Image Sharing- the NIBIB/RSNA image sharing project employing IHE solutions David S. Mendelson, M.D. Professor of Radiology Chief of Clinical Informatics The Mount Sinai Medical Center Co-chair IHE International Board IHE-Providing the Foundation for Interoperability Fourth China- U.S. Roundtable Meeting on Scientific Data Cooperation:

Presentation Objectives Integrating the Healthcare Enterprise (IHE) Overview- How is IHE organized? Healthcare Interoperability in the United States Challenges ARRA (American Recovery and Reinvestment Act) Image Sharing Via HIE Image Sharing Project- Personal Health Records (PHRs)

Integrating the Healthcare Enterprise The state of IHE David S. Mendelson, M.D. Chief of Clinical Informatics The Mount Sinai Medical Center Co-chair IHE Board

International Adoption of IHE 4 France  Local Deployment  National Extensions (Local Adaptions)  Promotional & Live Demonstration Events  Funding USAGermanyItalyJapanUKCanadaKoreaTaiwanNorwayHollandSpainChina Year 1 (1999)Year 2 (2000)Year 3 (2001)Year 4 (2002)Year 5 (2003)Year 6 (2004) Year 7 (2005)Year 8 (2006) Pragmatic global standards harmonization + best practices sharing Austria

National and Regional Projects Using IHE Profiles 5 Quebec, Toronto, Alberta, British Columbia Canada Infoway Denmark (Funen) Italy (Veneto) Spain (Aragon) THINC- New York NCHICA – N. Carolina Italy (Conto Corrente Salute) Boston Medical Center - MA France DMP UK CfH (Radiology WF) Philadelphia HIE CHINA-MoH Lab results sharing CPHIC – Pennsylvania CHINA-Shanghai Imaging Info Sharing JAPAN-Nagoya Imaging Info Sharing South Africa Malaysia VITL-Vermont CareSpark – TN & VA Netherland Amsterdam Lower Austria

6 IHE Organizational Structure Contributing & Participating Vendors IHE International Board Global Development Radiology Cardiology IT Infrastructure Patient Care Coordination Patient Care Devices Laboratory Pathology Eye CareRadiation Oncology Regional Deployment IHE Europe IHE North America France USA Canada IHE Asia-Oceania Japan KoreaTaiwan Netherlands Spain Sweden UK Italy Germany Norway China Austria ACC ACCE ACEP JAHIS JIRA JRS METI-MLHW MEDIS-DC JAMI RSNA SFR SFIL SIRM BIR EuroRec COCIR EAR-ECR DRG ESC Professional Societies / Sponsors ACP GMSI HIMSS

7 Thank You for Your Attention Prof. Jianping Dai, MD IHE China:

8 Events: Promotion Education and Promotion by JournalsEducation and Promotion by Workshop

9 Events: Connectathon The IHE-C Connectathon was held at April 26, 2008 in Beijing Tiantan Hospital There are 7 companies attendedDr. Zhu, Chairman of IHE China, past vice Minister of Healthcare attended

10 The IHE-C Connectathon was held at April 26, 2008 in Beijing Tiantan Hospital Events: Connectathon

IHE – the process Identify Interoperability issues Develop Integration Profiles Actors and Transactions Workflow Gather relevant standards Connectathon Testing Publish Integration Statements Vendors list tested profiles 11

Problem to Profile ProblemDomainIntegration Profile TransactionActors Patient Identity across multiple settings IT Infrastructure Patient Identifier Cross- Referencing (PIX) Patient Identity feed Patient Identity Source Patient Identity Cross Reference Manager Make CAD results available with images RadiologyEvidence Documents Evidence Document Stored Evidence Creator (Post Processing Workstation Image Manager/Image Archive 12

Interoperability in the US- Challenges Privacy rights HIPAA No Single identifier

Office of the National Coordinator for Healthcare IT (ONC) Health Information Technology Standards Panel (HITSP) Certification Commission for HIT (CCHIT) American Recovery and Reinvestment Act (ARRA) Includes financial incentives for adoption of the Electronic Health Record throughout the US Interoperability is a cornerstone Funding for related research- NIH Quality -Comparative Effectiveness EHR

XDS (Cross-Enterprise Document Sharing) XDS.a XDS- I.a XDS.b ?? XDS-I.b a vs. b Related to web standards and transactions

XDS

XDS-I

NIBIB contract summary Consumer Control Employ IHE solutions whenever possible IHE generally has not focused on consumer driven solutions but rather on institutional and enterprise workflow 5 Academic Institutions Mayo Clinic Mount Sinai Medical Center University of California San Francisco University of Chicago University of Maryland Establish a clearinghouse Engage PHRs 300,000 patients over 2 years

Elements of Solution Edge Server Register a patient Listens to a Radiology Information System (RIS)- looking for a complete exam Retrieves Image set from PACS and Report from RIS Send both to clearinghouse Clearinghouse – functions as a secure router Transiently hold encrypted patient data PHR Consumer controls upload and future access Develop web based viewers Download full DICOM data set

XDS (Cross-Enterprise Document Sharing) XDS.a XDS- I.a XDS.b ?? XDS-I.b

Software architecture Prepare contentPoll database, get report, get exam,prepare big fat file Background java srvlet25 days Transfer contentPoll database for transfer out, package content into xds.b Background java srvlet35 days HL7 receiverReceive HL7 A04 messages, extract reports and store them in database Mirth HL7 Channel. Let Mirth create its default database, all script work-but may have to customize per site 65 days for 5 sites Token AppCreate new tokens based on two parts, associate token with accession numbers, update database, user interface with login, get patient info,create job Ajax based web front-end,JavaServlet for CFIND using dcm4che, creating job in the RSNA database, creating tokens using kerberos – tokens generated locally 30 days DatabaseStore reports, logs, audit trails, user accounts, etc. Mirth instance for HL7 & DICOM, RSNA instance for everything else 50 days – 2 databases Management AppCreate users, monitor logs, check health Ajax gui front end, backend servlet, dicom targets etc. 45 days

Future Directions Refine Workflow Initial workflow is to replace a CD Exam updates Download DICOM data and archive in a local PACS Edge server as a platform Radiation Monitoring Peer Review Quality Metrics

Radiation Exposure Monitoring Profile - REM Supplement to Technical Framework for Trail Implementation Acquisition modalities inlcudes information regarding dose exposure Estimates Permits communication of that information to other systems Useful for Individual lifetime estimates as well as Population analysis 30

Radiation Exposure Monitoring (REM) Includes CT Plain X-Ray Mammography Current Exclusions Nuclear Medicine RT Brachytherapy 31

DICOM Dose SR objects DICOM 2008 PS 3.3: A.35.8 X-Ray Radiation Dose SR IOD