Cardiac Cath Workflow Bob Baumgartner, BSN McKesson IHE-Cardiology Planning Committee

June 28-29, 2005IHE Workshop2 The Problem Cardiac Cath is a complex procedure with a challenging workflow –Many times the procedure is not scheduled –Many times the patient demographics are unknown –Evidence-gathering can start prior to an order –Multiple devices collect data for the procedure –Most procedures begin as diagnostic and extend to an interventional

June 28-29, 2005IHE Workshop3 The Problem Can you see it? This is an example of cath workflow. No need to be able to read it just look at whole of the picture. Complexity at its finest!

June 28-29, 2005IHE Workshop4 Cardiac Cath Workflow Abstract This profile establishes the continuity and integrity of basic patient data by managing the workflow, in particular: –Management of cath exams Multi-modality, multiple procedure steps –Reconciliation of patient information Unscheduled and emergency procedures –Time synchronization X-ray, hemo, IVUS

June 28-29, 2005IHE Workshop5 Cardiac Cath Workflow Value Proposition This profile provides the very basis for data consistency across the disparate modalities within the cath lab. So which time is correct? How do you spell Baumgartner again?

June 28-29, 2005IHE Workshop6 Cardiac Cath Workflow Transaction Diagram New for year 2 Evidence Documents & Displayable Reports Profile

June 28-29, 2005IHE Workshop7 Cardiac Cath Workflow Actors Acquisition ModalityAcquisition Modality – A system that acquires and creates medical images or waveforms while a patient is present, e.g., an X-ray angiography or hemodynamic measurement system. A modality may also create other evidence objects such as Structured Report Documents containing measurements. ADTADT – A system responsible for adding and/or updating patient demographic and encounter information (Admission/Discharge/Transfer). In particular, it registers a new patient with the Order Placer and Department System. Department System Scheduler/Order FillerDepartment System Scheduler/Order Filler – A department-based (for instance, Cardiology or Radiology) information system that provides functions related to the management of orders received from external systems or through the department system’s user interface. Evidence CreatorEvidence Creator – A system that creates additional evidence objects, such as derived images or measurements. Image ArchiveImage Archive – A system that provides long term storage of evidence objects such as images, presentation states, Key Image Notes and Evidence Documents.

June 28-29, 2005IHE Workshop8 Cardiac Cath Workflow Actors Image DisplayImage Display – A system that offers browsing of patients’ studies. In addition, it may support the retrieval and display of selected evidence objects including sets of images, presentation states, Key Image Notes, and/or Evidence Documents. Image ManagerImage Manager – A system that provides functions related to safe storage and management of evidence objects. It supplies availability information for those objects to the Department System Scheduler. Order PlacerOrder Placer – A hospital or enterprise-wide system that generates orders for various departments and distributes those orders to the correct department. Performed Procedure Step ManagerPerformed Procedure Step Manager – A system that re-distributes the Modality Performed Procedure Step information from the Acquisition Modality to the Department System Scheduler/Order Filler and Image Manager. Time ClientTime Client – A system unit that synchronizes its time of day clock to the correct time provided by a time server

June 28-29, 2005IHE Workshop9 Cardiac Cath Workflow Transactions Patient RegistrationPatient Registration – The ADT system registers and/or admits a patient and forwards the information to other information systems. [RAD-1] Placer Order ManagementPlacer Order Management – The Order Placer informs the Order Filler of the initiation or cancellation of an order. The Placer/Filler Order Management transaction will sometimes be referred to as “-New” when a new order is being initiated, or as “-Cancel” when an existing order is canceled. [RAD-2] Filler Order ManagementFiller Order Management – The Order Filler informs the Order Placer of the initiation, cancellation, or change in the status of an order. The Placer/Filler Order Management transaction will sometimes be referred to as “-New” when a new order is being initiated, or as “-Cancel” when an existing order is canceled. [RAD-3] Procedure ScheduledProcedure Scheduled – Schedule information is sent from the Department System Scheduler/Order Filler to the Image Manager. [RAD-4] Query Modality WorklistQuery Modality Worklist – Based on a query entered at the Acquisition Modality, a modality worklist is generated listing all the items that satisfy the query. This list of Scheduled Procedure Steps with selected demographic information is returned to the Acquisition Modality [RAD-5].

June 28-29, 2005IHE Workshop10 Cardiac Cath Workflow Transactions Modality Procedure Step In Progress CARD-1Modality Procedure Step In Progress – An Acquisition Modality notifies the Performed Procedure Step Manager of the start of a new Procedure Step and the PPS Manager informs the Department System Scheduler/Order Filler and Image Manager. [ CARD-1, derived from RAD-6 Modality Procedure Step CompletedModality Procedure Step Completed – An Acquisition Modality notifies the Performed Procedure Step Manager of the completion of a Procedure Step and the PPS Manager informs the Department System Scheduler/Order Filler and Image Manager. [RAD- 7] Modality Images/Evidence Stored CARD-2Modality Images/Evidence Stored – An Acquisition Modality sends acquired or generated images, waveforms, or other evidence documents to the Image Archive. [CARD-2, derived from RAD-8 and RAD-43] Storage Commitment CARD-3Storage Commitment – A requestor (Acquisition Modality) requests that the Image Manager confirm ownership for the specified DICOM objects (images, waveforms, evidence documents, or any combination thereof) that the requestor stored in the Image Archive, thus allowing the sender to delete those objects now owned by the Image Manager. [CARD-3, derived from RAD-10]

June 28-29, 2005IHE Workshop11 Cardiac Cath Workflow Transactions Patient UpdatePatient Update – The ADT Patient Registration System informs the Order Placer and the Department System Scheduler/Order Filler of new information for a particular patient. The Department System Scheduler may then further inform the Image Manager. [RAD-12] Procedure UpdateProcedure Update – The Department System Scheduler/Order Filler sends the Image Manager updated order or procedure information. [RAD-13] Query ImagesQuery Images – An Image Display queries the Image Archive for a list of entries representing images by patient, study, series, or instance. [RAD-14] Retrieve Images CARD-4Retrieve Images – An Image Display requests and retrieves a particular image or set of images from the Image Archive. [CARD-4, derived from RAD-16] Maintain TimeMaintain Time – Synchronize the local time with the time maintained by the Time Server. [ITI-1]

June 28-29, 2005IHE Workshop12 Cardiac Cath Workflow Options Instance Availability NotificationInstance Availability Notification – The Image Manager/Image Archive notifies interested workflow actors (such as the Department System Scheduler/Order Filler and Report Manager) about the availability status of instances at specified storage locations. [RAD-49] PPS Exception ManagementPPS Exception Management – The Acquisition Modality Actor will provide an appropriate reason code for the DISCONTINUED status of the MPPS message using one of the values defined in DICOM 2003 PS 3.16 Annex B Context ID Availability of PPS-Referenced InstancesAvailability of PPS-Referenced Instances – As a result of receiving the notification, the Department System Scheduler/Order Filler (or other actors) shall take appropriate action knowing that the referenced instances are available for further use in the workflow.

June 28-29, 2005IHE Workshop13 Cardiac Cath Workflow Use Cases All use cases must be supported 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

June 28-29, 2005IHE Workshop14 Case C1: Patient Registered at ADT and Procedure Ordered at the Order Placer Clinical ContextClinical 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 ContextIHE Context –MPPS in Progress from first modality used to update worklists for others

June 28-29, 2005IHE Workshop15 Case C2: Patient Registered at ADT and Procedure Ordered at DSS/OF Clinical ContextClinical 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 ContextIHE Context –Filler Order Management (New Order) transaction [RAD-3] is sent from Department System Scheduler/Order Filler to the Order Placer.

June 28-29, 2005IHE Workshop16 Case C3: Patient Registered at ADT and Procedure Not Ordered Clinical ContextClinical 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 ContextIHE 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.

June 28-29, 2005IHE Workshop17 Case C4: Patient Registered at DSS/OF and Procedure Ordered Clinical ContextClinical 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 ContextIHE 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.

June 28-29, 2005IHE Workshop18 Case C5: Patient Not Registered Clinical ContextClinical 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 ContextIHE 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

June 28-29, 2005IHE Workshop19 Case C6: Patient Updated During Procedure Clinical ContextClinical 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 ContextIHE 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.

June 28-29, 2005IHE Workshop20 Case C7: Change Rooms During Procedure Clinical ContextClinical 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 ContextIHE 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

June 28-29, 2005IHE Workshop21 Case C8: Cancel Procedure Clinical ContextClinical 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 ContextIHE 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.

June 28-29, 2005IHE Workshop22 Case C9: Post-Procedure Evidence Creation Clinical ContextClinical 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 ContextIHE 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.

June 28-29, 2005IHE Workshop23 More information…. Web sites: Technical Frameworks, Supplements Radiology Technical Framework Cardiology Technical Framework Cath and Echo Options for Evidence Documents Supplement Non-Technical Brochures : Calls for Participation IHE Fact Sheet and FAQ IHE Integration Profiles: Guidelines for Buyers IHE Connect-a-thon Results Vendor Products Integration Statements

June 28-29, 2005IHE Workshop24 W W W. I H E. N E T Providers and Vendors Working Together to Deliver Interoperable Health Information Systems In the Enterprise and Across Care Settings