Waveform, Workflow, Archiving…

Assessment of Standard Interfaces

Opportunities for Cooperation

Three Levels for Connectivity Standards

DeviceConnectivity

DepartmentalIntegration

Hospital/AmbulatoryWorkflow

EMR Integration

Radiology

Cardiology

ICU

ImagingModalitiesImage proc.CAD, …

RISR-PACS

AD

TO

rder P

lacerE

MR

, …Cap

tors,

Actu

ator

s

Bed-SideMonitors Cluster

MonitorICUIS

Cardiac MonitorsHemodynamics

Rest, Stress, Holter ECG CardiacIS, C-PACS

En

terprise A

rchive

1073HL7

DICOM

DICOM

SCP ?HL7 ?DICOM ?1073 ?

Three Examples Overlap Coordination Needed

Three Topics, Three Opportunities ?

1. Persistent Waveform Objects

2. Departmental Workflow Integration

3. Enterprise Archiving of Images & Waveforms

DICOM WaveformsQuick Refresher

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.

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)

Streams of

Waveform Samples

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

Waveforms Standardization for Departemental Integration

-Key Objectives-

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

Departmental Workflow Integration

DICOM and HL7…..

Much more than combining standards !

Store ImagesStore Images

Storage CommitmentStorage CommitmentStorageStorage

CommitmentCommitment

List of ImagesList of Images

PACS &PACS &ArchiveArchive

RISRIS

ModalityModalityPerformedPerformedProcedure Procedure StepStep

Performed Step:Performed Step:

Status = CompletedStatus = CompletedPerformed CT HeadPerformed CT HeadPat Name/ID, Dose, Pat Name/ID, Dose,

Accession #, Study UIDAccession #, Study UIDComplete List of ImagesComplete List of Images

A Closed LoopA Closed Loop•Update IS SchedulingUpdate IS Scheduling

•Match Procedure with OrderMatch Procedure with Order•Support Billing Based on MPPSSupport Billing Based on MPPS

•Avoid Reading incomplete ProceduresAvoid Reading incomplete Procedures

IHE Scheduled Workflow

Modality WorklistModality Worklist

WorklistWorklist

Procedure Scheduled (HL7)Procedure Scheduled (HL7)

Patient Registration/UpdatePatient Registration/UpdateOrder Management (HL7)Order Management (HL7)

AcquisitionModality

AcquisitionModality

Structuring the Departmental Workflow with an Enterprise perspective

ORDERA request for RadiologicService

Radiology Department

Set of Codifiable,

Billable, ActsOne or more series of images

PerformedProcedure

Step P1

ScheduledProcedure

Step B

RequestedProcedure

1

ScheduledProcedure

Step A

Report

One or more series of images

PerformedProcedure

Step P2

DICOMModality Worklist

DICOMModality Worklist

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).

Enterprise Archiving of Images and Waveforms

1: Pt registration 12: Pt Update

Pt Registration: 1 Pt Update: 12 2: Placer Order Management

3: Filler Order Management

ADT

14: Query Images 15: Query GSPS 16: Retrieve Images 17: Retrieve GSPS 30: Query Key Image Notes 31: Retrieve Key Image Notes

Image Display

Storage Commitment: 10

8: Modality Image Stored 9: Modality GSPS Stored 29: Key Image Notes Stored

Storage Commitment: 10

18: Creator Image Stored 19: Creator GSPS Stored 29: Key Image Notes Stored

4: Procedure Scheduled 11: Image Availability Query 12: Patient Update 13: Procedure Update

5: Modality Worklist Provided

Image Creator

PerformedProcedure

Step Manager

ImageManager

ImageArchive

6: Modality PPS in Progress 7: Modality PPS Completed 20: Creator PPS in Progress 21: Creator PPS Completed

6: Modality PPS in Progress 7: Modality PPS Completed 20: Creator PPS in Progress 21: Creator PPS Completed

6: Modality PPS in Progress 7: Modality PPS Completed

20: Creator PPS in Progress 21: Creator PPS Completed

Order PlacerOrder Filler

PrintServer

AcquisitionModality

PrintComposer 23: Print Request

with presentation LUT

24: Report Submission

Structured Report Export: 28

25: Report Issuing

Report Creator

26: Query Reports 27: Retrieve Reports

26: Query Reports 27: Retrieve Reports

Report Repository

Report Reader

External Report RepositoryAccess

Report Manager

Enterprise Report Repository

Charge Processor

36: Account Management 35: Charge Posted

33: Maintain Time

Secure Node

Time Server

Secure Node

32: Authenticate Node

Audit Report Repository

34: Record Audit Event

34: Record Audit Event

Post-ProcessingManager 37: GP Worklist Provided

38: GP Workitem Claimed 39: GP Workitem Completed 40: GP PPS In Progress 41: GP PPS Completed

PerformedWork StatusUpdate: 42

IHE Integration Profiles

Access to Radiology InformationConsistent access to images and reports

Consistent Presentation of Images

Hardcopy and softcopy grayscale presentation state

Key ImageNotes

Flag significant images

Simple Image and Numeric Reports

Simple reports with image links and, optionally,

measurements

Basic SecurityAudit 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

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.

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 : ihe@rsna.org

Store ImagesStore Images

Storage CommitmentStorage CommitmentStorageStorage

CommitmentCommitment

List of ImagesList of Images

PACS &PACS &ArchiveArchive

RISRIS

ModalityModalityPerformedPerformedProcedure Procedure StepStep

Performed Step:Performed Step:

Status = CompletedStatus = CompletedPerformed CT HeadPerformed CT HeadPat Name/ID, Dose, Pat Name/ID, Dose,

Accession #, Study UIDAccession #, Study UIDComplete List of ImagesComplete List of Images

A Closed LoopA Closed Loop•Update IS SchedulingUpdate IS Scheduling

•Match Procedure with OrderMatch Procedure with Order•Support Billing Based on MPPSSupport Billing Based on MPPS

•Avoid Reading incomplete ProceduresAvoid Reading incomplete Procedures

IHE Scheduled Workflow

Modality WorklistModality Worklist

WorklistWorklist

Procedure Scheduled (HL7)Procedure Scheduled (HL7)

Patient Registration/UpdatePatient Registration/UpdateOrder Management (HL7)Order Management (HL7)

Enterprise Archiving of Images and Waveforms

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.

Enterprise ArchivingDICOM : 10 years of experience

EnterprisePersistent Objects

Repository

DepartmentalIS System

RIS, PACS, CIS, etc.

Study/Patient

Series

PersistentObject Instance

Store (Class/Instance UID)

Storage Commitment

Retrieve (Instance UID)

Store (Class/Instance UID)

Media Interchange (Inst. + DIR)

Query (Study Root)

WebAccessNative or presented forms

Transparent PersistentObject Payload (except for Class)

Web Access to Persistent DICOM Objects

Retrieve one "entire document" (either in a presentation view or as a data set) using its "Persistent Document Instance UID"

Persistent ObjectsRepository

ClientAccessingHealthcareDocuments

e.g.EPR

Retrieve a "presentation view"

Retrieve a "Data Set"

"Form ofthe reference"

"Form ofthe reference"

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

Intent is not to offer a "Query":- Need is only to get access to an object

Waveforms Standardization for Departemental Integration

-Key Objectives-

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