1. Waveform, Workflow, Archiving…
Assessment of Standard Interfaces
Opportunities for Cooperation

2. Three Levels for Connectivity Standards
Device Connectivity
Departmental Integration
Hospital/Ambulatory Workflow
EMR Integration
Radiology
Imaging
Modalities
Image proc.
CAD, …
DICOM
RIS R-PACS
Enterprise Archive
ADT Order Placer
EMR, …
DICOM
Cardiac IS, C-PACS
Cardiology
Rest, Stress, Holter ECG
Cardiac Monitors Hemodynamics
Captors,
Actuators
Bed-Side Monitors
ICU IS
ICU
Cluster Monitor
SCP ?
HL7 ? DICOM ? 1073 ?
1073
HL7
Three Examples  Overlap  Coordination Needed

3. Three Topics, Three Opportunities ?
Persistent Waveform Objects
Departmental Workflow Integration
Enterprise Archiving of Images & Waveforms

4. DICOM Waveforms Quick Refresher

5. Key Aspects of DICOM
DICOM domain is communications for imaging-based care
DICOM is an Object-based standard
Persistent objects
Inter-object referential capability
Binary tagged data element format
Objects are hierarchically organized
Patient / Study / Series (modality) “folders”
DICOM: Persistent Object workflow services over TCP/IP
Generally in client-server architecture
Object transfer, storage, storage commitment, query and retrieval
Media-Interchange (CD, DVD, Floppy, etc.) with clinical directory.
Network Archiving
Departmental workflow management (worklist, performed steps)
Broadly used and accepted world-wide for many years.

6. DICOM Waveforms Supplement 30: Waveform – in DICOM 2001
Introduces general structure for waveform composite (persistent) objects
Waveform channels identified by coded-entry triplet
Coding Scheme / Code Value / Code Meaning
Allows externally defined terminology (e.g., SCP-ECG for leads)
Triplets also used in HL7 and DICOM Structured Reporting
Triplet values may be constrained by Templates defined in Part 16
Specific waveform Object Definitions (particularly for cardiology)
Hemodynamics
Cardiac Electrophysiology
Electrocardiography (12-lead, ambulatory, general)
Basic Voice Audio
In progress, Ultrasound Doppler Waveform (Suppl 56)

7. DICOM Waveform Object
Waveform object encodes digital data from a discrete time period
Multiple channels; all channels have common time base
Flexible waveform sample format
8 or 16 bit data; Signed, unsigned, u-law, A-law
Separate sampling frequencies for each channel, or multiplexed channels at common frequency
Objects may be temporally contiguous, or temporally selective
“Store and forward” (not for real time monitoring)
Waveform object encodes full definition of each channel
Quality being sampled, Sensor location (anatomic),Function (measurement or stimulus), Resolution and range, Technique (e.g., pull-back)
Based on HL7 V2 definition
Waveform object encodes DICOM + HL V2 context information in header
Equipment information (manufacturer, serial number, location)
Temporal frame of reference (synchronization with other objects, in particular images)
Waveform object encodes optional annotation
Identify features or regions of interest
Generated by acquisition unit
Constructed of label and time or sample reference
Streams of
Waveform Samples

8. Waveforms Standardization for Departemental Integration -Key Objectives-

9. Waveforms: why integrated & separated ?
Integrated with other persistent objects
Images
Supporting the waveforms (e.g., for documentation of EP catheter location)
Supported by waveforms (e.g., simultaneous ECG for IVUS post processing)
Various categories of Structured Reports with waveform references.
Clinical reports
Measurement reports (e.g., hemodynamics, or ECG)
Procedure Log documents (full procedural context for waveform acquisition)
Key object selection (electronic “Post-It”)
Workflow integration:
worklists and status monitoring of scheduled tasks
including distribution of patient demographics
Object archiving and retrieval – Key for archiving of recorded vitals signs
Web accessible as persistent objects (presented or original data)
Focused on Full Fidelity Acquired Data:
No Presentation: to be addressed independently.
Compression: compact encoding, separate from the object definition
Clearly distinguished from derived measurements and reports
Patient/Visit/Order context driven by HL7

10. Departmental Workflow Integration DICOM and HL7…
Departmental Workflow Integration DICOM and HL7….. Much more than combining standards !

11. IHE Scheduled Workflow
Patient Registration/Update Order Management (HL7)
IHE Scheduled Workflow
Modality Worklist
Worklist
Procedure Scheduled (HL7)
RIS
Modality
Performed
Procedure Step
Performed Step:
Status = Completed
Performed CT Head
Pat Name/ID, Dose, Accession #, Study UID
Complete List of Images
Storage Commitment
List of Images
Store Images
PACS & Archive
As Performed Procedure Step, the most recent of the four Service Classes become available, a fully integrated solution for the modalities is on the horizon.
Implementing Modality Worklist is the first step and can be done today with most recent modality products.
Closing this loop delivers many benefits to the overall operation efficiency of the radiology department in the context of the overall hospital.
A Closed Loop
Update IS Scheduling
Match Procedure with Order
Support Billing Based on MPPS
Avoid Reading incomplete Procedures

12. Structuring the Departmental Workflow with an Enterprise perspective
DICOM Modality Worklist
Radiology Department
ORDER
A request for Radiologic Service
Scheduled Procedure
Step A
Acquisition Modality
One or more series of images
Performed Procedure
Step P1
Report
Set of Codifiable,
Billable, Acts
Requested
Procedure 1
DICOM Modality Worklist
Scheduled Procedure
Step B
One or more series of images
Performed Procedure
Step P2
Acquisition Modality
Representation includes: healthcare providers, information systems vendors, imaging systems vendors, and standards groups participating

13. What is IHE ?
An Initiative Sponsored by Users: HIMSS plus clinical societies (e.g.RSNA)
Active Industry Leadership, shaping direction
Leverage existing standards (HL7, IEFT, DICOM, etc.) in an industry defined integration framework
Proceed in pragmatic incremental steps to deliver easier to integrate product implementations
Proven approach in IT & Radiology (over 100 vendors already participate).

14. Enterprise Archiving of Images and Waveforms

15. IHE Integration Profiles
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

16. What is Unique about IHE ?
A User/Vendor Team Effort :
Voluntary and Open to All Vendors. It is not a consortium.
Professional Associations Engaged (e.g. HIMSS leadership)
Starts from concrete user integration needs, selects standards, sets a technical framework, provides a test-bed, and demonstrates/educates marketplace.
Does not define product architectures or features, only the glue between products.
Successful. Benefits both small and large vendors, worldwide : North America, Europe, Asia.

17. Industry is invited to shape and expand IHE
A kick-off meeting in order to :
Review the current state of integration in the healthcare information technology industry
Identify IT Infrastructure priorities necessary for building an EMR
Establish the structure and timeline for implementation.
All vendors are invited :
Product marketing & technical leadership
When & where :
November 4-5, 2002
Malvern, (near Philadelphia, PA)
Respond to invitation :

18. IHE Scheduled Workflow
Patient Registration/Update Order Management (HL7)
IHE Scheduled Workflow
Modality Worklist
Worklist
Procedure Scheduled (HL7)
RIS
Modality
Performed
Procedure Step
Performed Step:
Status = Completed
Performed CT Head
Pat Name/ID, Dose, Accession #, Study UID
Complete List of Images
Storage Commitment
List of Images
Store Images
PACS & Archive
As Performed Procedure Step, the most recent of the four Service Classes become available, a fully integrated solution for the modalities is on the horizon.
Implementing Modality Worklist is the first step and can be done today with most recent modality products.
Closing this loop delivers many benefits to the overall operation efficiency of the radiology department in the context of the overall hospital.
A Closed Loop
Update IS Scheduling
Match Procedure with Order
Support Billing Based on MPPS
Avoid Reading incomplete Procedures

19. Enterprise Archiving of Images and Waveforms

20. Enterprise Archiving for complex clinical data: images and waveforms
Large and "specialized" complex clinical data sets call for archiving outside of central EMR database
Images are being handled by PACS (radiology, cardiology, etc.) and hospital wish to also share resource for waveforms
A consistent set of standards is required to achieve this integration of image and waveform enterprise archiving in an EMR driven environment.

21. Enterprise Archiving DICOM : 10 years of experience
Media Interchange (Inst. + DIR)
Enterprise Persistent Objects
Repository
Store (Class/Instance UID)
Departmental IS System
RIS, PACS, CIS, etc.
Storage Commitment
Retrieve (Instance UID)
Store (Class/Instance UID)
Transparent Persistent
Object Payload (except for Class)
Study/Patient
Query (Study Root)
Series
Persistent Object Instance
Web Access
Native or presented forms

22. Web Access to Persistent DICOM Objects
e.g.EPR
"Form of the reference"
Persistent Objects
Repository
"Form of the reference"
Retrieve a "presentation view"
Client
Accessing Healthcare Documents
Retrieve a "Data Set"
Data Set "Retrieve":
-Preferred transfer Syntax
-Default transfer Syntax ?
Presentation View "Retrieve":
-Type of encoding for images (JPEG, GIF, etc.)
-Type of document presentation format (PDF, HTML, CDA-L1)
-Size of Images
Retrieve one "entire document" (either in a presentation view or as a data set) using its "Persistent Document Instance UID"
Intent is not to offer a "Query":
Need is only to get access to an object

23. Waveforms Standardization for Departemental Integration -Key Objectives-

24. Waveforms: why integrated & separated ?
Integrated with other persistent objects
Images
Supporting the waveforms (e.g., for documentation of EP catheter location)
Supported by waveforms (e.g., simultaneous ECG for IVUS post processing)
Various categories of Structured Reports with waveform references.
Clinical reports
Measurement reports (e.g., hemodynamics, or ECG)
Procedure Log documents (full procedural context for waveform acquisition)
Key object selection (electronic “Post-It”)
Workflow integration:
worklists and status monitoring of scheduled tasks
including distribution of patient demographics
Object archiving and retrieval – Key for archiving of recorded vitals signs
Web accessible as persistent objects (presented or original data)
Focused on Full Fidelity Acquired Data:
No Presentation: to be addressed independently.
Compression: compact encoding, separate from the object definition
Clearly distinguished from derived measurements and reports
Patient/Visit/Order context driven by HL7