Client Server Interoperability Training Reference Guide-PACS

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Introduction

This section of the Client Server Training Reference Guide (TRG) demonstrates how to setup your PACS interface suite within the ITS application. This section of the TRG is used in conjunction with the MIS section of the TRG during your training call.

Table of Contents

I. Overview.............................................................................................................................2

II. Specifications......................................................................................................................3

III. Setup...................................................................................................................................4

A. Orders Outbound..........................................................................................................4

B. Reports/Results Outbound...........................................................................................5

C. Status Updates Inbound...............................................................................................6

D. EMR Image Launch.....................................................................................................8

IV. Considerations and Notes.................................................................................................10

V. Modules and Routines Affected........................................................................................15

A. ITS..............................................................................................................................15

B. EMR............................................................................................................................15

VI. Testing Notes....................................................................................................................16

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I) Overview

PACS (Picture Archiving Communication System) is a completely film-less electronic imaging system designed to process, report, read, archive and store medical images. These images can be viewed in multiple locations simultaneously and can be sent to various departments for viewing. Interfaces will send patients’ demographic information as well as orders and reports to the PACS system. With in the PACS system images are stored and linked to the Orders/Reports. Once linked and an image is available, MT will get back an image status update message containing a URL for any images that are available from PACS. ITS will then send this information to the EMR.

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II) Specifications

ADT Outbound

R404: HL7 MEDITECH MAGIC C/S Admissions System to Other Vendor Ancillary System

The ADT interface provides for the transmitting of new or updated demographic and visit information about patients.

Orders Outbound

R948: MEDITECH MAGIC C/S Imaging and Therapeutic Services HL7 Orders to Other Vendor Image Viewing System

The Order interface provides for the transmission of orders or information about orders between MEDITECH ITS and the PAC's Vendor(Broker)s applications that capture the order. An order is a request for material or services, usually for a specific patient from another vendor.

Reports Outbound

R949: HL7 MEDITECH MAGIC C/S ITS Reports to Other Vendor Image Viewing System

The Report interface provides for the transmission of results/reports on the patients order to send from MEDITECH ITS to the PAC's Vendor(Broker)s applications that capture the report and associate it to the order/images.

Image Status Update Inbound

R953: Other Vendor Image Status Updates to MEDITECH Imaging and Therapeutic Services Application

The Update interface will give an order status update from PACS to ITS. The status update indicates the number of picture available, and can update the order status, when images have been reviewed by the radiologist.

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III). Setup (ITS/EMR)

Customer Defined Parameters:

A). Orders (ORM Messages):

For PAC's orders to be sent to the Other Vendor, via. the interface, the Category must be linked as the “Outbox Recipient” to the interface:

Category Dictionary:

ITS -> Dictionaries (A-O) -> Category -> Enter/Edit 1. F9 Lookup in the "Mnemonic" field. (IE: Select CT for Cat Scan) 2. On Page 1 tab, verify that the "Outbox Recipients" list contains the mnemonic for the PACS Orders interface (IE: ITS ORD PACS).

This will need to be repeated for each category interfacing to PACS.

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B). Reports/Results (ORU Messages):

For PAC's reports to be sent to the Other Vendor, via. the interface, the Department must be linked as the “Outbox Recipient” to the interface:

Department Dictionary:

ITS -> Dictionaries (A-O) -> Department -> Enter/Edit 1. F9 Lookup in the "Mnemonic" field. (IE: Select DI for Diagnostic Imaging) 2. On Page 2 tab, verify that the "Rpt Outbox Recipients" list contains the mnemonic for the PACS Reports/Results interface (IE: ITS RES PACS). 3. Verify the "Temp Pats" field is "N" This will need to be repeated for each department interfacing to PACS.

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C). Status Updates (ORM Messages):

The Primary function of the Order Status Updates Interface is to notify the MEDITECH HCIS that an Image is available and to give "directions" on how to access the image. Contained within this message will be an image status indicator (OBR|25) as well as the image launch information (OBX|5). This message is sent to MEDITECH once an image is loaded into the PAC's system and is linked to the Order/Report in the PAC's system.

For URL Image Viewing, there are two mechanisms available. You will need to identify from the PAC's Vendor whether they are sending a partial or complete URL for the image.

1. FULL URL Launch, denoted with 'RP' in OBX|2 . MEDITECH will store the entire URL string passed in OBX| 5 of the status updates message, and simply pass this string to the browser when a user invokes the Image Launching functions within the MEDITECH ITS and EMR applications

For FULL URL, OBX|5 should contain the pointer or Java Bean URL to the image, the length cannot be more than 256 characters. e.g. http://123.456.789.10:80/WaveletBeanServlet?patient_id=M1000 &accession_number=12345.001&user=epr&password=epr 2. DYNAMIC URL, denoted with 'ST' in OBX|2. If a partial URL is being sent, find out from the PACS vendor what the constant (static) part will be. The value passed as the partial URL in OBX|5 of the status updates message is stored as the PACS ID Field within the ITS application. The PACS ID Field is appended to the BASE URL (static portion). The static portion of the URL is stored within the MEDITECH ITS Tool Box. This Parameter is entered by MEDITECH. The DYNAMIC URL approach provides the flexibility to change the base location of the server, while keeping the reference pointers associated to the ITS Order functionally intact. In filing of the URL this way, it allows for the Image Launch functionality in EMR and ITS. For example, if the base parameter for an order is: http://123.456.789.10:80/WaveletBeanServlet? and OBX 5 was valued as: patientid=V12345&study_id=7486716735.173676 The dynamically generated URL for the order in question would be: http://123.456.789.10:80/WaveletBeanServlet?patientid=V12345&study_id=7486716735.173676

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WORKFLOW

When a status message from PACS arrives with one of the PACS status (OBR|25) below, the order status in ITS will automatically be updated to “Taken”, and a 'SC' Order Message will be sent to the Other Vendor.

OBR|25 (TABLE 9002) - PACS OBJECT STATUS

This field contains the status sent by the Other Vendor. The Other Vendor values will be mapped to MEDITECH values. Value Description

1 Object has been registered from modality 2 Object has been verified (QA’s) 4 Object has been Reported

1 = REGISTERED This is the process in which MEDITECH accepts the image into the system and matches it up with the order that was submitted through the HL7 orders interface. 2 = VERIFIED This status is by the Other Vendor when a QA technician modifies any image orientation, add annotations, etc. The QA technician will at this time verify that all images that were acquired from a modality are now present on the PACS. At this point a diagnosis is feasible as a full complement of images are available. 4 = REPORTED This notification is when the Radiologist has viewed ALL images for a given procedure and physically accepts the images as part of the diagnosis. The images will no longer be able to be modified or changed. This is also generally at the time of dictation of the report. 8 = ARCHIVED This is the notification when the image is officially burnt onto long-term media. This is a future enhancement that is not yet available. MEDITECH will map the codes as follows: PACS Value MEDITECH Value

1 (Registered) Taken 2 (Verified) Images Available 4 (Reported) All Images Read

8 (Archived) “A” will be displayed in the EMR to indicate that the image has been Archived by PACS (Future Enhancement).

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D). EMR Image Launch:

1. Camera Icon:

The EMR application has a camera icon that can be used to view PAC's images. A PACS image can not be viewed in EMR until the image status is at least the value contained in the "Image EMR Status" field.

To access PACS images via the camera icon in EMR the following minimum parameters need to be set in ITS. ITS -> Dictionaries (P - Z) -> Parameters -> Enter/Edit Customer Defined Parameters:

1. Set the "Image Taken Status" to Registered

Here you have the choice of Registered, Verified, or Reported

2. Set the "Image EMR Status" to Registered.

Here you have the choice of Registered, Verified, or Reported. This is the status at which PACS info is sent to the EMR.

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2. To allow for the viewing of images with a file maintained order in EMR:

Procedure Dictionary:

ITS -> Dictionaries (P-Z) -> Procedure -> Enter/Edit

The "Save History" prompt for all procedures that will have PACS images filed should be set to Yes. This will allow images on file maintained orders to be viewed in the EMR. If this prompt is set to No, an image will not be viewable in the EMR after the procedure has purged from ITS.

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IV). Considerations and Notes

MEDITECH Defined Parameters:

1). ADT – Patient Demographic Information

Provide a List of Inpatient Facilities that you will need the ADT information from in the Other Vendor System:

2). Other Vendor Information:

A. Who is the Broker?

B. Who is the PAC's Vendor?

3). IMAGE STATUS UPDATE

Identify if the PACS broker is sending a partial or complete URL for the image.

A. If they are sending a partial URL:

What is the Constant Part of the URL?

4) The following are known changes when the Other Vendor is FUJI

Both ITS rpts and ITS orders to OV PACS

Send 2 digit Exam Modality in OBR:18 and OBR:2 - Customization is necessary in

the Radiology application to capture this. C/S uses a MIS MAP Dictionary to

accomplish this same goal of mapping Category to Modality.

We can call the Map 'FUJIMAPS' and can be for both Orders and Reports.

(This is needed if the site has category mnemonics larger then 2 characters.

The DICOM limit is 16 characters for the Order Number)

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ADT to FUJI

1. Add the Facility Mnemonic to MSH:4 of the ADT

ITS rpts to OV PACS

1. Remove \H\ formatting character from outbound report msgs in OBX:5 segment.

2. Send a separate report msg for every order attached to a rpt.So if 3 orders

are attached to 1 rpt, send 3 rpt msgs one for each order.

3. Send the value normally sent in OBR:18 in OBR:2 instead of the order control

#. using the following format CCYYYYMMDD-TTTT (Standing for category,

year,month,day and test#)

4. Send the full PID segment that is currently being sent in the Orders.

5. Send Procedure Code and Description in OBR:4 as it is currently being sent in

the Order. This is in the format: Cat Mnemonic.Proc Mnemonic^Proc Description.

6. Send the Requested Date/Time in OBR:6 as it is currently being sent in the

Order.

ITS orders to OV PACS.

1. Send the response to the "Are you Pregnant" CDS query and the "Reason for

Exam" CDS query in PV1:15 and OBR:31.2 respectively. Site needs to give us

specific query mnemonics.

2. Send the value normally sent in OBR:18 in OBR:2 instead of the order control

#. using the following format CCYYYYMMDD-TTTT (Standing for category,

year,month,day and test#)

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Situational

3. If the site hasn't previously set up Right/Left Indicators in the Procedure

Description, capture a CDS and send it in OBR:15.1.

OV order status updates to MT ITS

1. Accept inbound msgs without OBX segments,

2. Expect the value now sent in OBR:2 for the outbound orders and rpt msgs in

OBR:2 of the inbox msg and use this value as the URL to be attached to the

base URL stored in ITS.

Note:

-----

The changes outline above are based on previous Fuji implementations. It is

important that you review these changes with your Fuji contact and inform your

MEDITECH Interoperability specialist if additional customization is needed.

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5) The following are known changes when the Other Vendor is Amicas

Admissions Custom:

------------------

- Suppress OBX segments. OBX segments are used for Height and Weight

information

- Combine Admissions and Orders/Reports connections to use one TCP/IP port.

(Note: The customers who get results on a separate port are using an

interface engine. If MEDITECH is feeding the AMICAS server directly,

everything needs to be sent to the same port)

Order and Results Customs:

--------------------------

- Send 2 digit Exam Modality in OBR|21 and OBR|24

(uses the MIS MAP Dictionary to map Category to Modality)

- Suppress Category from formatting in OBR|4.1

- Send Accession Number in OBR|3 as well as OBR|2

- Send Service Date/Time in OBR|7

- Send Report status in OBX|11 as well as OBR|25

- Suppress all but Signed Reports

- Map "S", or signed, status to "F", or Final, status for both OBX|11 and 25

- Ensure AL1 segment after PV1 segment in order per RAD DTS 2397

- Format one ORC/OBR pair in Report message for each associated order

(with "RE" as the ORC code for the last order)

- Change Status code from "SC" to "XO", and send all New Orders that were

created as amends of original orders with "NW"

Send Reason for Exam Query in OBR 31

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Status Update custom:

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- Ignore "RP" in OBX 2 of status update and process url as full url

Note:

-----

The changes outline above are based on previous Amicas implementations. It is

important that you review these changes with your Amicas contact and inform your

MEDITECH Interoperability specialist if additional customization is needed (i.e.

reformatting of the accession number).

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V). Modules and Routines Affected

A. ITS (Imaging and Therapeutic Services) From the Technologists Desktop, perform a Find Patient. The Find Patient routine will list all the procedures ordered for that patient. Select the procedure and then the Images button on the right side of the screen. The Images screen will allow the Technologist to view the order information, order and report statuses, and the image associated with the order. The technologist can select the image and click launch at the bottom of the screen to view the PACS image directly in ITS.

B. EMR (Enterprise Medical Record) Once the images have been associated to an order in ITS and the “Image EMR Status” has been met, images can be displayed in EMR. Once in EMR, select the patient and then “Imaging.” This will display a list of Exams/Reports for the patient. If there are images associated with the exam, there will be a camera in the “Image” column. The images can be viewed by clicking on the camera icon. MEDITECH does not suspend the EMR client session or control the PACS viewer.

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VI). Testing:

1. PAC's Software must be loaded on the client in order to view images.

Place an order in ITS at a logged status. Once the “PACS Taken Status” is reached as defined in the Customer Defined Parameters, ensure that the order status has been automatically updated to “Taken” in Process Orders.

In Process Orders on the “M” button go to the routine “View PACS Information.” From here you should be able to view PACS status information and PACS images should be viewable.

Once the PACS EMR Status is reached as defined in the Customer Defined Parameters ensure that the image icon (camera) for that order associated to the patient is in the EMR. The image icon should be found on the Imaging panel in the EMR. Click on the image icon and the PACS viewer should automatically launch the appropriate image.

Go to Enter/Edit Report in ITS and transcribe a report on the appropriate account # and associated the order(s) with the image attached. Next, go into the dictating doctor’s sign queue and click on the “S” button or Sign Document button while highlighting the appropriate document. If there are viewable images for the orders associate with that report; there should be a special function key on the toolbar at the top of the page. This key should launch PACS and you should be able to view the images.

(The following steps should be taken with an image associated to an ITS order)

Disassociate an order from a report and associate the order to another report. Ensure that the order and the image are now displaying with the correct order/report in the EMR.

Cancel a report with an associated order/image. Ensure that the order and image camera icon display with the order and not with the canceled Radiology Report under the Imaging Panel in the EMR.

Disassociate an image from an ITS order and associate it to another Order. Ensure that the EMR is displaying the camera icon next to the appropriate order/report under the Imaging Panel.

2. Testing Checklists are available at the following links:

ADT Outbound

R404: HL7 MEDITECH MAGIC C/S Admissions System to Other Vendor Ancillary System

https://www.meditech.com/prnmi/pages/NMIcbASguide404adt.htm

Orders Outbound

R948: MEDITECH MAGIC C/S Imaging and Therapeutic Services HL7 Orders to Other Vendor Image Viewing System

https://www.meditech.com/prnmi/pages/NMIcbASguide948its_orders_image_view.htm

Reports Outbound

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R949: HL7 MEDITECH MAGIC C/S ITS Reports to Other Vendor Image Viewing System

https://www.meditech.com/prnmi/pages/NMIcbASguide949its_reports_image_view.htm

Image Status Update Inbound

R953: Other Vendor Image Status Updates to MEDITECH Imaging and Therapeutic Services Application

https://www.meditech.com/prnmi/pages/NMIcbASguide953itsimagestatusupdates.htm