1. IHE-RO Prabhakar Tripuraneni, MD, FACR, FASTRO On behalf of IHE-RO & ASTRO

2. I have a dream! We have a dream, that one day, We can buy any radiation therapy hardware or software, plug and play! We have a dream! --Jay Cooper --Prabhakar Tripuraneni --Phillip Devlin

3. Ever Frustrated with Connectivity?

4. Have you ever had any connectivity problems with Radiation Oncology hardware and software? Would you like to buy hardware and software from different vendors and still be able to use it? If yes, why don’t you?

5. IHE-RO: The Concept Hell is a place where nothing connects. - T S Eliot

6. Radiation Therapy is a Complex Process With Many Parts … And We All Want The Best

7. The Risk Of Choosing Each “Best Of Breed” Is the Tower of Babel

8. I Want To Buy Equipment I Can Plug In My Network And Not Worry About The Shape of The Plug!

9. We Need To Agree on Standards of Interchange

10. A nd Not “Creatively Apply” The Standards

11. IHE-RO BASICS IHE-RO does not & will not dictate what a product does IHE-RO ONLY specifies how a product interacts with other products For example …

12. Jaguar, Lexus, Mercedes, BMW Unique non-interchangeable parts, but … Gasoline, oil, etc. non-specific Choices for tires. Compete on features!

13. What Is IHE-RO? IHE-RO = Integrating the Healthcare Enterprise in Radiation Oncology Global effort of radiotherapy healthcare professionals, societies and vendors to improve interoperability in radiation oncology domain

14. IHE-RO A multi-specialty, -society, -national initiative to integrate radiotherapy equipment and patient health information systems The IHE-RO initiative is driven forward by both a Planning and Technical Committee

15. IHE-RO IHE-RO IHE-RO Co-Chairs Prabhakar Tripuraneni Jatinder Palta Planning Co-chairs Technical Co-chairs May Abdel-Wahab Bruce Curran Mika Miettinen Stuart Swerdloff Colin Field Ramesh Rengan

16. IHE Integrating HealthCare Enterprise  HIMS  RSNA together formed IHE

17. IHE Standards-Based Integration Solutions Professional Societies Sponsorship Healthcare Providers & Software Developers  Healthcare IT Standards HL7, DICOM, etc. General IT Standards Internet, ISO, etc. Interoperable Healthcare IT Solution Specifications  IHE Integration Profile  Interoperable Healthcare IT Solution Specifications  IHE Integration Profi  le  Interoperable Healthcare IT Solution Specifications  IHE Integration Profile  Interoperable Healthcare IT Solution Specifications IHE Integration Profile IHE Process

18. IHE Organizational Structure Multi-Domain & Multi-National IHE Organizational Structure Multi-Domain & Multi-National Participants contribute Global Development: Radiology, IT Infrastructure, Cardiology, Radiation Oncology Lab, etc. Delegates IHE Europe IHE North America IHE Asia/Oceania Regional & National Deployment supervise s reports IHE (International) Strategic Development Committee Sponsor Co-Chairs Global Interoperability IHE Domain-related Planning and Technical Committees

19. IHE Organizational Structure ASTRO AAPM ACR AROI CARO CSRO ESTRO JASTRO

20. IHE-RO Participants Professional society participants include: ASTRO AAPM ACR AROI (India) CARO (Canada) CSRO (China) ECS-RO (Egypt) ESTRO (Europe) JASTRO (Japan) RSNA Vendor participants include: BrainLab CMS-Elekta-IMPAC MIM-Vista Nucletron Philips Siemens Tomotherapy Varian Others: ATC, IAEA, NCI, NEMA

21. IHE–RO What does it do for you? Improves the connectivity of various radiation oncology hardware and software products Improves radiation oncology work flow Helps you to select products based on features, productivity and cost efficiency Helps vendors to focus on improving patient care instead of solving interface and connectivity problems

22. IHE-RO Process

23. IHE-RO process Identify interoperability problems Specify integration profiles Test integration profiles at Connectathon Publish integration profiles for use in RFPs(Request for Proposal)

24. IHE-RO 2006 Connectathon Washington DC

25. IHE-RO 2007 Connectathon Washington DC NucletronVarian Philips Tomotherapy Impac CMS Brainlab Elekta

26. IHE-RO 2008 Connectathon Houston TX

27. Proposed Use Cases 2006 - 2008 Simple Treatment Planning Use Dose Compositing Residual Dose Optimization Image Fusion for Dose Review On-line Image Review Off-line Image Review Treatment Delivery Workflow Instance-level Query-Retrieve Configuration Management Advanced Integration Objects Clinical Trial Submissions Prescription Automation Transfer of Anatomy/Aperture Data for Localization User Authentication and Authorization Registration Data Transfer Radiotherapy Planning and Treatment Record Structure Template Creation, Import And Export Brachytherapy Integration with Proton Therapy Bronchoscopy position data transfer Radiation Oncology Schedule Workflow (ROSWF)  Use cases are prioritized in a multi-year roadmap

28. IHE-RO Progress 2007-2008 Imaging Study Contouring System Simulation System Planning Workstation Rad Onc IMS Treatment Delivery Treatment Verification

29. IHE-RO 2007-2008 Achievements Objective #1  Reduce DICOM RT connectivity problems in CT- simulation and Treatment Planning domain Objective #2  Break the CT-simulation and Treatment Planning tasks to smaller, well-defined tasks (actors) Contouring, image registration, geometric planning, dose calculation, dose display  Define how the communication between these tasks (actors) happens Enables you to choose the best of all treatment planning tools in the market place, and connect them reliably together

30. Example of Benefits - Retreat Patient With Confidence Available patient dosimetry information from previous treatment using a different TPS is often inadequate IHE-RO unifies information format of treatment and dosimetry in RT devices  You can view the plan and dosimetry of previous RT on your TPS  Design the best new treatment plan for your patient. DRR of previous RT Planned new RT

31. Success Stories from Formal Connectathon “At the IHE-RO Formal Connectathon,  We were able to take a head and neck patient CT, draw contours on Brainlab, place a non-co- planar beam on Brainlab, dose plan on Philips, dose display on Varian, archiving and distributing with Impac.  For the prostate patient CT, we drew contours on TomoTherapy, beam placement and dose plan on CMS, and displayed on Elekta.”* *Real life examples of Interconnectivity among Radiation Oncology Systems

32. Formal Connecthaton Results (2007-2008 )

33. IHE-RO 2009 (Future) Treatment Delivery Workflow Problem  New techniques, like IGRT, are difficult to implement due to lack of standardized data and workflow between products Objective  Break the treatment deliver process to well-defined tasks (actors)  Standardize the data and workflow between information management system, patient positioning device, treatment delivery device, and mass data storage Benefits  Single clinic-wide schedule  Centralized DICOM RT data storage to manage e.g. rapidly increasing image data  Smooth IGRT and adaptive therapy workflow in both single and multiple system/vendor Tx environments

34. How IHE-RO Helps You Purchasing Products? You’ll get the product connectivity you wanted  Specify your connectivity needs using IHE-RO terminology, which is also unambiguously understood by the vendors  Vendors are required to publish IHE Integration Statement Describes what tasks in the radiation oncology workflow the product is able to perform in terms of connectivity States the version number (or estimated release date), when the product conforms the IHE-RO specifications Use IHE-RO Integration Profiles in your RFP (Request for Proposal) –process

35. IHE-RO Integration Profiles 2007- Technical Descriptions Simple Treatment Planning -profile  Data flow of DICOM images and treatment planning data, from CT scan through contouring, for 3D conformal planning and dose display of external beam radiation therapy.  The emphasis is to reduce ambiguity and facilitate basic interoperability in the exchange of DICOM RT objects. Information Exchange Between (Actors) :  CT Scanner Performs CT Imaging and is able to export CT images  Contourer Is able to import CTs & contours, perform contouring, and export CT images & contours  Geometric Planner Is able to import CTs & contours, perform beam geometry planning, and export geometric plan  Dosimetric Planner Is able to import CT, contours & geometric plan, perform dose calculation, and export plan & dose distribution  Dose Displayer Is able to import CT, contours, geometric plan, dose distribution, and display the dose  Archive Is able to import & export CT images, contours, geometric plan, and dose distribution

36. IHE-RO Integration Profiles 2008 - Technical Descriptions Multi-Modality Image Registration -profile  Specifies how images, RT Structure Sets, RT Doses, and associated spatial registration information can be exchanged, stored, processed and displayed Information Exchange Between (Actors) :  Registrator Is able to import image sets, perform spatial registration between the image sets, and export spatial registration information  Registered Display Is able to import image sets, contours, spatial registration information, and display the registered images  Registered Dose Display Is able to import image sets, contours, spatial registration information, dose distributions, and display the registered images and dose distributions  Registered Contourer Is able to import image sets, contours and spatial registration information, perform image registration and contouring (on registered images), and export contours and spatial registration information  Archive Is able to import & export CT images, spatial registration information and contours

37. Purchase Situation- Example #1 Your clinic is evaluating new treatment planning systems Y & Z  You are getting quite many referrals (complicated cases; patients already received RT in the past) from one of the satellite hospitals, which is using product X  You want to make sure you are able to review the dose distributions from the treatment planning system X (used in the other clinic) with your new planning system Your requirements to the vendors (as part of RFP)  Request vendors of products Y & Z to provide an integration statement, which includes dose displayer  Request vendor of product X (as part of the upgrade) to provide an integration statement, which includes dosimetric planner

38. Purchase Situation- Example #1 TPS Product X Contourer - Defines contours Geometric Planner - Defines plan geometry Dosimetric Planner - Calculates dose Dose Displayer - Displays dose distribution Registered Contourer - Defines contours on multimodality images Registrator - Registers multimodality images Registered Display - Displays image fusion Registered Dose Displayer - Displays dose on multimodality images TPS Product Y or Z Contourer - Defines contours Geometric Planner - Defines plan geometry Dosimetric Planner - Calculates dose Dose Displayer - Displays dose distribution Registered Contourer - Defines contours on multimodality images Registrator - Registers multimodality images Registered Display - Displays image fusion Registered Dose Displayer - Displays dose on multimodality images

39. Purchase Situation- Example #1 TPS Product X Dosimetric Planner - Calculates dose TPS Product Y or Z Dose Displayer - Displays dose distribution

40. Purchase Situation- Example #2 Satellite clinic is planning to buy a treatment planning system  Main Campus has product X  Physicians like the image registration & contouring tools and dose review of product Y  Physicists want consistency between clinics Your requirements to the vendors (as part of RFP)  Request vendor of product Y to provide an integration statement, which includes contourer, registrator, registered display and registered contourer, dose displayer and registered dose displayer  Request vendor of product X (as part of the upgrade) to provide an integration statement, which includes geometric planner and dosimetric planner

41. Purchase Situation- Example #2 TPS Product X Contourer - Defines contours Geometric Planner - Defines plan geometry Dosimetric Planner - Calculates dose Dose Displayer - Displays dose distribution Registered Contourer - Defines contours on multimodality images Registrator - Registers multimodality images Registered Display - Displays image fusion Registered Dose Displayer - Displays dose on multimodality images TPS Product Y Contourer - Defines contours Geometric Planner - Defines plan geometry Dosimetric Planner - Calculates dose Dose Displayer - Displays dose distribution Registered Contourer - Defines contours on multimodality images Registrator - Registers multimodality images Registered Display - Displays image fusion Registered Dose Displayer - Displays dose on multimodality images

42. Purchase Situation- Example #3 TPS Product X Geometric Planner - Defines plan geometry Dosimetric Planner - Calculates dose TPS Product Y Contourer - Defines contours Dose Displayer - Displays dose distribution Registered Contourer - Defines contours on multimodality images Registrator - Registers multimodality images Registered Display - Displays image fusion Registered Dose Displayer - Displays dose on multimodality images

43. Future (2009) Purchase Situation- Example #3 You have been tasked to find the best system solution to provide state-of-art IG-IMRT treatments in your clinic  Vendor Z has introduced very innovative and accurate new patient positioning device using X-rays, which you are very interested about  You have invested heavily to the treatment devices from vendor Y  The data storage must be scalable due to massive amount of imaging data  You must make sure that all this works with your existing Treatment Management System W Your requirements to the vendors (as part of RFP)  Request positioning system vendor Z to provide an integration statement, which includes patient positioning device -actor of Managed Delivery Workflow  Request vendor of product Y (as part of the treatment device upgrade) to provide an integration statement, which includes treatment device –actor of Managed Delivery Workflow  Request vendor of product W (as part of the treatment management system upgrade) to provide an integration statement, which includes treatment management system –actor of Managed Delivery Workflow  Request vendors competing for the RT data storage solutions to provide an integration statement, which includes archive- actor of Managed Delivery Workflow

44. Future (2009) Purchase Situation- Example #3 Product W Treatment Management System - Plan management and Tx records - Scheduling Product Z Patient Positioning System - Patient localization and positioning using e.g. X-rays, optical, internal fiducials Product Y Treatment Delivery System - Tx verification & delivery Product X Archive - Stores all DICOM RT data

45. Impact to Radiation Oncology Vendors Participation in IHE-RO Development  Marketing : Planning Committee  Engineering : Technical Committee  Connectathons Product Development to adhere to the Profiles Advantages for vendors  Cost-effective and efficient interface testing  Simplifies the tender (RFP) stage  Eventually lesser overall engineering effort  Easier & quicker installations  Improved promotion opportunities  Improved workflow leading to happier customers  Excellent channel to communicate with the radiation therapy thought-leaders

46. What can you do for IHE-RO? Healthcare professionals  Encourage your vendors to participate in IHE-RO  Be an evangelist for IHE-RO in the community  Use IHE-RO integration profiles in your RFP (Request for Proposals) when you buy new products Vendor employees  Encourage your customers to participate in IHE-RO  Participate on planning and technical committee  Increase the awareness of IHE-RO in your company Participate in the process of IHE-RO in identifying the interconnectivity problems and defining standards

47. How to Contact IHE-RO? ASTRO  Sunita Ranjitkar (sunitar@astro.org) IHE-RO Co-Chairs  Prabhakar Tripuraneni (prabhakar@tripuraneni.com)  Jatinder Palta (paltajr@ufl.edu) IHE-RO Planning Committee Co-chairs  May Abdel-Wahab (MWahab@med.miami.edu)  Mika Miettinen (mika.miettinen@varian.com)  Colin Field (cfield@cancerboard.ab.ca) IHE-RO Technical Committee Co-chairs  Bruce Curran (bcurran1@lifespan.org)  Stuart Swerdloff (sswerdloff@impac.com) On-line  http://wiki.ihe.net

48. IHE-RO Summary Wins for you:  Improves the connectivity of various radiation oncology hardware and software products  Improves radiation oncology work flow  Helps you to select products based on features, productivity and cost efficiency  Helps vendors to focus on improving patient care instead of solving interface and connectivity problems How to help:  Evangelize IHE-RO in the community  Encourage your colleagues, vendors, customers to participate  Use IHE-RO profiles in purchasing (RFP) process  Participate in the process of IHE-RO in identifying the interconnectivity problems and defining standards

49. http://wiki.ihe.net

50. We have a dream! We have a dream, that one day, We can buy any radiation therapy hardware or software, plug and play! We have a dream! --Jay Cooper --Prabhakar Tripuraneni --Phillip Devlin IHE-RO is making this dream to come true…