1. Cardiology Workflow & Display Requirments
IHE Vendors Workshop 2006
IHE Cardiology Education
Bob Baumgartner, BSN, MBA
McKesson Corporation
IHE-Cardiology Planning Committee Administrative Co-Chair

2. Agenda Cardiology Workflows General Content Display Requirements
Cath Workflow
Echo Workflow
Stress Workflow
Content Display Requirements
Stress Echo
Stress
Nuclear Cardiology

3. Cardiology Workflows Cardiology: heart its action and diseases
the study of the
heart
its action
and diseases

4. Workflow is the linchpin to data integrity
The Problem
This is an example of a cardiology workflow.
Any questions!
Workflow is the linchpin to data integrity

5. General Workflow

6. Agenda Cardiology Workflows General Cath Workflow
Echo Workflow
Stress Workflow
Content Display Requirements
Stress Echo
Stress
Nuclear Cardiology

7. Cath Lab 7 6 5 8 9 10 11 4 3 2 1 Multiple re-entry of Patient ID
Error prone
Results fragmented across systems
Results inconsistently time-tagged
Custom solutions needed for data sharing
Difficult to manage
Uncoordinated with Hospital Information System
Unidentified patients (emergency)
Un-ordered cath exams
Diagnostic and interventional procedures
Ad hoc scheduling of cath labs
Change of rooms during procedure 6 7 5 8 9 10 11 4 3 2 1
Anybody recognize this? Unfortunately it’s frighteningly familiar ! It is a typical cath lab control room. I count at least 7 monitors (there are some more in the lab room). Almost every one is a different system. On each one you need to enter the patient name and ID – the same each time (yeah, right …)

8. Administrative Process Flow
ADT
Order
Placer
Image
Manager
Acquisition
Modality
Placer Order Mgmt -
New [Rad-2]
Department System
Scheduler/ Order Filler
Procedure
Scheduled [Rad-4]
Register/
Admit
Patient
Create Order
Schedule
Registration [Rad-1]
Select
Query Modality Worklist [Rad-5]
Start

9. Procedure Performance Process Flow
Order
Department System
Image
Acquisition
Acquisition
Placer
Scheduler/ Order
Manager/
Modality
Modality n
Filler
Image Archive
Modality Procedure
Modality Procedure
Step In Progress [Card-1]
Step In Progress [Card-1]
Update Schedule
Query Modality Worklist [Rad-5]
Modality Procedure
Modality Procedure
Step In Progress [Card-1]
Step In Progress [Card-1]
Modality Images/
Perform
Evidence Stored
[Card-2]
Acquisition
Perform
Modality Images/Evidence Stored [Card-2]
Acquisition
Modality Procedure
Step Completed [Rad-7]
Modality Procedure
Step Completed [Rad-7]
Order Status
Storage
Update [Rad-3]
Commitment [Card-3]

10. Use Cases ALL Use Cases Must be Supported
Case C1: Patient Registered at ADT and Procedure Ordered at the Order Placer
Case C2: Patient Registered at ADT and Procedure Ordered at DSS/OF
Case C3: Patient Registered at ADT and Procedure Not Ordered
Case C4: Patient Registered at DSS/OF and Procedure Ordered
Case C5: Patient Not Registered
Case C6: Patient Updated During Procedure
Case C7: Change Rooms During Procedure
Case C8: Cancel Procedure
Case C9: Post-Procedure Evidence Creation
Case C10: EP Ablation / Implantation Lab
ALL Use Cases Must be Supported
Exception of C10 only required for EP Lab

11. Case C1: Patient Registered at ADT and Procedure Ordered at the Order Placer
Clinical Context
Corresponds to traditional Radiology workflow
Order placed in central system
Also deals with case where emergency identifier has been created
Common identifiers known ahead of time
IHE Context
MPPS in Progress from first modality used to update worklists for others

12. Case C2: Patient Registered at ADT and Procedure Ordered at DSS/OF
Clinical Context
Slight difference to Case 1
Order placed NOT in central system but in department
Department system provides info to Central ordering system
Typical of many institutes, relieves need for HIS terminal in lab
IHE Context
Filler Order Management (New Order) transaction [RAD-3] is sent from Department System Scheduler/Order Filler to the Order Placer.

13. Case C3: Patient Registered at ADT and Procedure Not Ordered
Clinical Context
Slight difference to Case 2
Procedural information is NOT entered at the departmental system
The first modality must initiate the process of creating common procedure identifiers (usually hemo)
The common procedure identifiers are created by the departmental system based on the information available from the first modality
Can generate a “generic cath procedure” if no coded procedural type is available
IHE Context
Upon receiving the first MPPS the DSS/OF will auto generate a Requested Procedure and its associated Scheduled Procedure Steps utilizing the Study UID provided in the first MPPS. All other modalities use the Query Modality Worklist transaction.

14. Case C4: Patient Registered at DSS/OF and Procedure Ordered
Clinical Context
This case accommodates the emergency case where there is not enough time to register the patient on ADT system
A temporary patient identifier is created at the department level
The order placer is notified only after the patient is registered and manually reconciled on the department system
IHE Context
The DSS/OF assigns a temporary Patient ID with a temporary name and schedules the required procedures
The DSS/OF does not send the Filler Order Management (New Order) transaction to the Order Placer until the patient is registered on the ADT system and reconciliation occurs on the DSS/OF.

15. Case C5: Patient Not Registered
Clinical Context
This is the Emergent Case where the patient information is not known or there is not enough time to enter the information
A temporary ID is assigned by the department and entered at the first modality and forwards that information to the departmental system to be shared with the other modalities
Like in C4 information is sent to the Order Placer post patient registration and reconciliation on the departmental system
IHE Context
Patient ID and name are selected based upon locally (usually department) base rules
The first modality will send an MPPS with the appropriate information to the DSS/OF which will in turn generate the appropriate requested procedure(s) using the Study UID assigned by the first modality

16. Case C6: Patient Updated During Procedure
Clinical Context
An unidentified patient may have been registered at the ADT and brought into the cath lab with the temporary ID
During the procedure the patient information is updated on the ADT which sends the patient update information
This can results is some of the information been associated with the temp ID and the rest with the permanent ID
The case defines how the reconciliation occurs.
IHE Context
The modality may have requested information from the DSS/OF prior the patient update
The Image Manager needs to update the items stored to Image Archive as well as any subsequent items received.

17. Case C7: Change Rooms During Procedure
Clinical Context
This is the case when the patient is moved due to any of the following reasons:
The change from a diagnostic to interventional procedure
The need to use the current room for another patient
Equipment failure
NOTE: This case does not cover the scenario where a patient is moved to the holding area from a procedure room.
IHE Context
Each modality will issue a MPS (Completed or Discontinued)
The DSS/OF will reassign the requested procedure to the new room
In the event the DSS/OF does not reassign, each modality in the new room would use the broad Modality Worklist Query
This insures consistency of the Study UID for all information

18. Case 7: Change Rooms During Procedure
Department System
Image
Scheduler/
Manager
Acquisition
Acquisition
Acquisition
Acquisition
Order Filler
Modality Room 1
Modality n Room 1
Modality Room 2
Modality n Room 2
Query Modality Worklist [Rad-5]
Modality Procedure
Modality Procedure
Perform
Step In Progress [Card-1]
Step In Progress [Card-1]
Acquisition
Update Schedule
Query Modality Worklist [Rad-5]
Modality Procedure
Modality Procedure
Step In Progress [Card-1]
Step In Progress [Card-1]
Perform
Acquisition
Modality Procedure
Modality Procedure
Step Discontinued [Rad-7]
Step Discontinued [Rad-7]
Reassign Procedure
Each modality in Room 1 issues an MPPS Discontinued
The Cath DSS/OF has an optional function to reassign the Cath Procedure to a new room, which will create SPSs for the new room modalities. If this option is not used, the DSS/OF will create SPSs for the new room modalities when it receives the MPPS In Progress (N-CREATE) from a modality in the new room.
Query Modality Worklist [Rad-5]
Modality Procedure
Modality Procedure
Perform
Step In Progress [Card-1]
Step In Progress [Card-1]
Acquisition
Update Schedule
Query Modality Worklist [Rad-5]
Modality Procedure
Modality Procedure
Step In Progress [Card-1]
Step In Progress [Card-1]
Perform
Acquisition

19. Case C8: Cancel Procedure
Clinical Context
This case allows for the information systems to keep track of cancelled procedures allowing the cath lab staff to appropriately respond to queries regarding that patient.
IHE Context
When the procedure is cancelled within the department the DSS/OF notifies the Order Placer system and Image Manager
The length of time this procedural information is maintained is determined by local policy.

20. Case C9: Post-Procedure Evidence Creation
Clinical Context
Allows for imaging and other procedural data to be analyzed post-procedure using specialized software (e.g., QCA, QLV, derived images)
This case does NOT apply to core lab analysis for clinical trials or outcome analysis
IHE Context
This analysis must be performed on a station that groups the Image Display and Evidence Creator Actors
The Evidence Creator notifies the IM/IA and DSS/OF of the activity via the MPPS In Progress and Complete transactions
The Evidence Creator stores its evidence to the IM/IA via the Storage Commit Transaction.

21. Case C10: EP Ablation / Implantation Lab
Clinical Context
Allows for the wide array of specialized equipment used in the EP lab
Provides demographic and time synchronization
IHE Context
Initial implementation is an extension of the CATH profile
Support for use cases C1 – C9
Emergency use cases C3 and C5 are highly unusual in the EP lab.
New CP

22. Agenda Cardiology Workflows General Echo Workflow
Cath Workflow
Echo Workflow
Stress Workflow
Content Display Requirements
Stress Echo
Stress
Nuclear Cardiology

23. Use Cases Case E1: Patient Registered at ADT and Procedure Ordered
Case E2: Intermittently Connected Modality
Case E3: Intermittently Connected Modality with Ad Hoc Procedure, Patient Registered, Scheduled Procedure
Case E4: Intermittently Connected Modality with Ad Hoc Procedure, Patient Registered, Unscheduled Procedure
Case E5: Intermittently Connected Modality with Ad Hoc Procedure, Patient Unregistered, Unscheduled Procedure
Case E6: Stress Echo Staged Protocol
Case E7: Echo Measurements Evidence Creation

24. Case E1: Patient Registered at ADT and Procedure Ordered
Clinical Context
Corresponds to traditional Radiology workflow
Order placed in central system
Also deals with case where emergency identifier has been created
Common identifiers known ahead of time
IHE Context
The Scheduled Procedure Steps are obtained by the modality through Query Modality Worklist, the acquisition is performed and statused thought Modality Performed Procedure Step.

25. Case E2: Intermittently Connected Modality
Clinical Context
Allows for the mobile workflow typical of TTE and TEE
Assumes the modality is only intermittently connected to the network
Also covers the case of the modality being turned off
IHE Context
Process flow identical to Case E1
Must be paired with an Image Manager/Image Archive that also supports Intermittent Connectivity
MPPS are stored and sent when connection established
Image Manage must queue N-Event Report messages for storage commitment

26. Case E3: ICM with Ad Hoc Procedure, Patient Registered, Scheduled Procedure
Clinical Context
This extends Case E2 to allow for a scheduled procedure but the modality can’t query the worklist since it is not connected to the network
IHE Context
The modality will treat this as unscheduled procedure
The patient ID and demographics must be manually entered
The modality must create the Study Instance UID
Manual matching process at DSS/OF to reconcile the scheduled and performed procedure information
Post match the DSS/OF will reconcile with the Image Manager to correct for the Study Instance UID

27. Case E4: ICM with Ad Hoc Procedure, Patient Registered, Unscheduled Procedure
Clinical Context
This is the drive by echo or Stat echo performed without an order placed in the system
IHE Context
This case is identical to other unscheduled procedure cases
Modality creates the Study Instance UID
When connected the modality will send a MPPS in Progress
DSS/OF will generate an exception for reconciliation
Patient demographic reconciliation should occur automatically based on patient ID
The Image Manager will use the Patient Update transaction to update the demographics

28. Case E5: ICM with Ad Hoc Procedure, Patient Unregistered, Unscheduled Procedure
Clinical Context
This case is similar to Case E4 except the patient is not yet registered. (Emergency Admit)
IHE Context
Temporary Name and ID entered into the modality
DSS/OF will generate an exception
Manual match of the temporary ID with the Patient Registration information
Patient Update sent to the Image Manager

29. Case E6: Stress Echo Staged Protocol
Clinical Context
Allows for appropriate identification of Stages and Views during a stress echo
IHE Context
Similar to Case E1
Type of stress protocol is specified in the Scheduled Protocol Code Sequence or Scheduled Step Description
Within the “perform acquisition” activity there are several stages but typically considered the same procedure step
A status of “Discontinued” can indicate technical failure to reach the end point of the exam.

30. Case E7: Echo Measurements Evidence Creation
Clinical Context
Measurements are normally obtained during the acquisition on the modality.
This case supports the ability to obtain additional measurements on the clinical workstation post acquisition and update the study data.
IHE Context
This case is similar to Cath C9
The actor participates in both the ECHO and ED profiles
Generation of a DICOM SR with reference to original

31. Now that I got your attention again!
Amazing Facts
Your heart beats about
70 beats per min
4200 beats per hour
100,800 beats per day
35 million times in a year.
Or more than 2.5 billion beats in your life time.
AND IT ONLY TAKES ONE IRREGULAR BEAT TO KILL YOU
Now that I got your attention again!

32. Agenda Cardiology Workflows General Stress Workflow
Cath Workflow
Echo Workflow
Stress Workflow
Content Display Requirements
Stress Echo
Stress
Nuclear Cardiology

33. So what is Stress Testing?
Uses exercise or medication to increase the work of the heart.
Continuous 12 lead ECG monitoring during study
Looking for changes in ST segments
Used as a screening tool
Or to test effectiveness of therapy
Done in Non-Invasive Lab, and Cardiologist Office

34. Stress
Image Intensive…multiple samples of 12 lead ECG during the protocol
Summary report usually one page in length
Physician will do comparisons to previous studies

35. Stress Options Stress Echo Nuclear Stress
Began in the early – mid 1990’s
Observation of wall motion and ejection fractions with the heart under stress
High specificity for correlating ischemia to functional abnormalities
Can be done with exercise but mainly chemical
Nuclear Stress
Most often combined with exercise or chemical stress testing
Use of radioisotope to detect presence and resolution of ischemic regions of the heart
Scan immediately post
Scan 4 hours to 1 day later
Resolution of ischemic area determines viability of muscle

36. Stress Workflow Diagram
Requires that Image Manager / Image Archive and Image Display support images, waveforms and structured reports
If a Report Creator wishes to participate in this profile, it does not have to support any transactions directly, however it is required to be grouped either with an Acquisition Modality, or with an Image Display in order to be able to Query/Retrieve the images, waveforms, and evidence documents. The Report Creator is expected to be able to transfer some contents of the created or retrieved objects into the reports it creates, and to send those reports in accordance with another Profile.

37. Stress Workflow – Actors and Options
Option Name
Optionality
Vol & Section
Acquisition Modality
Patient Based Worklist Query O
RAD-TF 2: 4.5
Broad Worklist Query
R (see note 1)
PPS Exception Management
RAD-TF 2: 4.7
Stress ECG
R (see note 2)
CARD-TF 2: 4.2
Stress Echo
Nuclear Medicine (see note 3)
RAD-TF 2: 4.8
Image Manager/ Image Archive
Intermittently Connected Modality R
CARD-TF 2: 4.3
Echocardiography
Availability of PPS-Referenced Instances
RAD-TF 3: 4.49
Image Display
CARD-TF 2: 4.4
Cardiac NM (see notes 3, 4)
RAD-TF 2: 4.16
Note 1: The Broad Worklist Query option facilitates effective workflow in the multimodality environment.
Note 2: An Acquisition Modality shall support one of the options Stress ECG, Stress Echo, or Nuclear Medicine.
Note 3: Nuclear Medicine (NM) is not formally an option, but is rather a separate IHE Profile. The Image Manager/Image Archive and the Image Display must support the NM Profile.
Note 4: The Image Display shall support the Cardiac NM Option of the NM Profile.

38. Use Cases Case S1: Cardiac Stress Test, ECG Only
Limited use with lower sensitivities and specificities
Screening tool only
Case S2: Cardiac Stress Test with Imaging
More common use case
Echocardiography – requires Consistent Time to combine clinical data from Stress Monitor and Echo Modality

39. Agenda Cardiology Workflows General Content Display Requirements
Cath Workflow
Echo Workflow
Stress Workflow
Content Display Requirements
Stress Echo
Stress
Nuclear Cardiology

40. Stage and Views Views Stress Echo Option Stage Number & View Number
Apical two chamber
Apical four chamber
Apical long axis
Parasternal long axis
Parasternal short axis
Parasternal short axis at the aortic valve level
Parasternal short axis at the level of the mitral chords
Parasternal short axis at the Mitral Valve level
Parasternal short axis at the Papillary Muscle level
Right Ventricular Inflow Tract View
Right Ventricular Outflow Tract View
Subcostal long axis
Subcostal short axis
Suprasternal long axis
Suprasternal short axis
Stress Echo Option
Stage Number & View Number
Stage Code Sequence & View Code Sequence
Coding
Scheme
Designator
(0008,0102)
Code Value
(0008,0100)
Code Meaning (0008,0104)
SRT P
Image acquisition at baseline P
Pre-stress image acquisition P
Mid-stress image acquisition P
Peak-stress image acquisition P
Image acquisition during recovery
Modality actors supporting the STRESS ECHO option are required to support a number of attributes in Multi-frame Ultrasound Images created for a stress echo procedure. These are transferred with the images so an image viewer that also supports the echo option can view them “unambiguously.”
A Stage is a phase in the stress echo exam protocol. A View is a particular combination of the transducer position and orientation at the time of image acquisition.
An additional option mechanism is defined in the DICOM Standard, but not required in IHE:
Names: Stage Name (0008,2120) and View Name (0008,2127) specify non-standardized textual names for Stages and Views.
While View Name (0008,2127) and Stage Name (0008,2120) enable correlating and labeling the images for display, their value sets are undefined. Therefore, IHE requires the use of coded identifiers to unambiguously describe the stage and view in the Stage Code Sequence and View Code Sequence.

41. Benefit: Stress Echo Viewing Consistency
Image Display actors supporting the STRESS ECHO option shall be able to negotiate and accept the JPEG Baseline (Process 1): Default Transfer Syntax for Lossy JPEG 8 Bit Image Compression for Ultrasound Multi-frame images, and shall support the YBR_FULL_422 photometric interpretation.
The Image Display actor may organize and present multiple images based on Stage and View for clinical comparison. Stage Number (0008,2122), View Number (0008,2128), Stage Code Sequence (0040,000A), and View Code Sequence (0008,2240) are mandated for the stress echo Modality (see section 4.2.3), and may be used by the Image Display Actor to determine the Stage and View of each image unambiguously.

42. Agenda Cardiology Workflows General Content Display Requirements
Cath Workflow
Echo Workflow
Stress Workflow
Content Display Requirements
Stress Echo
Stress
Nuclear Cardiology

43. Stress: Protocol and Stage
Procedure
Protocol
Stages

44. Stress: Protocol and Stage
Procedure : Exercise Stress
Protocol: Bruce
Stages:
Standard Bruce has 7 stages
Stage 1: % grade
Stage 7: % grade
Important Note: A procedure can be considered complete irrespective of the protocol being complete!

45. Attribute Summary Concept Modality Worklist Echo ECG NM
Requested Procedure
Requested Procedure Code Sequence (0032,1064)
Procedure Code Sequence (0008,1032)
Protocol
Scheduled Protocol Code Sequence (0040,0008)
Performed Protocol Code Sequence (0040,0260)
CID 12001*
CID 3261
CID 3261**
Protocol Stage Number
Acquisition Context Sequence (0040,0555) >(109055, DCM, “Protocol Stage”)
Patient State
Stage Number (0008,2122)
Stage Code Sequence (0040,000A)
CID 12002*
Acquisition Context Sequence (0040,0555) >(109054, DCM, “Patient State”)
CID 3262
Acquisition Context Sequence (0040,0555) >(109054, DCM, “Patient State”)
CID 3101

46. Agenda Cardiology Workflows General Content Display Requirements
Cath Workflow
Echo Workflow
Stress Workflow
Content Display Requirements
Stress Echo
Stress
Nuclear Cardiology

47. Nuclear Cardiology Image formats Color maps
Stress and Rest raw data review
Stress and Rest processed data
Gated SPECT data
Quantitative data
Screen captures, “snap shots”
Color maps
Gray scale is default
Color overlays can be applied

48. Raw Data Images

49. Perfusion Display Standard perfusion display Stress/Rest Short axis
Horizontal long axis
Vertical long axis

50. Perfusion Display - Color
Standard perfusion display
Stress/Rest
Short axis
Horizontal long axis
Vertical long axis
Color map can be overlaid on the image

51. Gated SPECT Display Apical, mid and basal short axis slices
Mid-ventricle vertical and horizontal long axis slices

52. Gated SPECT Display
The whole screen can be gated as an option

53. Quantitative Display
Output from 3rd party quantitative perfusion software can be displayed

54. Quantitative Display
Output from 3rd party quantitative gated software can be displayed

55. Screen Captures
Screen captures can be displayed to show important images