Integrating the Healthcare Enterprise Understanding and Optimizing Workflow with IHE Charles Parisot, GE Medical Systems – IT Kevin O'Donnell, Toshiba America Medical Systems

RSNA IHE Integration Profiles = Integration Capabilities Access to Radiology Information Retrieve & view images and reports Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Key Image Notes Flag & search for significant images Simple Image and Numeric Reports Simple reports with image links and measurements Basic Security Audit Trail Consolidation & Node Authentication Presentation of Grouped Procedures Manage subsets of 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 & store images with notification of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders

RSNA What are Key IHE Concepts? Problem/Solution Scenarios-> Integration ProfilesProblem/Solution Scenarios-> Integration Profiles Generalized Systems -> ActorsGeneralized Systems -> Actors Interactions between Actors -> TransactionsInteractions between Actors -> Transactions For each Integration Profile:For each Integration Profile: the context is described (which real-world problem)the context is described (which real-world problem) the actors are defined (what systems are involved)the actors are defined (what systems are involved) the transactions are defined (what to communicate)the transactions are defined (what to communicate)

RSNA Example: Scheduled Workflow Profile Registration Orders Placed Orders Filled Film Folder Image Manager & Archive Film Lightbox report Report Repository Diagnostic Workstation Modality acquisition in-progress acquisition completed images printed Acquisition Modality

RSNA The two sides of IHE It specifies information flows (requests, images, tasks done, reports, etc.) between HIS, RIS, PACS, Modalities, Workstations and Printers.It specifies information flows (requests, images, tasks done, reports, etc.) between HIS, RIS, PACS, Modalities, Workstations and Printers.  Makes Connections Easier It defines a foundation upon which to streamline the activities in a radiology departmentsIt defines a foundation upon which to streamline the activities in a radiology departments  Makes Workflow Easier This second point will be our primary focus

RSNA Workflow Capabilities Access to Radiology Information Retrieve & view images and reports Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Key Image Notes Flag & search for significant images Simple Image and Numeric Reports Simple reports with image links and measurements Basic Security Audit Trail Consolidation & Node Authentication Presentation of Grouped Procedures Manage subsets of 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 & store images with notification of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders

RSNA Store Images Storage Commitment List of Images PACS & Archive RIS ModalityPerformed Procedure Step Performed Step: Status = Completed Performed CT Head Pat Name/ID, Dose, Accession #, Study UID Complete List of Images IHE Scheduled Workflow The Connection side Modality Worklist Worklist Procedure Scheduled Patient Registration/Update Order Management

RSNA 2002 IHE Scheduled Workflow The Workflow side Procedure Steps : The smallest unit of work in the workflow: : ‘A unit of work to do’ : ‘A unit of work done’ Procedure Steps : The smallest unit of work in the workflow: SCHEDULED PROCEDURE STEP: ‘A unit of work to do’ PERFORMED PROCEDURE STEP: ‘A unit of work done’ IHE identifies four fundamental workflow information units : : Units of work resulting in one Report with associated codified, billable acts. REQUESTED PROCEDURE : Units of work resulting in one Report with associated codified, billable acts. A request for radiologic service ORDER : A request for radiologic service

RSNA 2002 IHE Workflow is User Driven Information Unit has its Prime User Information Unit has its Prime User ORDER: A request for imaging service REQUESTED PROCEDURE : Units of work resulting in one Report with associated codified, billable acts PROCEDURE STEP : The smallest unit of work in the workflow CLINICIAN OR REFERING DOC: The Imaging Dept Customer RADIOLOGIST : In charge of producing the Report the Report TECHNOLOGIST (and RADIOLOGIST) In charge of acquiring images, etc.

RSNA 2002 Why distinguishing these 3 concepts ? CLINICIAN OR REFERING DOC: I requested an exam RADIOLOGIST : I reported the exam TECHNOLOGIST I performed an exam Because not every order results in a single report and requires a single acquisition ! OK for chest X-Ray, confusion for a multi-modality acquisitions ! Before IHE …. CLINICIAN OR REFERING DOC: I placed an Order RADIOLOGIST : I reported the requested Procedure TECHNOLOGIST I performed a procedure step With IHE ….

RSNA 2002 ORDER: A multi-modality case, e.g. chest x-ray + NM ventilation REQUESTED PROCEDURE : one Report expected An IHE vocabulary for Workflow ORDER: A Simple one, e.g. chest x-ray REQUESTED PROCEDURE : one Report expected PROCEDURE STEP : Acquisition of chest x-ray For comprehensive workflow both simple and complex cases are supported PROCEDURE STEP : Acquisition of chest x-ray PROCEDURE STEP : Acquisition of NM Ventilation

RSNA IHE Scheduled Workflow 5 generic workflow cases are specified

RSNA 2002 Simple Workflow ORDER A request for Radiologic Service Requested Procedure Radiology Department Report Set of Codifiable, Billable, Acts Acquisition Modality One or more series of images Performed Procedure Step One Order – One Requested Procedure - One Scheduled Procedure Step – One Performed Procedure Step– One Report Scheduled Procedure Step A DICOM Modality Worklist

RSNA 2002 Acquisition Modality Multiple Modality Steps ORDER A request for Radiologic Service Radiology Department One or more series of images Performed Procedure Step P1 Scheduled Procedure Step B Requested Procedure 1 Scheduled Procedure Step A DICOM Modality Worklist

RSNA 2002 Acquisition Modality Multiple Modality Steps ORDER A request for Radiologic Service Radiology Department One or more series of images Performed Procedure Step P1 Scheduled Procedure Step B Requested Procedure 1 Scheduled Procedure Step A DICOM Modality Worklist Acquisition Modality One or more series of images Performed Procedure Step P2

RSNA 2002 Acquisition Modality Multiple Modality Steps ORDER A request for Radiologic Service Radiology Department Set of Codifiable, Billable, Acts One or more series of images Performed Procedure Step P1 Scheduled Procedure Step B Requested Procedure 1 Scheduled Procedure Step A Report One or more series of images Performed Procedure Step P2 The Requested Procedure collects Reporting inputs

RSNA 2002 Acquisition Modality Append Modality Steps ORDER A request for Radiologic Service Radiology Department Set of Codifiable, Billable, Acts One or more series of images Performed Procedure Step P1 Requested Procedure 1 Scheduled Procedure Step A Report One or more series of images Performed Procedure Step P2 A Requested Procedure collects Report inputs DICOM Modality Worklist

RSNA 2002 Acquisition Modality Discontinued Procedure Step ORDER A request for Radiologic Service Radiology Department One or more series of images Performed Procedure Step P1 Report Set of Codifiable, Billable, Acts Requested Procedure 2 Scheduled Procedure Step C Requested Procedure 1 Scheduled Procedure Step A DICOM Modality Worklist No Performed Procedure Step Discontinue DICOM Modality Worklist

RSNA 2002 Group Case ORDER A request for Radiologic Service Radiology Department Report Set of Codifiable, Billable, Acts Acquisition Modality Report Set of Codifiable, Billable, Acts Requested Procedure 2 Scheduled Procedure Step B Requested Procedure 1 Scheduled Procedure Step A One or more series of images Performed Procedure Step P1 DICOM Modality Worklist Each Requested Procedure collects Report inputs

RSNA Other Group cases… CT:Head bone / brain separationCT:Head bone / brain separation CR:Foot/ankle - hand/wristCR:Foot/ankle - hand/wrist –E.g., lateral image of foot shared between AP of ankle and AP of foot DR:Trauma patient AP / Lat re-groupingDR:Trauma patient AP / Lat re-grouping –I.e., do all the Aps then rotate the patient once then do Lats MR:MRI/MRAMR:MRI/MRA –To be viewed and billed separately IR:Diagnostic run and therapeutic runIR:Diagnostic run and therapeutic run –Performed contemporaneously, viewed/billed separately US:Abdomen and kidneys/ retroperitoneumUS:Abdomen and kidneys/ retroperitoneum The solution is……

RSNA IHE Presentation of Grouped Procedures Integration Profiles Access to Radiology Information Retrieve & view images and reports Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Key Image Notes Flag & search for significant images Simple Image and Numeric Reports Simple reports with image links and measurements Basic Security Audit Trail Consolidation & Node Authentication Presentation of Grouped Procedures Manage subsets of 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 & store images with notification of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders

RSNA IHE Presentation Of Grouped Procedures Workflow Allows splitting images resulting from a group case on the modality Allows managing the split image sets on the PACS

RSNA MODALITY Presentation of Grouped Procedures Profile Requested Procedure: CHEST Report: CHEST Report: AB/PELVIS Performs a single exam Operator groups 2 procedures Chest View RIS / PACS Requested Procedure: AB/PELVIS Chest View Ab/Pelvis View

RSNA Presentation of Grouped Procedures PGP maintains the link back to each one of the grouped procedures: PGP maintains the link back to each one of the grouped procedures: –without breaking the acquisition apart –Without duplicating images PGP ensures that each image subset related to a requested procedure is identified and ready to be presented. PGP ensures that each image subset related to a requested procedure is identified and ready to be presented.  This is key for quick display of new and prior studies.

RSNA Two new Workflow Options In Scheduled Workflow Access to Radiology Information Retrieve & view images and reports Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Key Image Notes Flag & search for significant images Simple Image and Numeric Reports Simple reports with image links and measurements Basic Security Audit Trail Consolidation & Node Authentication Presentation of Grouped Procedures Manage subsets of 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 & store images with notification of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders

RSNA IHE Scheduled Workflow with Assisted Protocol Setting PACS RIS Modality Worklist Incl. Scheduled Acquisition Protocols New Order OrderProtocolized Proposed Protocols Loaded & Reviewed ModalityPerformed Procedure Step Includes Performed Acquisition Protocols Store Images Storage Commitment Use Performed Acquisition Protocols Info for charge posting

RSNA IHE Scheduled Workflow with Exception Management PACS RIS Modality Worklist New Order ModalityPerformed Procedure Step Step Discontinued With Reason Store Images Storage Commitment ExceptionHappens If Wrong Worklist Images "removed" and Step "undone" e.g. Wrong Worklist entry selection e.g. Patient Condition

RSNA IHE Patient Information Reconciliation Integration Profile Access to Radiology Information Retrieve & view images and reports Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Key Image Notes Flag & search for significant images Simple Image and Numeric Reports Simple reports with image links and measurements Basic Security Audit Trail Consolidation & Node Authentication Presentation of Grouped Procedures Manage subsets of 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 & store images with notification of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders

RSNA IHE Patient Information Reconciliation ADT Patient Registration Order Placer Dept Scheduler Image Manager/Archive Modality When Institution Policy assumes pre- registration of ER patients (John/Jane Doe), IHE supports 3 possible cases:When Institution Policy assumes pre- registration of ER patients (John/Jane Doe), IHE supports 3 possible cases: PACS is synchronized with all patient registration and order information updates through Dept Scheduler.PACS is synchronized with all patient registration and order information updates through Dept Scheduler. 3.Unidentified Patient registered at ADT but acquisition completed at Modality prior to Order 1.Unidentified Patient registered at ADT and order placed at Order Placer 2.Unidentified Patient registered at ADT and order placed at Department Scheduler/Order Filler

RSNA IHE Scheduled Workflow + IHE Patient Information Reconciliation ADT Patient Registration Order Placer Dept Scheduler Image Manager/Archive Modality When Institution Policy allows departments to register ER patients, IHE supports 2 possible cases:When Institution Policy allows departments to register ER patients, IHE supports 2 possible cases: 1.Unidentified Patient assigned Temporary Departmental ID and Scheduled at Dept Scheduler/Order Filler 2.Image Acquisition Completed Without Scheduling at Dept Scheduler/Order Filler (Patient ID entered at Modality) Supports cases when ADT or Dept Scheduler is downSupports cases when ADT or Dept Scheduler is down

RSNA What about Reporting Workflow ? 1.Scheduled Workflow: Reporting is not explicitly addressed by Scheduled Workflow, but can be handled within the Image Manager and Order Filler.  Supported by the Scheduled Workflow Integration Profile 2.Simple Image and Numeric Report: This profile allow to produce a radiology report with coding of key elements and image references. The workflow is limited to report creation and access.  Supported by the Scheduled Workflow plus the Simple Image and Numeric Integration Profiles 3.Diagnostic Workstation: The Image Display Actor is only intended to provide access to images. The Report Creator is only intended to create report documents. A full a diagnostics/ reporting workstation needs to be part of an image manager or order filler.  A Full Workflow Integrated Diagnostics/Reporting can easily be supported within the image manager (PACS) or Order Filler (RIS) with Scheduled Workflow.  For a stand-alone diagnostics workstation, an additional profile is under consideration.

RSNA IHE Integration Profiles = Integration Capabilities Access to Radiology Information Retrieve & view images and reports Consistent Presentation of Images Hardcopy and softcopy grayscale presentation state Key Image Notes Flag & search for significant images Simple Image and Numeric Reports Simple reports with image links and measurements Basic Security Audit Trail Consolidation & Node Authentication Presentation of Grouped Procedures Manage subsets of 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 & store images with notification of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders

RSNA Where is More Information Available? IHE Technical framework for year 4 – V5.4 Non-Technical Brochures : IHE Primer and IHE FAQ IHE Integration Profiles: Guidelines for Buyers IHE Connectathon Results Ask Vendors for products IHE Integration Statements !