IHE Cardiology Image Enabled Office Harry Solomon Based on IEO draft 20 ftp://ftp.ihe.net/Cardio/Year5-2009-2010/Technical_Committee/Supplements/IEO/

Image Enabled Office Problem Statement An increasing number of clinicians have both imaging equipment and electronic medical records in their offices. The prevalence of imaging equipment is increasing as lower cost systems are being brought to market, and the universal deployment of EMRs is an explicit goal of the U.S. government. Note: The draft U.S. “meaningful use criteria” for 2015 would require EMRs to handle medical imaging objects, although the extent and nature of such support is undetermined. This equipment needs to be integrated into the office environment workflow, and the imaging results need to be seamlessly integrated into the EMR. Note that the systems in an office environment must in may ways be more technically sophisticated than in an in-patient environment, as they must operate with less IT-savvy human supervision, and combine features that would otherwise be distributed across multiple systems. IHE Cardiology

Profile Scope The Image-Enabled Office (IEO) Profile specifies the integration of an imaging suite (modalities, storage server, and workstations) with an electronic health record system in an ambulatory office setting. This is a fully bi-directional integration, including ordering/ scheduling of an imaging exam, status reporting for that exam, report creation, and web-based imaging exam review integration. It also addresses import of referral image exams from exchange media into the integrated office environment. Out of Scope: Exchange with other entities (supported by PDI, XDS and XDS-I functionality), except for image import from media IHE Cardiology

Use Case 1 Andy Carditis, a patient, is referred to Belle Plummer, a cardiologist, for consultation regarding a fever and associated heart murmur (potential infective endocarditis). Dr. Plummer orders blood labs and an echo study, which the patient elects to have performed in Dr. Plummer’s cardiology office. The patient and the cardiology office manager schedule the echo for later that day. At the scheduled time, Sue Skann, the sonographer in the office, preps Mr. Carditis. She uses the ultrasound machine to query for the scheduled exams, and selects Mr. Carditis from the list. She performs the echo study, and makes preliminary measurements on the ultrasound machine. The images and measurements are sent to a local mini-PACS image server. On an imaging workstation, Dr. Plummer reviews the images and measurements, and notes the vegetation on the mitral valve. She selects a representative image, and saves a reference to it in a note that is stored on the mini-PACS. She defers creating a report until the lab results will have been returned. The next morning, the lab results are returned electronically and recorded in the office EMR. On the EMR workstation, Dr. Plummer reviews both the lab results and the echo measurements, and creates a report with findings, selected measurements, and the representative image selected the previous day. She orders a two week regimen of intravenous antibiotics, which will be administered by her nurse practitioner. The report is stored in the EMR, and is also sent to the referring primary care physician. IHE Cardiology

Approach Reuse capabilities from existing IHE Profiles: Radiology Scheduled Workflow Radiology Import Reconciliation Workflow Radiology/Cardiology Evidence Documents Cardiology Displayable Reports IT Infrastructure Patient Demographics Query IT Infrastructure Consistent Time IHE Cardiology

In-patient Scheduled Workflow Diagram ADT 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] DSS/ Order Filler Order Placer ­ Modality PS in Progress [CARD-1] ¯ Procedure Scheduled [RAD-4] ­ Modality PS Completed [RAD-7] ¯ Patient Update [RAD-12] ¯ Procedure Updated [RAD-13] Evidence Creator Image Display ¯ Modality Image/Evidence Stored [CARD-2] Performed ¯ Query Images [RAD-14] Procedure ¯ Retrieve Images [CARD-4] Step Manager Image Manager Image Archive ® Modality PS in Progress [CARD-1] ® Modality PS Completed [RAD-7] Storage ­ Modality Image/Evidence Stored [CARD-2] Commitment [CARD-3] ­ ¬ Modality PS in Progress [CARD-1] ¬ Modality PS Completed [RAD-7] Acquisition Modality ¬ Query Modality Worklist [RAD-5] IHE Cardiology

IEO Functional Features Equivalent to in-patient “top half” systems should be a single actor incorporating both practice management and EHR Image Manager/Archive should be an actor separate from EHR-S Modality, Image Display, and Evidence Creator actors should operate with no changes from Scheduled Workflow / ED Modality worklist, MPPS, image/evidence storage Reports should be creatable on either an imaging workstation, or at an EHR-S workstation Report Creator actor should operate with no changes from Displayable Reports Destination of Encapsulated Report is EHR-S Image Manager/Archive shall support a web-based viewer interface Usable from EHR-S workstation Upon arrival of study images, the IM/IA shall send a link to the study to the EHR-S IHE Cardiology

Actor / Transaction Diagram Integrated EHR-S EHR-S Information Source Display  Encapsulated Report Submission [CARD-7]  Notify Study Access [CARD-14]  Invoke Image Display Service [CARD-15] Encapsulated Report Storage [CARD-9]  Patient Registration [RAD-1]  Placer Order Management [RAD-2]  Procedure Scheduled [RAD-4]  Outpatient Update [CARD-16]  Outpatient Update [CARD-16]  Filler Order Management [RAD-3]  Procedure Updated [RAD-13] Report Creator DSS / OF PPS Manager Query Images [RAD-14] Retrieve Images/ Evidence [CARD-4] Image Manager / Image Archive Image Display   Procedure Step in Progress […]  Query Modality Worklist [RAD-5] Procedure Step Completed […] Evidence Creator  Images /Evidence Stored [CARD-2] Acquisition Modality  Storage Commitment [CARD-3]

System Actors (top level) Report Submission EHR-S Procedure Scheduled / Update Patient Update Access DICOM Study for Display Report Storage Image Manager / Image Archive Retrieve Images/Evidence Image Display Patient Demographics Procedure Step in Progress/Completed Modality Worklist Acquisition Modality Images /Evidence Stored Storage Commitment Importer

Dynamic Model – Explicitly Ordered Exam: Acquisition IHE Cardiology

Dynamic Model – Imaging Study Analysis / Reporting IHE Cardiology

Transactions from DRPT Profile Encapsulated Report Submission [CARD-7] Report Creator to Report Manager (EHR-S) HL7 MDM OBX with encapsulated PDF or CDA Encapsulated Report Storage [CARD-9] Optional – allows EHR-S to store copy of report in DICOM study data set Report Manager (EHR-S) to Image Manager/Archive DICOM Encapsulated PDF or CDA Encapsulated Report Query/Retrieve [CARD-10/11] Image Display to Image Manager/Archive IHE Cardiology

New Transactions Notify Study Access [CARD-y] Image Manager/Archive to EHR-S (Report Manager) HL7 ORU^R01 Trigger Event – availability of study images at Image Manager OBX segment with Study Unique ID Or should it be a full URL? Access DICOM Study for Display [CARD-z] EHR-S (Display) to Image Manager/Archive Web service over HTTP Invokes navigation / viewing study in standard web browser What else needs to be standardized for execution environment? IHE Cardiology

Notify Study Access [CARD-y]: OBX SEQ LEN DT Usage Card. TBL# ITEM# ELEMENT NAME 1 4 SI R 00569 Set ID – OBX 2 3 ID 0125 00570 Value Type = HD 705 CWE 00571 Observation Identifier 5 70 HD 00573 Observation Value 11 0085 00579 Observation Result Status = R 14 24 DTM R2 00582 Date/Time of the Observation OBX-2 Value Type : “HD” (Hierarchical Designator) OBX-3 Observation Identifier : “113014^DICOM Study^DCM” OBX-5 Observation Value : DICOM Study Instance UID as an ISO OID OBX-11 Observation Result Status : “R” (Results entered -- not verified) OBX-14 Date/Time of the Observation : date and time of the most recent update made to the study content (e.g., most recent addition, deletion or modification of images or objects within the study). IHE Cardiology

Access DICOM Study for Display [CARD-z] Access based on Study UID or Patient ID Follows model of IHE ITI Retrieve Info for Display web services http://<location>/IHERetrieveDICOMInfo?requestType=STUDY&studyUID=<studyUID>&userID=<userID> http://<location>/IHERetrieveDICOMInfo?requestType=SUMMARY&patientID=<patientID_HL7v2CX>&lowerDateTime=<LDT>&upperDateTime=<UDT>&mostRecentResults=<num>&userID=<userID> Web service URL must be constructed at run-time Display actor (in EHR-S) must be configured with web access port of Image Manager (<location>) Uses Study UID from Notify Study Access transaction, or Patient ID from patient context Includes UserID from user context for informative annotation, not for access control on Image Manager/Archive IHE Cardiology

IEO Issues Security – no requirement for ATNA User ID on web service invocation – for annotation only How to specify display client in IHE Profile Web integration (RID) EHR-S to imaging workstation for access to clinical record SWF RAD-12 Patient Update (vs. PAM ITI-30) Grouping of defined transaction end-point actors DICOM workflow responsibility of EHR-S product Dual study notification to EHR-S: MPPS and ORU Study notification ORU UID (vs. URL) Import reconciliation workflow explicitly included Discrete data elements only through CDA (vs. ORU) Where to specify transcoding DICOM SR measurements? IHE Cardiology