cancelled procedures allowing the cath lab staff to appropriately respond to queries regarding that patient. This case allows for the information systems to keep track of cancelled procedures allowing the cath lab staff to appropriately respond to queries regarding that patient. IHE Context When the procedure is cancelled within the department the DSS/OF notifies the Order Placer system and Image Manager When the procedure is cancelled within the department the DSS/OF notifies the Order Placer system and Image Manager The length of time this procedural information is maintained is determined by local policy. The length of time this procedural information is maintained is determined by local policy.

20 20 Case C9: Post-Procedure Evidence Creation Clinical Context Allows for imaging and other procedural data to be analyzed post-procedure using specialized software (e.g., QCA, QLV, derived images) Allows for imaging and other procedural data to be analyzed post-procedure using specialized software (e.g., QCA, QLV, derived images) This case does NOT apply to core lab analysis for clinical trials or outcome analysis This case does NOT apply to core lab analysis for clinical trials or outcome analysis IHE Context This analysis must be performed on a station that groups the Image Display and Evidence Creator Actors This analysis must be performed on a station that groups the Image Display and Evidence Creator Actors The Evidence Creator notifies the IM/IA and DSS/OF of the activity via the MPPS In Progress and Complete transactions The Evidence Creator notifies the IM/IA and DSS/OF of the activity via the MPPS In Progress and Complete transactions The Evidence Creator stores its evidence to the IM/IA via the Storage Commit Transaction. The Evidence Creator stores its evidence to the IM/IA via the Storage Commit Transaction.

21 21 Case C10: EP Ablation / Implantation Lab Clinical Context Allows for the wide array of specialized equipment used in the EP lab Allows for the wide array of specialized equipment used in the EP lab Provides demographic and time synchronization Provides demographic and time synchronization IHE Context Initial implementation is an extension of the CATH profile Initial implementation is an extension of the CATH profile Support for use cases C1 – C9 Support for use cases C1 – C9 Emergency use cases C3 and C5 are highly unusual in the EP lab. Emergency use cases C3 and C5 are highly unusual in the EP lab.

22 22 Agenda Cardiology Workflows General Cath Workflow Cath Workflow Echo Workflow Echo Workflow Stress Workflow Stress Workflow Content Display Requirements Stress Echo Stress Echo Stress Stress

23 23 Use Cases Case E1: Patient Registered at ADT and Procedure Ordered Case E2: Intermittently Connected Modality Case E3: Intermittently Connected Modality with Ad Hoc Procedure, Patient Registered, Scheduled Procedure Case E4: Intermittently Connected Modality with Ad Hoc Procedure, Patient Registered, Unscheduled Procedure Case E5: Intermittently Connected Modality with Ad Hoc Procedure, Patient Unregistered, Unscheduled Procedure Case E6: Stress Echo Staged Protocol Case E7: Echo Measurements Evidence Creation

24 24 Case E1: Patient Registered at ADT and Procedure Ordered Clinical Context Corresponds to traditional Radiology workflow Corresponds to traditional Radiology workflow Order placed in central system Order placed in central system Also deals with case where emergency identifier has been created Also deals with case where emergency identifier has been created Common identifiers known ahead of time Common identifiers known ahead of time IHE Context The Scheduled Procedure Steps are obtained by the modality through Query Modality Worklist, the acquisition is performed and statused thought Modality Performed Procedure Step. The Scheduled Procedure Steps are obtained by the modality through Query Modality Worklist, the acquisition is performed and statused thought Modality Performed Procedure Step.

25 25 Case E2: Intermittently Connected Modality Clinical Context Allows for the mobile workflow typical of TTE and TEE Allows for the mobile workflow typical of TTE and TEE Assumes the modality is only intermittently connected to the network Assumes the modality is only intermittently connected to the network Also covers the case of the modality being turned off Also covers the case of the modality being turned off IHE Context Process flow identical to Case E1 Process flow identical to Case E1 Must be paired with an Image Manager/Image Archive that also supports Intermittent Connectivity Must be paired with an Image Manager/Image Archive that also supports Intermittent Connectivity MPPS are stored and sent when connection established MPPS are stored and sent when connection established Image Manage must queue N-Event Report messages for storage commitment Image Manage must queue N-Event Report messages for storage commitment

26 26 Case E3: ICM with Ad Hoc Procedure, Patient Registered, Scheduled Procedure Clinical Context This extends Case E2 to allow for a scheduled procedure but the modality cant query the worklist since it is not connected to the network This extends Case E2 to allow for a scheduled procedure but the modality cant query the worklist since it is not connected to the network IHE Context The modality will treat this as unscheduled procedure The modality will treat this as unscheduled procedure The patient ID and demographics must be manually entered The patient ID and demographics must be manually entered The modality must create the Study Instance UID The modality must create the Study Instance UID Manual matching process at DSS/OF to reconcile the scheduled and performed procedure information Manual matching process at DSS/OF to reconcile the scheduled and performed procedure information Post match the DSS/OF will reconcile with the Image Manager to correct for the Study Instance UID Post match the DSS/OF will reconcile with the Image Manager to correct for the Study Instance UID

27 27 Case E4: ICM with Ad Hoc Procedure, Patient Registered, Unscheduled Procedure Clinical Context This is the drive by echo or Stat echo performed without an order placed in the system This is the drive by echo or Stat echo performed without an order placed in the system IHE Context This case is identical to other unscheduled procedure cases This case is identical to other unscheduled procedure cases Modality creates the Study Instance UID Modality creates the Study Instance UID When connected the modality will send a MPPS in Progress When connected the modality will send a MPPS in Progress DSS/OF will generate an exception for reconciliation DSS/OF will generate an exception for reconciliation Patient demographic reconciliation should occur automatically based on patient ID Patient demographic reconciliation should occur automatically based on patient ID The Image Manager will use the Patient Update transaction to update the demographics The Image Manager will use the Patient Update transaction to update the demographics

28 28 Case E5: ICM with Ad Hoc Procedure, Patient Unregistered, Unscheduled Procedure Clinical Context This case is similar to Case E4 except the patient is not yet registered. (Emergency Admit) This case is similar to Case E4 except the patient is not yet registered. (Emergency Admit) IHE Context Temporary Name and ID entered into the modality Temporary Name and ID entered into the modality DSS/OF will generate an exception DSS/OF will generate an exception Manual match of the temporary ID with the Patient Registration information Manual match of the temporary ID with the Patient Registration information Patient Update sent to the Image Manager Patient Update sent to the Image Manager

29 29 Case E6: Stress Echo Staged Protocol Clinical Context Allows for appropriate identification of Stages and Views during a stress echo Allows for appropriate identification of Stages and Views during a stress echo IHE Context Similar to Case E1 Similar to Case E1 Type of stress protocol is specified in the Scheduled Protocol Code Sequence or Scheduled Step Description Type of stress protocol is specified in the Scheduled Protocol Code Sequence or Scheduled Step Description Within the perform acquisition activity there are several stages but typically considered the same procedure step Within the perform acquisition activity there are several stages but typically considered the same procedure step A status of Discontinued can indicate technical failure to reach the end point of the exam. A status of Discontinued can indicate technical failure to reach the end point of the exam.

30 30 Case E7: Echo Measurements Evidence Creation Clinical Context Measurements are normally obtained during the acquisition on the modality. Measurements are normally obtained during the acquisition on the modality. This case supports the ability to obtain additional measurements on the clinical workstation post acquisition and update the study data. This case supports the ability to obtain additional measurements on the clinical workstation post acquisition and update the study data. IHE Context This case is similar to Cath C9 This case is similar to Cath C9 The actor participates in both the ECHO and ED profiles The actor participates in both the ECHO and ED profiles Generation of a DICOM SR with reference to original Generation of a DICOM SR with reference to original

31 31 Agenda Cardiology Workflows General Cath Workflow Cath Workflow Echo Workflow Echo Workflow Stress Workflow Stress Workflow Content Display Requirements Stress Echo Stress Echo Stress Stress

32 32 Stress Testing Image Intensive…multiple samples of 12 lead ECG during the protocol Summary report usually one page in length Physician will do comparisons to previous studies

33 33 Stress Options Stress Echo Began in the early – mid 1990s Began in the early – mid 1990s Observation of wall motion and ejection fractions with the heart under stress Observation of wall motion and ejection fractions with the heart under stress High specificity for correlating ischemia to functional abnormalities High specificity for correlating ischemia to functional abnormalities Can be done with exercise but mainly chemical Can be done with exercise but mainly chemical Nuclear Stress Most often combined with exercise or chemical stress testing Most often combined with exercise or chemical stress testing Use of radioisotope to detect presence and resolution of ischemic regions of the heart Use of radioisotope to detect presence and resolution of ischemic regions of the heart Scan immediately post Scan immediately post Scan 4 hours to 1 day later Scan 4 hours to 1 day later Resolution of ischemic area determines viability of muscle Resolution of ischemic area determines viability of muscle

34 34 Stress Workflow Diagram

35 35 Stress Workflow – Actors and Options ActorOption NameOptionalityVol & Section Acquisition ModalityPatient Based Worklist QueryORAD-TF 2: 4.5 Broad Worklist QueryR (see note 1)RAD-TF 2: 4.5 PPS Exception ManagementORAD-TF 2: 4.7 Stress ECGR (see note 2)CARD-TF 2: 4.2 Stress EchoR (see note 2)CARD-TF 2: 4.2 Nuclear Medicine (see note 3)R (see note 2)RAD-TF 2: 4.8 Image Manager/ Image ArchivePPS Exception ManagementORAD-TF 2: 4.7 Intermittently Connected ModalityRCARD-TF 2: 4.3 Stress ECGRCARD-TF 2: 4.2 EchocardiographyRCARD-TF 2: 4.2 Nuclear Medicine (see note 3)RRAD-TF 2: 4.8 Availability of PPS-Referenced InstancesORAD-TF 3: 4.49 Image DisplayStress ECGRCARD-TF 2: 4.4 Stress EchoRCARD-TF 2: 4.2 Cardiac NM (see notes 3, 4)RRAD-TF 2: 4.16

36 36 Use Cases Case S1: Cardiac Stress Test, ECG Only Limited use with lower sensitivities and specificities Limited use with lower sensitivities and specificities Screening tool only Screening tool only Case S2: Cardiac Stress Test with Imaging More common use case More common use case Echocardiography – requires Consistent Time to combine clinical data from Stress Monitor and Echo Modality Echocardiography – requires Consistent Time to combine clinical data from Stress Monitor and Echo Modality

37 37 Agenda Cardiology Workflows General Cath Workflow Cath Workflow Echo Workflow Echo Workflow Stress Workflow Stress Workflow Content Display Requirements Stress Echo Stress Echo Stress Stress

38 38 Views Apical two chamber Apical four chamber Apical long axis Parasternal long axis Parasternal short axis Parasternal short axis at the aortic valve level Parasternal short axis at the level of the mitral chords Parasternal short axis at the Mitral Valve level Parasternal short axis at the Papillary Muscle level Right Ventricular Inflow Tract View Right Ventricular Outflow Tract View Subcostal long axis Subcostal short axis Suprasternal long axis Suprasternal short axis Stage and Views Stress Echo Option Stress Echo Option Stage Number & View Number Stage Number & View Number Stage Code Sequence & View Code Sequence Stage Code Sequence & View Code Sequence Coding Scheme Designator (0008,0102) Code Value (0008,0100) Code Meaning (0008,0104) SRTP5-01201Image acquisition at baseline SRTP5-01202Pre-stress image acquisition SRTP5-01203Mid-stress image acquisition SRTP5-01204Peak-stress image acquisition SRTP5-01205Image acquisition during recovery

39 39 Benefit: Stress Echo Viewing Consistency

40 40 Agenda Cardiology Workflows General Cath Workflow Cath Workflow Echo Workflow Echo Workflow Stress Workflow Stress Workflow Content Display Requirements Stress Echo Stress Echo Stress Stress

41 41 Stress: Protocol and Stage ProcedureProtocolStages

42 42 Stress: Protocol and Stage Procedure : Exercise Stress Protocol: Bruce Stages: Standard Bruce has 7 stages Standard Bruce has 7 stages Stage 1: 1.7 mph @ 10 % grade Stage 1: 1.7 mph @ 10 % grade Stage 7: 6.0 mph @ 22 % grade Stage 7: 6.0 mph @ 22 % grade Important Note: A procedure can be considered complete irrespective of the protocol being complete!

43 43 Attribute Summary ConceptModality WorklistEchoECGNM Requested Procedure Requested Procedure Code Sequence (0032,1064) Procedure Code Sequence (0008,1032) ProtocolScheduled Protocol Code Sequence (0040,0008) Performed Protocol Code Sequence (0040,0260) CID 12001* Performed Protocol Code Sequence (0040,0260) CID 3261 Performed Protocol Code Sequence (0040,0260) CID 3261** Protocol Stage Number Acquisition Context Sequence (0040,0555) >(109055, DCM, Protocol Stage) Patient StateStage Number (0008,2122) Stage Code Sequence (0040,000A) CID 12002* Acquisition Context Sequence (0040,0555) >(109054, DCM, Patient State) CID 3262 Acquisition Context Sequence (0040,0555) >(109054, DCM, Patient State) CID 3101

44 44


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