IHE Radiology Mammography Acquisition Workflow - from a RIS perspective Antje Schroeder – IHE Radiology Technical Committee Co-Chair (Siemens Healthcare) July 25, 2013

Background Mammography Image Profile has been well accepted in the Mammography field –Consistent creation and display of 2D Mammography Images Mammography Acquisition Workflow has been developed to address specific workflow needs/exception in screening Mammography –Rejection of images for quality reasons to eliminate low quality images from review –Correction of image view and laterality to avoid additional exposures or incorrect reporting –Procedure Updates performed at the modality. Profile has been well accepted with Modality and PACS vendors, however so far there is a lack of RIS support

Mammography Acquisition Workflow Use cases Supplemental Views Finish exam with supplemental views in a different room Conversion of a procedure at modality Screening recall – Patient returns for subsequent exam Screening recall – Technical reasons Mark image rejected for quality reasons View correction Use of coded values for scheduling and documentation purposes  RIS is essential to allow complete workflow and a consistent display at review station

Value Proposition Reduce Errors and enhance Patient Care Prevents additional exposure due to incorrect labeling Prevents review of bad quality images Prevents delays in patient care by only making relevant information available at the point of care. Improve Throughput Reduces staff time wasted identifying and correcting errors (in a coordinated fashion) among the HIS, RIS, PACS and modality Re-use functionality defined in other profiles

Actors and Transactions

Relationship to other Profiles Scheduled Workflow Basic Workflow model of SWF is extended: –Handling of exceptions in acquisition workflow (additional image acquisition, procedure updates at modality, changes of acquisition system, procedure conversion) –Use of Protocol and Reason codes to drive workflow –Handling for varying scheduled and performing procedure codes –Procedure updates in order to keep participating actors aligned to allow proper display of modified studies Mammography Image Consistent creation and display of Mammography Images Image Object Change Management Re-use mechanism (Rad-66 – Image Rejection Note Stored) to –flag bad quality images in order to prevent display –Correct incorrectly labeled images Key Image Note Re-use of manifest (Key Object Selection Document)

Convert procedure Convert diagnostic procedure: unilateral  bilateral Radiologist reviews images of left breast while patient still present. Radiologist decides that images of right breast are needed, too.  Change procedure directly at Modality, no canceling/rescheduling at RIS necessary  Based on MPPS RIS detects procedure change and updates Image Manager/ Archive and Order Placer to use correct information for subsequent workflow steps. Modality Archive WorkstationDSS/OF Store images of R breast MPPS in progress MPPS completed Query/ Retrieve images for bilateral diagnostic exam Procedure update: unilateral  bilateral MPPS forwarded

Finish acquisition in different acquisition room Supplemental images for one procedure acquired at a second Modality Radiologist decides to take additional images / convert a procedure, while patient is waiting outside acquisition room Original room is occupied, so the acquisition continues in different room  DSS/OFF needs to provide worklist for either a COMPLETED or a DISCONTINUED exam  Avoid unscheduled acquisition with manual reconciliation Archive WorkstationDSS/ OF Query/ Retrieve images from both Modalities as part of the same Study Modality 2 Store images MPPS in progress MPPS completed MPPS forwarded Query MWL (patient-based) MPPS in progress/ completed Store images Modality 1

Recall – patient returns for subsequent exam Screening recall Radiologist assesses acquired images incomplete (BIRADS 0). Patient has left and needs to come back for additional imaging.  DSS/OF schedules a new procedure (as part of the screening order) with –a specific Reason for Requested Procedure code value –a reference to the original study (Referenced Study Sequence)  link between the original and the recall study  Regular acquisition at Modality  Image Display presents both studies as one based on reason code and study reference MPPS forwarded Modality Archive WorkstationDSS/ OF Store images (recall study) MPPS Query/ Retrieve images from original and recall study Query MWL (on recall)

Mammography Acquisition Workflow Use of codes: DSS/OF, Modality, Archive Use of coded values for Scheduling and driving modality behavior: RIS provides Requested Procedure, Reason for Requested procedure and scheduled protocols to enable selection of modality settings and support technologies Documentation what was performed: enable displays to present images in adequate layout, enable tracking of performed work and compose charges  RIS needs to provide this information to enable all subsequent workflow steps Coding SchemeCode Value*Code MeaningDefinition DCM111590Recall for technical reasonsPatient returns for additional images to improve the quality of the current exam. DCM111591Recall for imaging findingsPatient returns for additional images to clarify findings from the current exam. DCM111416Follow-up at short interval from prior study The prior study recommended a follow-up breast imaging exam in 1 to 11 months (generally in 6 months). SRTR-408C3DiagnosticThe exam is done in order to answer a specific diagnostic question. * Note: This table is not shown completely (see MAWF TI Profile text: Table 4.5-6)

What does this mean for the RIS RIS is an important workflow driver in MAWF: Provide procedure codes to drive subsequent acquisition and documentation steps Detect and communicate procedure changes Schedule recall-studies with references to initial study and appropriate recall reason codes Provide work items already in use

Next Step Review Trial Implementation version of MAWF: – index.cfm#radiology Sign-up to participate in IHE Connectathon in January 2014

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Modality or QA workstation Archive WorkstationDSS/ OF Store rejection KOS MPPS (Modality) or Creator PPS PPS forwarded B) Rejected images are hidden or displayed A) Rejected images are hidden B) Rejected images are provided Availability Notification A) Rejected images not part of query result Q/R Reject images of insufficient quality Mark images as rejected for quality reasons After completed acquisition, images are considered of insufficient quality Modality or Evidence Creator create a Key Object Selection (KOS) object –Document Title “Rejected for Quality Reasons” –Document Title Modifier is valued (DICOM PS 3.16, CID 7011) –References to all rejected images Image Archive is configurable to provide or hide rejected images and KOS Image Display is configurable to present or hide rejected images and KOS

Correct view labels of images View, laterality or protocol are corrected After completed acquisition, incorrect view labeling is detected Modality or Evidence Creator create corrected images –Copy most values except e.g. View Codes, View Modifiers, Laterality, Protocol –Correct references from “For Presentation” to “For Processing” images –Evidence Creator records its identifying data (Contributing Equipment Seq.) Modality or Evidence Creator create a Key Object Selection (KOS) object –Document Title “Rejected for Patient Safety Reasons” (  DICOM CP) –References all incorrect images (For Presentation & For Processing) Image Archive & Image Display hide KOS and the incorrect images PPS forwarded Modality or QA workstation Archive WorkstationDSS/ OF Store rejection KOS Store corrected image(s) MPPS (Modality) or Creator PPS Q/R: incorrect images are not part of query result Incorrect images are hidden at Q/R Availability Notification

Supplemental views to a completed exam Supplemental implant displacement image after screening Append case, where Modality fills protocol codes in a new MPPS. Modality supports Assisted Acquisition Protocol Setting. –Procedure unchanged, e.g. “Screening bilateral” Note: Compared to SWF, Modality always fills in protocol code(s). Dept. Scheduler/ Order Filler may use protocol codes, e.g. notify user Image Display selects presentation layout based on procedure/ protocol/ reason codes Modality Archive WorkstationDSS/ OF Store suppl. images MPPS in progress MPPS completed MPPS forwarded Query/ Retrieve screening and implant images

Actors and Transactions