1. September, 2005What IHE Delivers 1 Cardiology – North American Connectathon and ACC 2007 IHE Interoperability Showcase Q&A IHE Cardiology Webinar Year 3 Sept, 2006 IHE Cardiology Education Teri Sippel Schmidt, ACC

2. 2 Profiles to be Tested at NA Connectathon: January 2007 Year 2004-2006 (Final Text)  Cath Workflow (Cath)  Echo Workflow (Echo)  Retrieve ECG for Display (ECG)  Evidence Documents (ED) for Cath and Echo  Displayable Reports (DRPT) > Year 2006-2007 (Trial Implementation/ACC IHE Interop 2007)  Stress Test Workflow (STRESS)  Implanted Device Cardiac Observations (IDCO)  Nuclear Medicine (NM) Cardiology Option  Cross Enterprise Document Sharing (XDS)  Cross Enterprise Document Sharing – Imaging (XDS-I)  Cross Enterprise Document Sharing – Medical Summary (XDS-MS) Note: all XDS Profiles tested within ITI Domain with additional ACC demo scenario testing.

3. 3 Cardiology Workflow Profiles Cardiology Workflows General  Cath Workflow  Echo Workflow  Stress Testing Workflow Content Display Requirements – Modality Acquisition and Image Display Actors  Stress Echo  Stress Testing  Nuclear Cardiology

4. 4 1. Cath Workflow Use Cases  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 C3: Patient Registered at ADT and Procedure Not Ordered  Case C4: Patient Registered at DSS/OF and Procedure Ordered  Case C5: Patient Not Registered  Case C6: Patient Updated During Procedure  Case C7: Change Rooms During Procedure  Case C8: Cancel Procedure  Case C9: Post-Procedure Evidence Creation  Case C10: EP Ablation / Implantation Lab ALL Use Cases Must be Supported Exception of C10 only required for EP Lab

5. 5 2. Echo Workflow 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

6. 6 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 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

7. 7 Benefit: Stress Echo Viewing Consistency

8. 8 3. Evidence Documents Echocardiography Measurement Patient: Doe, John Technologist: der Payd, N Measurements: Mitral valve diameter 3.1cm - shown in image at [ ] Ventricular length, diastolic 5.97 cm - shown in image at [ ] Ventricular volume, diastolic 14.1 ml - inferred from [ ] - inferred from VLZ algorithm Cath or Echo Measurements – “Evidence Creator” is an Actor in both Cath and Echo Workflows as well as Evidence Documents

9. 9 Evidence Documents Value proposition Measurements are managed in same study folder as images Data is structured and uses coded concepts and vocabulary Coded data can be searched, processed, databased (locally, national registry), … Avoids detour through “paper-space”  extra handling, delay and potential loss of paper  additional effort and errors

10. 10 Evidence Documents Technical Basis Based on:  DICOM Structured Report (SR) Objects  Storage Commitment  Query/Retrieve Addresses creation/distribution of the content Scheduling and progress reporting is supported by also implementing an appropriate IHE workflow profile

11. 11 4. So what is Stress Testing? Uses exercise or medication to increase the work of the heart. Continuous 12 lead ECG monitoring during study Looking for changes in ST segments Used as a screening tool Or to test effectiveness of therapy Done in Non-Invasive Lab, and Cardiologist Office

12. 12 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

13. 13 Stress: Protocol and Stage ProcedureProtocolStages

14. 14 Stress: Protocol and Stage Procedure : Exercise Stress Protocol: Bruce 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!

15. 15 Stress Options Stress Echo  Began in the early – mid 1990’s  Observation of wall motion and ejection fractions with the heart under stress  High specificity for correlating ischemia to functional abnormalities  Can be done with exercise but mainly chemical Nuclear Stress  Most often combined with exercise or chemical stress testing  Use of radioisotope to detect presence and resolution of ischemic regions of the heart  Scan immediately post  Scan 4 hours to 1 day later  Resolution of ischemic area determines viability of muscle

16. 16 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

17. 17 Stress Testing Use Cases Case S1: Cardiac Stress Test, ECG Only  Limited use with lower sensitivities and specificities  Screening tool only Case S2: Cardiac Stress Test with Imaging  More common use case Echocardiography – requires Consistent Time to combine clinical data from Stress Monitor and Echo Modality; consistent use of Protocol and Stage information Echocardiography – requires Consistent Time to combine clinical data from Stress Monitor and Echo Modality; consistent use of Protocol and Stage information Nuclear Medicine – consistent use of Protocol and Stage information; consistent time still important Nuclear Medicine – consistent use of Protocol and Stage information; consistent time still important

18. 18 5. Nuclear Cardiology Image formats  Stress and Rest raw data review  Stress and Rest processed data  Gated SPECT data  Quantitative data  Screen captures, “snap shots” Color maps  Gray scale is default  Color overlays can be applied

19. 19 Raw Data Images

20. 20 Standard Perfusion Display Stress Stress Stress Stress Rest Rest Rest Rest Short axis Horizontal long axis Vertical “Stress over Rest” Display

21. 21 Perfusion Display - Color Stress over rest standard Perfusion Display - with Color map overlaid on the image Note that text may be colorized

22. 22 Quantitative Display Output from 3 rd party quantitative gated software can be displayed Mapped segments of the heart (ASNC Guidelines) 3D models built from axial images

23. 23 Screen Captures Screen captures can be displayed to show important images

24. 24 6. ECG Scope Make ECG-specific extensions to RID  Place requirements on ECG source to ensure high-quality ECG documents.  Add ECG-specific request for list of ECGs to be returned as XML allowing more client flexibility.  Add SVG (vector graphics) as allowed ECG document format.

25. 25 PDF ECG Source required to support PDF so it is compatible with existing RID clients. PDF is a common document type and most computers already have a viewer. ECG Source required to use vector graphics for waveforms in PDF.  Gives high quality line drawings at any screen resolution and zoom factor.  Rasterized (e.g. scanned, bitmapped) ECG “images” not allowed.

26. 26 Example ECG in PDF Format

27. 27 SVG Scalable Vector Graphics – “XML Graphics for the Web” – a W3C standard. Well suited for line drawings (e.g. waveforms) in a XML/Web environment. Currently supported through web browser plug-ins. Allows scripting to enable advanced user- side display control.

28. 28 Serial Comparison Example

29. 29 7. Implantable Device Cardiac Observations (IDCO) Enable management of ICD follow-up information in a central system such as an Device Clinic Management System or EMR Improve efficiency and quality of related clinical processes  Single point of access for ICD information  Automation of current manual processes for data collection, aggregation and analysis  Standardization of workflow processes  Enabling of analytics

30. 30 Implantable Cardiac Devices Pacemakers – therapy for heart rate problems Defibrillators – therapy for life threatening heart rhythms Cardiac Resynchronization – therapy for congestive heart failure

31. 31 IDCO Profile Use Cases In-Clinic Implants or Follow-ups  Patients present themselves in-clinic for implantation or follow-ups  Information is collected using vendor specific “programmers”  Information is sent from interrogation system to a central Device Clinic Management System or EMR Remote Follow-ups  Patients devices are interrogated in the home health care environment  Information is collected using vendor specific communication devices and systems  Information is sent from interrogation system to a central Device Clinic Management System or EMR

32. 32 IDCO Profile Systems Model

33. 33 8. Cross Enterprise Document Sharing (XDS) XDS is the sharing of clinical documents between two different Electronic Healthcare Record (EHR) systems  e.g., between a clinic EHR and a hospital based EHR  HIPAA requirements considered  Lifetime patient record, across clinical specialities, considered  Very applicable to Cardiology

34. 34 XDS Affinity Domain (NHIN sub-network) Community Clinic Lab Info. System PACS Teaching Hospital PACS ED Application EHR System Physician Office EHR System XDS Scenario + use of ATNA & CT Showcased at HIMSS 2006 PMS Retrieve Document Register Document Query Document XDS Document Registry ATNA Audit record repository CT Time server Record Audit Event MaintainTime MaintainTime Event Maintain Time Provide & Register Docs Record Audit Event XDS Document Repository Secured Messaging

35. 35 XDS Affinity Domain (NHIN sub-network) Community Clinic Lab Info. System PACS Teaching Hospital PACS ED Application EHR System Physician Office EHR System XDS Scenario + use of PIX & PDQ Showcased at HIMSS 2006 A87631 PACS L-716 Affinity Domain Patient Identity Source M8354673993 Retrieve Document Provide & Register Docs Register (using Pt ID) Query Document (using Pt Id) Patient Identity Feed Document Registry 14355 M8354673993 L-716 A87631 Patient Identity Feed PIX Query PIX Query Patient Identity Feed Patient Identity XRef Mgr Patient Identity Feed PDQ Query to Acquire Affinity Domain Patient ID M8354673993 A87631 L-716 M8354673993 XDS Document Repository XDS Document Repository ATNA Audit record repository CT Time server

36. 36 IHE Patient Care Coordination Profiles Content Integration Profiles (2005)  Medical Summaries (XDS-MS) PCP to Specialist Referral PCP to Specialist Referral Acute Care Discharge (to PCP) Acute Care Discharge (to PCP)  Unstructured Document Exchange (XDS-pdf) Content Integration Profiles (in-progress 2006)  Medical Summaries (XDS-MS) PCP to ED Referral PCP to ED Referral  Pre-procedure History & Physical (PPHP)  Exchange of Personal Health Record (XPHR)  Basic Patient Privacy Consents (BPPC)  Sharing of Lab Reports (XDS-LAB)

37. 37 XDS for Images (XDS-I) Cross Enterprise Sharing of Imaging Information (XDS-I) from IHE Radiology Options (at least one):  Extensive Set of DICOM Instances  PDF Report  Text Report  Multipart Text/PDF Report

38. 38 Q&A Any Questions?:  North American Connectathon: Contract Due Sept 15 th, 2006, via Kudu web tool registration (www.ihe.net) Contract Due Sept 15 th, 2006, via Kudu web tool registration (www.ihe.net)www.ihe.net January 15-19, 2007, Chicago, IL January 15-19, 2007, Chicago, IL  American College of Cardiology: Contract Due Sept 15 th, 2006, www.acc.org/ihe.htm Contract Due Sept 15 th, 2006, www.acc.org/ihe.htmwww.acc.org/ihe.htm March 24-27, 2006, New Orleans, LA March 24-27, 2006, New Orleans, LA