Image Sharing

Review and Update

2011

Image Sharing

David S. Mendelson, M.D.

Professor of Radiology

Chief of Clinical Informatics

The Mount Sinai Medical Center

Co-chair IHE International Board

• Benefit of historical exam during interpretation• Rapidly growing cost of healthcare especially

growing utilization of imaging– Overutilization– Prevent duplicate exam because a recent exam is

inaccessible• Radiation exposure• Quality

– Expedites clinical care through easy availability of imaging examination

Image sharing- Why?

• What is our product?

• Who are our customers?

• What are the mechanisms of sharing?

• What are the impediments?– Technology– Policy

Issues that govern sharing Imaging Exams

• Imaging Exam– Order– Direct patient history– Prior exams

• Report– Demographics

• Referring Clinician• Reporting Team

– Indication– Narrative

• Procedure– Impression– Structured report

Our Product – Information!






Patient Radiology Physician

2nd Radiology

Consulting Physician

Clinical Trial

Patient






• Are you old enough to remember film?

• Still exists– Clinical offices

Film

• Portable

• Compact

• Can hold thousands of images

• Inexpensive ($0.50 or less)

• What’s wrong here?

The “CD”- “better than sliced bread” or “be careful what you ask for – you may get it”

• Different data formats– Non-Dicom

• Different viewers– End-user confusion

• Defective Discs• Disc must be in your possession• Patient Identity• Wrong Patient on Disc• Time consuming• Clinician’s are confused

– They share their confusion with their Radiologist

CDs- Problems

Help!

• Importing a disc provides the opportunity to correct• Robust import solutions -commercial

– Standard import interface• Reconciliation process

– Trained personnel• Standards

– DICOM– PDI extensions (IHE- Portable Documents for Imaging)– BIR- (IHE- Basic Image Review)

• Minimum requirement for review

CD- Opportunities to improve

• Mail• RIS• FAX• E-Mail• PACS

– VPN• Internet

– EMR-Patient Portal– PHR

Mechanisms of Sharing- Reports

When to release a Report vs. Image?

• The patient is entitled– Legal– Practical

– Is the patient prepared for the information in the report?

• Immediate use to clinician

• May be meaningless to most patients other than a curiosity

• Replace the CD (SneakerNet) with the Internet

• Convenience vs. Security

• New opportunities– Shared Image processing

• Efficiencies

Network/Internet base sharing

• Proprietary applications– Usually used within an enterprise or a limited

domain with legal agreements

• Health Information Exchange (HIE)– Multiple enterprises with a set of legal agreements– Often have selected their own standards- not truly

open standards based– Sustainability

Network/Internet base sharing

• VPN/Enterprise Portal– Clinical Staff– Patient– Temporary credentials

• Enterprise- multi-sites; proprietary solution– Multiple PACS and RIS feed one central archive– All credentialed can view that archive

• Point to Point networks• HIE

– Standards based or proprietary sharing network• IHE model

• Patient Centric model / PHR

Network/Internet

• Who pays for an exchange infrastructure• What is the persistence of the information in the exchange• Are images different from other forms of healthcare data• Easy secure access is good for the patient

– Does it endanger the provider?- is this an impediment?– Economic adjustments and evolution are likely to occur

• Balance of cost control vs. Quality• Reduction in Radiation exposure

– Not all patients agree

Challenges to exchange

• A limited number of entities establish direct connections

• Usually requires a direct formal relationship (legal)

• Can be successful to address very specific interoperability problems

• Doesn’t scale

Point to Point

• Requires legal relationships between participants• Requires patient identity management• Enables a greater number of entities to participate

– May be scalable– HIE to HIE

• Consent issues– Commonly all or nothing rather than episode or event based

– Patients may wish to only expose limited pieces of data

HIE

Sharing Healthcare Information in the Cloud

Hospital

Imaging Center

Primary Doctor

Specialist

Hospital

Patient Patient Surrogate

Cloud Computing

• WHO

• Enterprise• HIE• Consumer

• WHAT

• Services• Transactions• Archive

• XDS.a

• XDS- I.a

• XDS.b– ?? XDS-I.b

• a vs. b– Related to web standards and transactions

IHE-XDS (Cross-Enterprise Document Sharing)

XDS

XDS-I

Canada Health Infoway

NIBIB/RSNA IMAGE SHARING PROJECT

A Standards Based Solution

• NIBIB contract

• Bootstrap an IHE based network– Primary emphasis is Consumer Control through

PHRs– Can be extended to other forms of sharing

• HIE

• Security and Confidentiality are drivers

• Replacement / Alternative to CD

Goals of Contract

NIBIB contract summary

• Consumer Control• Employ IHE solutions

whenever possible– IHE generally has not

focused on consumer driven solutions but rather on institutional and enterprise workflow

• 5 Academic Institutions– Mayo Clinic– Mount Sinai Medical

Center– University of California

San Francisco– University of Chicago– University of Maryland

• Establish a clearinghouse• Engage PHRs• 300,000 patients over 2

years

• Edge Server– Register a patient– Listens to a Radiology Information System (RIS)- looking for a

complete exam– Retrieves Image set from PACS and Report from RIS– Send both to clearinghouse

• PHI hidden; an RSNA ID and 2nd factor security token are used to identify the patient

• Clearinghouse (XDS-I) – functions as a secure router– Transiently hold encrypted patient data

• PHR– Consumer controls upload and future access

• Must have RSNA ID available and know answer to 2nd factor question– Develop web based viewers– Download full DICOM data set

• Misc Consumers

Image Sharing/Elements of Solution

Protocol Flow

Web/JavaSrv

MIRTHHL7

DICOM

From RIS

Dbase

OS

PACS Qry/Rtrv

Firewall

Clearing House

XDS.b &

token

Edge Appliance

ADMIN

RSRCH

Software architecture

Prepare content Poll database, get report, get exam,prepare big fat file

Background java srvlet 25 days

Transfer content Poll database for transfer out, package content into xds.b

Background java srvlet 35 days

HL7 receiver Receive HL7 A04 messages, extract reports and store them in database

Mirth HL7 Channel. Let Mirth create its default database, all script work-but may have to customize per site

65 days for 5 sites

Token App Create new tokens based on two parts, associate token with accession numbers, update database, user interface with login, get patient info,create job

Ajax based web front-end ,JavaServlet for CFIND using dcm4che, creating job in the RSNA database, creating tokens using kerberos – tokens generated locally

30 days

Database Store reports, logs, audit trails, user accounts, etc.

Mirth instance for HL7 & DICOM, RSNA instance for everything else

50 days – 2 databases

Management App Create users, monitor logs, check health

Ajax gui front end, backend servlet, dicom targets etc.

45 days

• Security is paramount– Restrictive policy– PHI is never unsecured

• Consumer controls the flow of information by placing it in the PHR– Diminishes the need for BAAs between enterprises

• Imaging Site to Clearinghouse• Clearinghouse to PHR

Project design assumptions

Image Enabled PHR

Report

• Push model– No Query of PACS from outside the firewall

• Full DICOM data set is available– Web viewers– Download and Import to PACS

• Report is available• Historical exams can be sent simultaneously• Consumer controls flow of information

– Affords the patient the ability to select what information to share

• Is this good?

Advantages of Approach

• Refine Workflow– Initial workflow is to replace a CD– Exam updates– Download DICOM data and archive in a local PACS

• Edge server as a platform– Radiation Monitoring– Peer Review– Quality Metrics

Future Directions

• CTP is a stand-alone program that provides all the processing features of a MIRC site for clinical trials in a highly configurable and extensible application. It connects to FieldCenter applications and can also connect to MIRC sites when necessary. CTP has the following key features:

• Single-click installation.• Support for multiple pipelines.• Processing pipelines supporting multiple configurable stages.• Support for multiple quarantines for data objects which are rejected during processing.• Pre-defined implementations for key components:

– HTTP Import– DICOM Import– DICOM Anonymizer– XML Anonymizer– File Storage– Database Export– HTTP Export– DICOM Export– FTP Export

• Web-based monitoring of the application's status, including:– configuration– logs– quarantines– status

Research CTP- The RSNA Clinical Trial Processor






• We live in a heterogeneous world needing multiple solutions• CDs and portable media have both advantages and drawbacks

– Compliance with standards helps• We are transitioning to network/internet solutions

– Security and confidentiality are even more difficult– ONC and State policies will foster these solutions– Solutions are evolving

• Proprietary solutions are often easier to implement• Solutions based on open standards will provide the patient with greater

flexibility• Interoperability will require an adjustment to the way we all think of healthcare

data

Conclusions