IHE Cardiology Image Enabled Office Harry Solomon Based on IEO draft 19 ftp://ftp.ihe.net/Cardio/Year /Technical_Committee/Supplements/IEO/

IHE Cardiology Page 2 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.

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 Page 3

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 Page 4

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 Page 5

IHE Cardiology Page 6 In-patient Scheduled Workflow Diagram    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 [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 DSS/ Order Filler  Patient Update [RAD-12] Evidence Creator Modality Image/Evidence Stored [CARD-2] 

IHE Cardiology Page 7 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

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

Dynamic Model – Explicitly Ordered Exam: Acquisition IHE Cardiology Page 9

Dynamic Model – Imaging Study Analysis / Reporting IHE Cardiology Page 10

Dynamic Model – EHR-S based reporting IHE Cardiology Page 11

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 IHE Cardiology Page 12

IHE Cardiology Page 13 New Transactions Notify Study Access [CARD-14] Image Manager/Archive to EHR-S (Report Manager) HL7 ORU^R01 Trigger Event – availability of study images at Image Manager OBX segments with Study Unique ID and with display service URL Invoke Image Display Service [CARD-15] EHR-S to Image Manager/Archive Web service over HTTP Invokes navigation / viewing study in standard web browser Outpatient Update [CARD-16] Similar to Patient Update [RAD-12], only 2 outpatient-related trigger events HL7 ADT^A08 and A40

Notify Study Access [CARD-14]: OBX 1 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 Page 14 SEQLENDTUsageCard.TBL#ITEM#ELEMENT NAME 14SIR00569Set ID – OBX 23IDR Value Type = HD 3705CWER00571Observation Identifier 570HDR00573Observation Value 111IDR Observation Result Status = R 1424DTMR200582Date/Time of the Observation

Invoke Image Display Service [CARD-15] Access based on Study UID or Patient ID Follows model of IHE ITI Retrieve Info for Display web services /IHERetrieveDICOMInfo?requestType=STUDY&st udyUID= &userID= /IHERetrieveDICOMInfo?requestType=SUMMARY &patientID= &lowerDateTime= &upper DateTime= &mostRecentResults= &userID= IHE Cardiology Page 15