1. September, 2005Cardio - June 2007 Cardiology Workflow Cath, Echo, and Stress Workflow

2. Cardio - June 2007 2 Agenda Cardiology Workflows  Cath Workflow  Echo Workflow  Stress Workflow

3. Cardio - June 2007 3 The Problem This is a piece of a typical cardiology workflow. Any questions? (!) Workflow is the linchpin to data integrity

4. Cardio - June 2007 4 IHE Workflow Concepts PROCEDURE STEP : The smallest unit of managed work: Scheduled Procedure Step: ‘A unit of work to do’ Performed Procedure Step: ‘A unit of work done’ PROCEDURE STEP : The smallest unit of managed work: Scheduled Procedure Step: ‘A unit of work to do’ Performed Procedure Step: ‘A unit of work done’ IHE uses three UNAMBIGUOUS HL7/DICOM terms for all workflow management (cardiology, radiology, lab, etc.) ORDER : A request for departmental service(s) ORDER : A request for departmental service(s) REQUESTED PROCEDURE : A unit of work resulting in Clinical Report (with associated codified, billable acts) REQUESTED PROCEDURE : A unit of work resulting in Clinical Report (with associated codified, billable acts)

5. Cardio - June 2007 5 3 Levels are Role Oriented ORDER: A request for departmental service (Accession Number) REQUESTED PROCEDURE : Unit of work resulting in Clinical Report with associated codified, billable acts (Requested Procedure ID) PROCEDURE STEP : The smallest unit of managed work in the workflow (Modality Worklist entry) CLINICIAN OR REFERING DOC: The imaging dept customer CARDIOLOGIST : In charge of producing the Report the Report TECHNOLOGIST (and CARDIOLOGIST) In charge of acquiring images, etc.

6. Cardio - June 2007 6 Simple Workflow – e.g., Echo ORDER A request for Departmental Service Requested Procedure Imaging Department Report Set of Codifiable, Billable, Acts Acquisition Modality Scheduled Procedure Step DICOM Modality Worklist One or more series of images Performed Procedure Step

7. Cardio - June 2007 7 Acquisition Modality Multiple Modality Steps ORDER A request for Departmental Service Imaging Department Set of Codifiable, Billable, Acts One or more series of images Performed Procedure Step P1 Scheduled Procedure Step B Requested Procedure Scheduled Procedure Step A Report One or more series of images Performed Procedure Step P2 DICOM Modality Worklist

8. Cardio - June 2007 8 General Workflow Actors    Pt. Registration [RAD-1]  Patient Update [RAD-12] Pt. Registration [RAD-1]  Patient Update [RAD-12]   Placer Order Management [RAD-2]  Filler Order Management [RAD-3] ADT  Query Images [RAD-14]  Retrieve Images/Evidence [CARD-4] Image Display Modality Image/Evidence Stored [CARD-2] Storage Commitment [CARD-3]  Procedure Scheduled [RAD-4]  Procedure Updated [RAD-13]  Query Modality Worklist [RAD-5] Performed Procedure Step Manager  Modality PS in Progress [CARD-1]  Modality PS Completed [RAD-7]  Modality PS in Progress [CARD-1]  Modality PS Completed [RAD-7]  Modality PS in Progress [CARD-1]  Modality PS Completed [RAD-7] Order Placer Acquisition Modality Image Manager Image Archive Dept System Scheduler / Order Filler  Patient Update [RAD-12] Modality Image/Evidence Stored [CARD-2] Storage Commitment [CARD-3]   Evidence Creator  Modality PS in Progress [CARD-1]  Modality PS Completed [RAD-7] Instance Availability Notification [RAD-49]  Time Client

9. Cardio - June 2007 9 Workflow Interaction Model - 1 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]

10. Cardio - June 2007 10 Workflow Interaction Model - 2 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]

11. Cardio - June 2007 11 Agenda Cardiology Workflows  Cath Workflow  Echo Workflow  Stress Workflow Content Display Requirements  Stress Echo  Stress  Nuclear Cardiology

12. Cardio - June 2007 12 Cath Lab 1 2 3 4 5 6 7 Multiple re-entry of Patient ID Error prone data entry Results fragmented across systems Results inconsistently time-tagged Custom solutions needed for data sharing Difficult to manage Uncoordinated with Hospital Information System Unidentified patients (emergency) Un-ordered cath exams Diagnostic and interventional procedures Ad hoc scheduling of cath labs Change of rooms during procedure 8 9 10 11

13. Cardio - June 2007 13 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 The Unknown Patient Case ALL Use Cases Must be Supported Exception of C10 only required for EP Lab

14. Cardio - June 2007 14 Case C1: Patient Registered at ADT and Procedure Ordered at the Order Placer Clinical Context  Corresponds to traditional Radiology workflow  Order placed in central system  Also deals with case where emergency identifier has been created  Common identifiers known ahead of time IHE Context  MPPS in Progress from first modality used to update worklists for others

15. Cardio - June 2007 15 Case C2: Patient Registered at ADT and Procedure Ordered at DSS/OF Clinical Context  Slight difference to Case 1  Order placed NOT in central system but in department  Department system provides info to Central ordering system  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.

16. Cardio - June 2007 16 Case C3: Patient Registered at ADT and Procedure Not Ordered Clinical Context  Slight difference to Case 2  Procedural information is NOT entered at the departmental system  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  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.

17. Cardio - June 2007 17 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  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 IHE Context  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.

18. Cardio - June 2007 18 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  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 IHE Context  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

19. Cardio - June 2007 19 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  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  The case defines how the reconciliation occurs. IHE Context  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.

20. Cardio - June 2007 20 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 need to use the current room for another patient  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)  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  This insures consistency of the Study UID for all information

21. Cardio - June 2007 21 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

22. Cardio - June 2007 22 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. IHE Context  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.

23. Cardio - June 2007 23 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)  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  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.

24. Cardio - June 2007 24 Case C10: EP Ablation / Implantation Lab Clinical Context  Allows for the wide array of specialized equipment used in the EP lab  Provides demographic and time synchronization IHE Context  Initial implementation is an extension of the CATH profile  Support for use cases C1 – C9  Emergency use cases C3 and C5 are highly unusual in the EP lab.

25. Cardio - June 2007 25 Agenda Cardiology Workflows  Cath Workflow  Echo Workflow  Stress Workflow

26. Cardio - June 2007 26 Echo Workflow The “drive-by echo” – Cardiologist to sonographer in CCU: “While you’re here, do a TTE on bed 3”  Unordered, unscheduled exam  Machine disconnected from network Stress echo – After exam, sonographer creates new quad displays of stages and views  No intrinsic value add  Data is redundantly copied to storage in quad format

27. Cardio - June 2007 27 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 The Drive-by Echo Case Use Cases The Stress Test Case

28. Cardio - June 2007 28 Case E1: Patient Registered at ADT and Procedure Ordered Clinical Context  Corresponds to traditional Radiology workflow  Order placed in central system  Also deals with case where emergency identifier has been created  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.

29. Cardio - June 2007 29 Case E2: Intermittently Connected Modality Clinical Context  Allows for the mobile workflow typical of TTE and TEE  Assumes the modality is only intermittently connected to the network  Also covers the case of the modality being turned off IHE Context  Process flow identical to Case E1  Must be paired with an Image Manager/Image Archive that also supports Intermittent Connectivity  MPPS are stored and sent when connection established  Image Manage must queue N-Event Report messages for storage commitment

30. Cardio - June 2007 30 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 can’t query the worklist since it is not connected to the network IHE Context  The modality will treat this as unscheduled procedure  The patient ID and demographics must be manually entered  The modality must create the Study Instance UID  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

31. Cardio - June 2007 31 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 IHE Context  This case is identical to other unscheduled procedure cases  Modality creates the Study Instance UID  When connected the modality will send a MPPS in Progress  DSS/OF will generate an exception for reconciliation  Patient demographic reconciliation should occur automatically based on patient ID  The Image Manager will use the Patient Update transaction to update the demographics

32. Cardio - June 2007 32 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) IHE Context  Temporary Name and ID entered into the modality  DSS/OF will generate an exception  Manual match of the temporary ID with the Patient Registration information  Patient Update sent to the Image Manager

33. Cardio - June 2007 33 Case E6: Stress Echo Staged Protocol Clinical Context  Allows for appropriate identification of Stages and Views during a stress echo IHE Context  Similar to Case E1  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  A status of “Discontinued” can indicate technical failure to reach the end point of the exam.

34. Cardio - June 2007 34 Case E7: Echo Measurements Evidence Creation Clinical Context  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. IHE Context  This case is similar to Cath C9  The actor participates in both the ECHO and ED profiles  Generation of a DICOM SR with reference to original

35. Cardio - June 2007 35 Agenda Cardiology Workflows General  Cath Workflow  Echo Workflow  Stress Workflow

36. Cardio - June 2007 36 Amazing Facts Your heart beats about  70 beats per min  4200 beats per hour  100,800 beats per day  35 million times in a year.  Or more than 2.5 billion beats in your life time.  AND IT ONLY TAKES ONE IRREGULAR BEAT TO KILL YOU Now that I got your attention again!

37. Cardio - June 2007 37 So what is Stress Testing? Uses exercise or medication to increase the work of the heart – incremental stages Continuous 12 lead ECG monitoring during study Looking for changes in ECG (ST segments) Used as a screening tool, or to test effectiveness of therapy May include imaging at different stages of stress; multiple views of heart Includes comparisons to previous studies

38. Cardio - June 2007 38 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 or Nuclear cardiology imaging  Exercise or pharmaceutical stress

39. Cardio - June 2007 39 Stress Imaging 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 pharmaceutical Nuclear Stress  Most often combined with exercise or pharmaceutical stressor  Use of radioisotope to detect presence and resolution of ischemic regions of the heart  Scan immediately post stress induction  Scan 4 hours to 1 day later  Resolution of ischemic area determines viability of muscle

40. Cardio - June 2007 40 Cases S1 and S2 Patient known and registered in all cases; exam scheduled in all cases Echo operates as in Case E6 Nuclear scanner follows Radiology Scheduled Workflow Profile ECG monitor is a DICOM modality  Gets modality worklist, notifies modality performed procedure step, data in DICOM format Multi-modality synchronization using Consistent Time Profile