12/6/2002 RSNA 2002 DICOM & IHE: What Are They, and Why Do We Need Them? Sanjay Jain Director, Engineering, Cerner Corporation Co-Chair, IHE Planning Committee Sanjay Jain Director, Engineering, Cerner Corporation Co-Chair, IHE Planning Committee RSNA 2002

12/6/2002 RSNA 2002 What Is DICOM Digital Imaging and COmmunications in Medicine Began with ACR-NEMA initiative in late 1980s (also known as DICOM 2) Defines standard method to transfer images and related information between devices manufactured by various vendors DICOM 3.0 was introduced in 1992 with 9 parts, now there are 16 parts

12/6/2002 RSNA 2002 The DICOM Standard Each part has a specific purpose –Part 2 : Conformance Statement –Part 4 : Service Class Specification –Part 6 : Data Dictionary –Part 10 : Media Storage and File Format for data interchange –Part 14 : Gray Scale Standard Display Function

12/6/2002 RSNA 2002 What Is DICOM (contd.) Relates the transactions to the real- world and defines a data dictionary Defines the role that a given system can play –Service Class Provider (SCP), keeper of the data and makes it available to users –Service Class User (SCU), gets the data from SCP, but has no responsibility to make it available to other SCUs

12/6/2002 RSNA 2002 The DICOM Standard (contd.) Defines Communication Protocol and content structure –Service Requested (e.g Modality Worklist) –Message structure and encoding (big endian, little endian) –Tag Value pair for identifying information, regardless of the transaction Patient Name: (0010,0010) – Group 0010, Element 0010 Patient ID: (0010,0020) – Group 0010, Element 0020

12/6/2002 RSNA 2002 Why DICOM? Imagine if film from your camera could not be processed by neighborhood store but only a special agency –How timely would your pictures be available? –Will you keep on using the camera? –You want to process it easily and quickly. It was the same situation in Imaging DICOM enabled exchange of digital imaging and textual information using a Common Communication Protocol But left interpretation for implementers, so?

12/6/2002 RSNA 2002 Where do you use DICOM? Digital Scanners (CT, MR, CR, DR, etc.) Picture Archival and Communication System (PACS) Softcopy Display and Reading systems (Workstations) Film Printers Others… How do you know if your scanner can save to the PACS?

12/6/2002 RSNA 2002 DICOM Conformance Statement It is a detail document explaining implementation of DICOM standard in the Product –Defines the service classes implemented and the role that system plays (SCP or SCU) for each class. E.g. ProVision implements Modality Worklist as an SCP Required to compare when reviewing systems for connectivity Need a technical staff person

12/6/2002 RSNA 2002 Is DICOM sufficient? What is the role of other standards like HL7? What is IHE (Integrating the Healthcare Enterprise? Lets answer these in context of Care Process

12/6/2002 RSNA 2002 HL7/ DICO M HL7 DICO M examination orders for J Doe HIS Enter patient as J Doe modality worklist for J Doe RIS report Patient Care Workflow

12/6/2002 RSNA 2002 Where do you use DICOM? Communication between: –RIS and Modality –Modality and PACS –PACS and Reading Workstation and Printers How about the rest of the process? –Registration -> Order -> RIS, … They all use HL7 for exchanging care data. Patient demographics, Orders, Statuses, Results, Charges

12/6/2002 RSNA 2002 HL7 and DICOM They are both important for healthcare and digital imaging The information communicated using HL7 is typically Patient, Encounter, Procedure, Charges Same information is useful for Imaging process But how does information flow between systems implementing two standards?

12/6/2002 RSNA 2002 Communication Challenges Systems need Information other systems have But, systems communicate poorly or not at all Result: - tedious, inefficient workflows - data that is inconsistent or unavailable Responsibility for information flow between systems and between departments, is often unclear

12/6/2002 RSNA 2002 Integrating the Healthcare Enterprise It’s an initiative promoting and supporting the integration of systems in the healthcare enterprise Integration Goal: Improve the efficiency and effectiveness of clinical practice by: –Improved Information Flow –Advanced Multi-System Functions

12/6/2002 RSNA 2002 Who is IHE? Participants: –Professional Societies (RSNA/HIMSS/…) –Vendors (over 30 companies) –Standards Group Committee Members RSNA and HIMSS sponsor IHE to provide a neutral forum for working on the Big Picture

12/6/2002 RSNA 2002 What Does IHE Do? Users and vendors work together to identify and design solutions for integration problems Intensive process with annual cycles: –Identify key healthcare workflows and integration problems –Research & select standards to specify a solution –Write, review and publish IHE Technical Framework –Perform cross-testing at “Connectathon” –Demonstrations and Education at tradeshows (RSNA/HIMSS)

12/6/2002 RSNA 2002 Key IHE Concepts Generalized Systems -> Actors Interactions between Actors -> Transactions Problem/Solution Scenarios -> Integration Profiles

12/6/2002 RSNA 2002 For each Integration Profile: the context is described (which real- world problem) the actors are defined (what systems are involved) the transactions are defined (what must they do) Key IHE Concepts

12/6/2002 RSNA 2002 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 Integration Profiles

12/6/2002 RSNA 2002 Scheduled Workflow Patient Info Reconciliation Specify transactions that function to maintain the integrity of patient, image, and order information across systems PIR, extends Scheduled Workflow Handle unidentified patient (e.g. trauma) Handle demographic information mistakes Propagate changes to all affected systems, update all affected data Reduces incorrectly identified or “lost” studies

12/6/2002 RSNA 2002 What the Radiologist Displays: What the Reviewing Physician Sees: The Radiologist’s Transformations Are Saved Original Image & Presentation State Original Image Window Level Flip Zoom Area Of Interest Annotate The Radiologist’s Transformations Are Lost Original Image Area Of Interest Prepared Image Original Image Consistent Presentation of Images

12/6/2002 RSNA 2002 MODALITY Presentation of Grouped Procedures Requested Procedure: HEAD Report: HEAD Report: CHEST Performs a single exam Operator groups 2 procedures Head View RIS / PACS Requested Procedure: CHEST Head View Chest View

12/6/2002 RSNA 2002 Simple Image and Numeric Report Report Verification Report and Image Review for Patient Care Images retrieved Preliminary Report Verified Report Report & Images retrieved

12/6/2002 RSNA 2002 Radiologist Flags Images: Referring Physician Sees Key Images First: for refering physician This image shows the renal rupture. Note1 for refering physician This image has the hematoma. Note2 For referring physician: This image shows the renal rupture. Note1 For referring physician: This image has the hematoma. Note2 for refering physician This image shows the renal rupture. Note1 for refering physician This image has the hematoma. Note2 Study & Key Image Notes Key Image Notes Profile

12/6/2002 RSNA 2002 Measurements CAD report……………… Store Images Store SR Storage Commitment List of Images/SR PACS & Archive RIS Post- Processing Performed Procedure Step PP-Performed Step: Pat Name/ID Accession #, Study UID Complete List of Images/SR Performed 3D - Status = Completed A Closed Loop Update IS SchedulingUpdate IS Scheduling Match Procedure with OrderMatch Procedure with Order Support Billing Based on PP-PPSSupport Billing Based on PP-PPS Post-Processing Workflow Post-Processing Worklist Worklist WorkItem Claimed/Completed PP-Perform Step Completed

12/6/2002 RSNA 2002 BENEFITS Initial Capture of Patient Demographics HIS BILLING SYSTEM Modality Patient Information Account Complete Procedure Information RIS Redundancy Eliminated All Systems Updated Maximum Data Integrity Billing Available ASAP Charge Posting Workflow

12/6/2002 RSNA 2002 Integrating trusted nodes System A System B Secured System Secure network Strong authentication of remote node (digital certificates) network traffic encryption is not required Secured System Local access control (authentication of user) Audit trail with: Real-time access Time synchronization Central Audit Trail Repository

12/6/2002 RSNA 2002 Secured Domain: Integrating trusted nodes Secured Node Actor Other Actors Secured Node Actor Other Actors Secured Node Actor Other Actors Secured Node Actor Other Actors Time Server Central Audit Trail Repository

12/6/2002 RSNA 2002 Where is IHE going? Further Expansion in Radiology –Handling multiple Archives within the institution Horizontal Expansion to –IT Infrastructure (Enabling EMR) –Desktop Integration –Cardiology Geographical Expansion to –Europe (Germany, France, UK, Italy) –Japan –…

12/6/2002 RSNA 2002 How do You benefit from IHE? Clinical UsersClinical Users Greater access to more consistent informationGreater access to more consistent information Fewer errors, fewer tedious tasksFewer errors, fewer tedious tasks AdministratorsAdministrators Increased throughputIncreased throughput Better scheduling and trackingBetter scheduling and tracking BuyersBuyers Specify/purchase integration capabilities easilySpecify/purchase integration capabilities easily Freedom to acquire your selection of systemsFreedom to acquire your selection of systems IT ProfessionalsIT Professionals Faster, more predictable integration projectsFaster, more predictable integration projects

12/6/2002 RSNA 2002 What IHE is NOT It is not a StandardIt is not a Standard Has produced a FrameworkHas produced a Framework Defines consistent and unambiguous use of standardDefines consistent and unambiguous use of standard It is not an OrganizationIt is not an Organization Is an initiativeIs an initiative It is not a ProductIt is not a Product Can’t buy IHE as a productCan’t buy IHE as a product Ask for IHE integration profile implemented in Actors/Products you buyAsk for IHE integration profile implemented in Actors/Products you buy It may be an upgrade, a feature or an option in the productIt may be an upgrade, a feature or an option in the product

12/6/2002 RSNA 2002 DICOM & IHE: Can you have an integrated Enterprise Without Them? What Are They, and Why Do We Need Them?

12/6/2002 RSNA 2002 Resources medical.nema.org FAQs Integration Profiles Primer on IHE Presentations IHE Technical Framework Thank You