2. IHE Radiology Integration Profiles Overview San Diego, Jan 2003 Charles Parisot IHE Planning Committees: IT, Radiology, Laboratory, Cardiology GE Medical Systems – Information Technology

3. HL7 San Diego – January 2004 2 Access to Radiology Information Consistent access to images and reports Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Key Image Notes Flag significant images Simple Image and Numeric Reports Simple reports with image links and, optionally, measurements Basic Security Audit Trail Consolidation & Node Authentication Presentation of Grouped Procedures Subset a single acquisition Post- Processing Workflow Schedule, perform, & notify image processing & CAD steps Charge Posting Collection of billable procedure details Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders IHE Radiology Integration Profiles

4. HL7 San Diego – January 2004 3 Problems Before the Technologist performs the acquisition, how do I make sure the correct info is used ?Before the Technologist performs the acquisition, how do I make sure the correct info is used ? Paper based workflow with data re-entryPaper based workflow with data re-entry Risk of error AND InefficientRisk of error AND Inefficient Stale informationStale information Changes between time of print and time of data entryChanges between time of print and time of data entry Cancel orders, Generic Order / Order ChangesCancel orders, Generic Order / Order Changes After the Technologist completes acquisition, how do I let all systems know ?After the Technologist completes acquisition, how do I let all systems know ? When are things ready to be read (PACS)When are things ready to be read (PACS) When can things be deleted (Modality)When can things be deleted (Modality) How do I know what to bill (RIS)How do I know what to bill (RIS) When do I wake up the referring physicianWhen do I wake up the referring physician The solution is……

5. HL7 San Diego – January 2004 4 IHE Radiology Scheduled Workflow : Transactions IHE Radiology Scheduled Workflow

6. HL7 San Diego – January 2004 5 Store Images Storage Commitment List of Images PACS & Archive RIS A Closed Loop Update IS SchedulingUpdate IS Scheduling Match Procedure with OrderMatch Procedure with Order Support Billing Based on MPPSSupport Billing Based on MPPS Avoid Reading incomplete ProceduresAvoid Reading incomplete Procedures IHE Scheduled Workflow Modality Worklist Procedure Scheduled Proposed Protocols Loaded and ReviewedWorklist Pt A, …, SPS=P1, P4 Pt C, …, SPS=P1, P5 Pt B, …, SPS=P2 Pt E, …, SPS=P4 ModalityPerformed Procedure Step With Performed Acquisition Protocols Performed Step: Status = Completed Performed Procedure: CT Head Performed Protocol Code=P1 Performed Protocol Code=P1 Pat Name/ID, Dose, Accession #, Study UID Complete List of Images Scheduled Protocol Code=P1, P5 Patient Registration/Update Order Management Order Protocolized

7. HL7 San Diego – January 2004 IHE Workflow is User Driven Information Unit has its Prime User Information Unit has its Prime User ORDER: A request for imaging service (Accession Number) REQUESTED PROCEDURE : Units of work resulting in one Report with associated codified, billable acts (Requested Procedure ID) PROCEDURE STEP : The smallest unit of work in the workflow (modality worklist entry) CLINICIAN OR REFERING DOC: The Imaging Dept Customer RADIOLOGIST : In Charge of producing the Report the Report TECHNOLOGIST (and RADIOLOGIST) In charge of acquiring images, etc.

8. HL7 San Diego – January 2004 7 Problems John Doe Trauma Clean-UpJohn Doe Trauma Clean-Up Recovering After Systems Are DownRecovering After Systems Are Down Error in manual entry at modalityError in manual entry at modality VIP PrivacyVIP Privacy The solution is……

9. HL7 San Diego – January 2004 8 Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders Integration Profiles

10. HL7 San Diego – January 2004 9 IHE Scheduled Workflow + IHE Patient Information Reconciliation ADT Patient Registration Order Placer Dept Scheduler Image Manager/Archive Modality When Institution Policy assumes pre- registration of ER patients (John/Jane Doe), IHE supports 3 possible cases:When Institution Policy assumes pre- registration of ER patients (John/Jane Doe), IHE supports 3 possible cases: 1.Unidentified Patient registered at ADT and order placed at Order Placer 2.Unidentified Patient registered at ADT and order placed at Department Scheduler/Order Filler 3.Unidentified Patient registered at ADT but acquisition completed at Modality prior to Order PACS is synchronized with all patient registration and order information updates through Dept Scheduler.PACS is synchronized with all patient registration and order information updates through Dept Scheduler.

11. HL7 San Diego – January 2004 10 IHE Scheduled Workflow + IHE Patient Information Reconciliation ADT Patient Registration Order Placer Dept Scheduler Image Manager/Archive Modality When Institution Policy allows departments to register ER patients, IHE supports 2 possible cases:When Institution Policy allows departments to register ER patients, IHE supports 2 possible cases: 1.Unidentified Patient assigned Temporary Departmental ID and Scheduled at Dept Scheduler/Order Filler 2.Image Acquisition Completed Without Scheduling at Dept Scheduler/Order Filler (Patient ID entered at Modality) Supports cases when ADT or Dept Scheduler is downSupports cases when ADT or Dept Scheduler is down

12. HL7 San Diego – January 2004 11 Problems Schedule and track post-processing workflow steps for accuracy of workSchedule and track post-processing workflow steps for accuracy of work Share workload among workstations, chain workflow steps to avoid redundancyShare workload among workstations, chain workflow steps to avoid redundancy Store and Query/Retrieve of Evidence Documents for CAD, Image Processing etc.Store and Query/Retrieve of Evidence Documents for CAD, Image Processing etc. The solution is……

13. HL7 San Diego – January 2004 12 Post- Processing Workflow Schedule, perform, & notify image processing & CAD steps Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders Integration Profiles

14. HL7 San Diego – January 2004 13 Post-Processing Workflow Profile Post-Proc.WorkflowManager PACS System CAD *Workstation Report Repository Acquisition Modality 3-D *Workstation Work Status Worklist … Source Data Results Workstation Results Work Status

15. HL7 San Diego – January 2004 14 Problems The solution is…… How to standardize the Charge Posting and billing for work performedHow to standardize the Charge Posting and billing for work performed How to Reduce System Interface Installation Time between Clinical Systems and the Charge ProcessorsHow to Reduce System Interface Installation Time between Clinical Systems and the Charge Processors How to avoid Billing System needing to know the Radiology InternalsHow to avoid Billing System needing to know the Radiology Internals

16. HL7 San Diego – January 2004 15 Post- Processing Workflow Schedule, perform, & notify image processing & CAD steps Charge Posting Collection of billable procedure details Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders Integration Profiles

17. HL7 San Diego – January 2004 16 Charge Posting Profile ChargePoster *Billing System CAD *Workstation Report Repository … Report Generated / Signed CAD Performed Post Charges Acquisition Modality ADT Terminal 3-D *Workstation Account Management 3-D Performed Study Performed / Materials Used

18. HL7 San Diego – January 2004 17 Workflow RIS indicates to the Billing System that procedures are available for Technical and/or Professional billing – maintain accuracyRIS indicates to the Billing System that procedures are available for Technical and/or Professional billing – maintain accuracy Charge Posted Transaction may be sent at various times in the workflow - flexibilityCharge Posted Transaction may be sent at various times in the workflow - flexibility –Regulations and site policies determine when a procedure is eligible for Charge Posting

19. HL7 San Diego – January 2004 18 Problems Ensuring print quality outside of the departmentEnsuring print quality outside of the department Radiologist discussing images with remote physiciansRadiologist discussing images with remote physicians Capture image manipulation to avoid redundant work (coronal CT, MR reading, etc.)Capture image manipulation to avoid redundant work (coronal CT, MR reading, etc.) The solution is……

20. HL7 San Diego – January 2004 19 Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders Integration Profiles Post- Processing Workflow Schedule, perform, & notify image processing & CAD steps Charge Posting Collection of billable procedure details

21. Original Image The Radiologist Saves a New Presentation State: What the Reviewing Physician Sees: The Radiologist’s Transformations Are Saved With Presentation State Original Image+Windowing +Zoom Area Of Interest +Annotation Inconsistent Presentation On an Uncalibrated Display Consistent Presentation of Images On a Calibrated Display Area Of Interest All the Transformations Are Completely Lost No Presentation State Image Original Image Radiologist Views Images

22. HL7 San Diego – January 2004 Grayscale Standard Display Function (GSDF) Acquisition Soft Copy Review Film Review 6 modalities  4 cameras, 26 workstations The current way = 180 calibrations Independent device calibration delivers consistency with simplicity Barten Curve Just Noticeable Differences LuminanceLuminanceLuminanceLuminance DICOM Standard Display Function The IHE way = only 36 calibrations

23. HL7 San Diego – January 2004 22 Problems An hematologist/oncologist orders:An hematologist/oncologist orders: –“CT CAP, Lymphoma, R/O disease” –We do “CT CHEST, ABDOMEN, PELVIS w/CON” –3 orders in RIS, 3 accession numbers, 3 CPTs, 3 reports –Chest radiologist will read chest –Body Imager will read abdomen and pelvis With One Spiral CT Exam what do we do ?With One Spiral CT Exam what do we do ? The solution is……

24. HL7 San Diego – January 2004 23 Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Presentation of Grouped Procedures Subset a single acquisition Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders Integration Profiles Post- Processing Workflow Schedule, perform, & notify image processing & CAD steps Charge Posting Collection of billable procedure details

25. HL7 San Diego – January 2004 24 MODALITY IHE – Presentation of Grouped Procedures Requested Procedure: CHEST Report: CHEST Requested Procedure: ABDOMEN Report: ABDOMEN Performs a single exam Operator groups 2 procedures Chest View Abdomen View RIS / PACS Chest View Abdomen View

26. HL7 San Diego – January 2004 25 Presentation of Grouped Procedures PGP maintains the link back to each one of the grouped procedures: PGP maintains the link back to each one of the grouped procedures: –without breaking the acquisition apart –Without duplicating images PGP ensures that each image subset related to a requested procedure is identified and ready to be presented. PGP ensures that each image subset related to a requested procedure is identified and ready to be presented.  This is key for quick display of new and prior studies.

27. HL7 San Diego – January 2004 26 Problems “Dave, you read that 3000 slice MR study last night. Can you highlight the 5 most important images for me”“Dave, you read that 3000 slice MR study last night. Can you highlight the 5 most important images for me” –Thinking… “#$@%!%# You”, says “Sure” #$@%!%# You#$@%!%# You “Dr., I just reviewed 40 cases and marked my questions on yellow stickies. Can you review those”“Dr., I just reviewed 40 cases and marked my questions on yellow stickies. Can you review those” Tech to radiologist: “The patient wouldn’t hold still”Tech to radiologist: “The patient wouldn’t hold still” The solution is……

28. HL7 San Diego – January 2004 27 Access to Radiology Information Consistent access to images and reports Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Key Image Notes Flag significant images Presentation of Grouped Procedures Subset a single acquisition Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders Integration Profiles Post- Processing Workflow Schedule, perform, & notify image processing & CAD steps Charge Posting Collection of billable procedure details

29. HL7 San Diego – January 2004 28 The radiologist selects Key Images, and creates appropriate Notes. The referring physician views the Key Image Note prepared by radiologist. Results in improved communication between the radiologist and the referring physician for refering physician Hematoma everywhere Note 3: for refering physician In this image you can see the hematoma. Note 3:

30. HL7 San Diego – January 2004 29 Key Image Notes There is more to teamwork than images and reportsThere is more to teamwork than images and reports With IHE, it is possible to attach « electronic post-it™ » to images to increase informal but critical communication between:With IHE, it is possible to attach « electronic post-it™ » to images to increase informal but critical communication between: –The Technologist and the Radiologist about specific examination events –The Radiologist and the Technologist about image quality issues –The Radiologist and other department clinicians (surgeon, orthopedist,..) –The Radiologist and collegues about selecting images for conferences –The Radiologist to the Referring Provider, …..etc. This IHE Integration Profile is the cost effective solution (increases radiology and overall efficiency).This IHE Integration Profile is the cost effective solution (increases radiology and overall efficiency).

31. HL7 San Diego – January 2004 30 Access to Radiology Information Consistent access to images and reports Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Key Image Notes Flag significant images Simple Image and Numeric Reports Simple reports with image links and, optionally, measurements Presentation of Grouped Procedures Subset a single acquisition Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders IHE Integration Profiles Post- Processing Workflow Schedule, perform, & notify image processing & CAD steps Charge Posting Collection of billable procedure details

32. HL7 San Diego – January 2004 31 Simple Image & Numeric Reports Based on DICOM SRBased on DICOM SR Allows to include without transcription: - measurements - Image links - structured contentAllows to include without transcription: - measurements - Image links - structured content Integrated with the imaging workflowIntegrated with the imaging workflow Friendly to XML implementationsFriendly to XML implementations Easy to export to the CPR (HL7)Easy to export to the CPR (HL7)

33. HL7 San Diego – January 2004 32 Simple Image and Numeric Report Report content is more than words…..Report content is more than words….. With IHE, it is possible to add value to reporting with input from modalities and image processing applications (e.g. Measurements).With IHE, it is possible to add value to reporting with input from modalities and image processing applications (e.g. Measurements). This IHE Integration Profile is the cost effective solution for sharing reports and inclusion of image enabled reports into the Electronic Patient Record.This IHE Integration Profile is the cost effective solution for sharing reports and inclusion of image enabled reports into the Electronic Patient Record.

34. HL7 San Diego – January 2004 33 Problems How did Person X view MVP’s ankle images? How to maintain Clinical Use and Privacy – –authorized persons must have access to medical data of patients, and the information must not be disclosed otherwise. How to guarantee: – –Confidentiality – –Integrity – –Availability – –Authenticity The solution is……

35. HL7 San Diego – January 2004 34 Access to Radiology Information Consistent access to images and reports Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Key Image Notes Flag significant images Simple Image and Numeric Reports Simple reports with image links and, optionally, measurements Basic Security Audit Trail Consolidation & Node Authentication Presentation of Grouped Procedures Subset a single acquisition Post- Processing Workflow Schedule, perform, & notify image processing & CAD steps Charge Posting Collection of billable procedure details Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders Integration Profiles

36. HL7 San Diego – January 2004 35 Basic Security Profile AuditRecordRepository … Image Manager & Archive “Images Queried / Retrieved” Diagnostic Workstation Report Repository … Report & Image Review “Reports Queried / Retrieved” “Images Printed” “Reports Stored” “Reports Retrieved” “Reports Printed”

37. HL7 San Diego – January 2004 36 IHE Year 4 has a proposal for a basic set of Security functions definedIHE Year 4 has a proposal for a basic set of Security functions defined –User Log-on –Node Authentication –Audit Trail This targets the HIPAA requirement for Accountability and Access controlThis targets the HIPAA requirement for Accountability and Access control Is this sufficient for HIPAA in the Radiology imaging domain? Who decides?Is this sufficient for HIPAA in the Radiology imaging domain? Who decides? IHE Basic Security HIPAA-Readiness

38. HL7 San Diego – January 2004 37 Where is More Information Available? www.rsna.org/IHE IHE Technical framework – V5.5 Non-Technical Brochures : IHE Primer and IHE FAQ IHE Integration Profiles: Guidelines for Buyers IHE Connectathon Results IHE Integration Statements from Vendors