IHE CardiologyIHE Cardiology

Michio KimuraMichio Kimura Hamamatsu medical schoolHamamatsu medical school

Masaaki HiraiMasaaki Hirai Nihon Kohden Co.,Nihon Kohden Co.,

Why IHE in cardiology? (1)Why IHE in cardiology? (1)

• Cardiology workflow is complexCardiology workflow is complex

• Multiple diagnostic tests are very Multiple diagnostic tests are very commoncommon– Large number of manual demographic Large number of manual demographic

input steps is common.input steps is common.– This leads to inefficiency, invalid data in This leads to inefficiency, invalid data in

clinical archives and can lower the quality clinical archives and can lower the quality of careof care

Why IHE in cardiology?Why IHE in cardiology? 　　 (2)(2)

• The Cardiology position in the IT technology The Cardiology position in the IT technology adoption cycle makes the IHE an ideal adoption cycle makes the IHE an ideal foundationfoundation

• The concepts of the IHE TF have broad The concepts of the IHE TF have broad general applicability, many can be directly general applicability, many can be directly leveraged in Cardiologyleveraged in Cardiology

• Some of Cardiology’s special requirements Some of Cardiology’s special requirements can be well met by the IHE TFcan be well met by the IHE TF

• The TF could be adapted to meet Cardiology The TF could be adapted to meet Cardiology specific needsspecific needs

MissionMission

• In order to reduce medical errors, In order to reduce medical errors, improve quality, and efficiency IHE shall improve quality, and efficiency IHE shall develop intercommunication standards develop intercommunication standards to manage order entry, acquisition, and to manage order entry, acquisition, and billing, and provide a consistent display billing, and provide a consistent display of images, waveforms, measurements, of images, waveforms, measurements, and reports leveraging existing IHE and reports leveraging existing IHE technical frameworks.technical frameworks.

Cardiac examination workflowCardiac examination workflow

Holter ECGHolter ECG

Stress ECGStress ECG LabsLabs

ECGECGPatient complaintPatient complaint Chest X-rayChest X-ray

CatheterizationCatheterizationHemodynamicsHemodynamics

Interventional ProcedureInterventional Procedure

Nucleus Nucleus EchoEcho 、、 Stress EchoStress Echo

Common needsCommon needs

• Cardiology departments have needs similar to Cardiology departments have needs similar to Radiology departmentsRadiology departments– Both are driven by imaging modalitiesBoth are driven by imaging modalities– Workflow is similar at a very high levelWorkflow is similar at a very high level– Need to manage distributed departmental Need to manage distributed departmental

resourcesresources– Desire an integrated patient-centered viewDesire an integrated patient-centered view– Need for administrative reportingNeed for administrative reporting– Need to improve lab efficiency via workflow Need to improve lab efficiency via workflow

managementmanagement– Legacy installed base technology issuesLegacy installed base technology issues

Complexity of Core DataComplexity of Core Data

• RadiologyRadiology– Diagnostic ImagingDiagnostic Imaging

• CT,MR,US,NM…CT,MR,US,NM…• Scanned FilmScanned Film

– Text ReportsText Reports– MeasurementsMeasurements

• CardiologyCardiology– Diagnostic ImagingDiagnostic Imaging

• XA, US, NM, CT, MRXA, US, NM, CT, MR

– WaveformsWaveforms• ECG, Hemo, EP, ECG, Hemo, EP,

StressStress

– Extensive numeric Extensive numeric measurementsmeasurements

– Lab data Lab data – Complex ReportsComplex Reports

• Stress,Holter, CathStress,Holter, Cath

Cardiology Workflow ElementsCardiology Workflow Elements

• Workflow elements in common with Workflow elements in common with Radiology:Radiology:– Patients are admittedPatients are admitted– Demographics entered (often multiple Demographics entered (often multiple

times for the same patient)times for the same patient)– Imaging studies are performed and readImaging studies are performed and read– Reports generatedReports generated

Cardiology Workflow ElementsCardiology Workflow Elements

• Additional Workflow elements:Additional Workflow elements:– Echo, ECG & lab data often prerequisites Echo, ECG & lab data often prerequisites

to treatmentto treatment– Consumable materials and clinical data Consumable materials and clinical data

tied to procedures tied to procedures – Monitoring data is part of the Cath Monitoring data is part of the Cath

procedureprocedure– Echo as follow on to a Cath procedureEcho as follow on to a Cath procedure– Interpretation generally uses multiple Interpretation generally uses multiple

clinical inputsclinical inputs

Scheduled Workflow “Works” for CardiologyScheduled Workflow “Works” for Cardiology

HISDICOMImage

Manager/Archive

&Report

Repository

Patient

Demographics,

Schedules

DMWLMPPS

DMWL

MPPS

ECG

ECG LAB

ECHO

ECHO LAB

CATH

CATH LAB

HEMODYNAMICS

PatientDemographics,

Schedules

Patient Demographics,

Schedules

Storage Commitment

Storage Commitment

Images & Reports

Waveform

& Report

Waveform & Report

CIS(Performed Procedure Step Mgr,

Order Placer/FillerActors)

ADT,OMG,ADT,OMG,(ORM)(ORM)

Image & Reports

Scheduled Workflow “Works” for CardiologyScheduled Workflow “Works” for Cardiology

• Minimizing redundant demographic Minimizing redundant demographic input and producing valid header data in input and producing valid header data in the clinical archive is important in the clinical archive is important in CardiologyCardiology– Multiple modality inputs of Cardiology Multiple modality inputs of Cardiology

drives the valuedrives the value– Basic problem is well addressed by the Basic problem is well addressed by the

Scheduled Workflow and Patient Scheduled Workflow and Patient Reconciliation Integration Profiles in IHE Reconciliation Integration Profiles in IHE Year 3Year 3

Patient Information Reconciliation Profile “Works” for Patient Information Reconciliation Profile “Works” for CardiologyCardiology

• Extends Scheduled WorkflowExtends Scheduled Workflow– Handle unidentified patient (e.g. emergent)Handle unidentified patient (e.g. emergent)– Handle demographic information mistakesHandle demographic information mistakes– Propagate changes to all affected systems, Propagate changes to all affected systems,

update all affected dataupdate all affected data

• Reduces incorrectly identified or “lost” Reduces incorrectly identified or “lost” studiesstudies

• Can reduce lost charge postings (billing)Can reduce lost charge postings (billing)

Easy Wins for IHE in CardiologyEasy Wins for IHE in Cardiology

• Workflow in the Cath lab can be Workflow in the Cath lab can be streamlinedstreamlined– Minimize data re-entryMinimize data re-entry– Automate pre-fetchingAutomate pre-fetching

• Since Scheduled Workflow leverages Since Scheduled Workflow leverages DICOM MPPS, near real time updates DICOM MPPS, near real time updates on Cath procedure status are possibleon Cath procedure status are possible

• DICOM SR and Waveform allow the DICOM SR and Waveform allow the use of a common DICOM archive for use of a common DICOM archive for waveform and imaging systemswaveform and imaging systems

Connectivity ChallengesConnectivity Challenges

• DICOM MPPS is a limiting capability for DICOM MPPS is a limiting capability for integrating Cardio modalities.integrating Cardio modalities.– NewNew Imaging modalities are starting to have IHE Imaging modalities are starting to have IHE

Modality Actor support, but the legacy installed Modality Actor support, but the legacy installed base will be an integration challenge.base will be an integration challenge.

• Waveform modalities need to either adopt Waveform modalities need to either adopt DICOM modality messaging and storage or DICOM modality messaging and storage or the IHE TF needs to be extended to allow the IHE TF needs to be extended to allow HL7 or “other” methods.HL7 or “other” methods.– There are underlying standards (IEEE, SCP-ECG) There are underlying standards (IEEE, SCP-ECG)

that could be leveraged by the IHE in the future.that could be leveraged by the IHE in the future.– MFER(ISO 11073-92001) is available.MFER(ISO 11073-92001) is available.

Clinical Challenges in Cardiology for the IHEClinical Challenges in Cardiology for the IHE

• IS driven order creation in Cardiology is not IS driven order creation in Cardiology is not generally availablegenerally available

• GSPS and Key Image Note have value, but GSPS and Key Image Note have value, but are clearly limited todayare clearly limited today– Cardiologists use motion images and color data Cardiologists use motion images and color data

that depicts cardiac functionthat depicts cardiac function

• Simple Image and Numeric ReportsSimple Image and Numeric Reports– Pictorial diagrams for anatomy, function and Pictorial diagrams for anatomy, function and

viability are needed for clinical reportsviability are needed for clinical reports– Extensions to manage specific frames of cine Extensions to manage specific frames of cine

objects and waveform objects would be neededobjects and waveform objects would be needed

Other Technology ChallengesOther Technology Challenges

• Some Cardiology tasks are still hard to Some Cardiology tasks are still hard to “do digital”“do digital”– Pediatric Echo is just now able to enter the Pediatric Echo is just now able to enter the

digital era digital era • Huge volume of data required to “do a search Huge volume of data required to “do a search

mission” on a tiny fast beating heartmission” on a tiny fast beating heart• Extensive measurements needed to Extensive measurements needed to

understand the clinical situationunderstand the clinical situation

– EP data volumeEP data volume– Real-time critical care monitoring Real-time critical care monitoring

Modality Connectivity in CardiologyModality Connectivity in Cardiology

• Critical care monitoring is out of scope Critical care monitoring is out of scope for now.for now.

• Waveform systems are challenging.Waveform systems are challenging.– Some Hemo systems and ECG information Some Hemo systems and ECG information

systems support HL7 ADT and ORM systems support HL7 ADT and ORM messaging allowing functionality similar to messaging allowing functionality similar to DICOM MWL.DICOM MWL.

– Others have proprietary connectivity Others have proprietary connectivity capabilities which could be “rigged” to capabilities which could be “rigged” to enable MWL “style” modality messagingenable MWL “style” modality messaging

Cardiac Cath/EchoCardiac Cath/Echo Actors & TransactionsActors & Transactions

Pt. Registration [RAD-1]

Patient Update [RAD-12]

Pt. Registration [RAD-1] Patient Update [RAD-12]

Placer Order Management [RAD-2] Filler Order Management [RAD-3]

ADT

Query Images [RAD-14]Retrieve Images/Evidence [CARD4]

ImageDisplay

Modality Image/Evidence Stored [CARD-2] Storage Commitment [CARD3-1]

Procedure Scheduled [RAD-4]

Procedure Updated [RAD-13]

Query Modality Worklist [RAD-5]

PerformedProcedureStep Mgr

Modality PS in Progress [CARD-1]Modality PS Completed [RAD-7]

Modality PS in Progress [CARD1]Modality PS Completed [RAD-7]

Modality PS Completed [RAD-7]

Order Placer

AcquisitionModality

ImageManager

ImageArchive

DSS/ Order Filler

Patient Update [RAD-12]

Modality Image/Evidence Stored [CARD-2]

Storage Commitment [CARD-3]

EvidenceCreator Modality PS in Progress [CARD-1]

Modality PS Completed [RAD-7]

Query Evidence [RAD-44]

Instance Availability Notification [RAD-49]

Modality PS in Progress [CARD-1]

Cardiac Cath Workflow Use CasesCardiac Cath Workflow Use Cases

• Case C1:Case C1: Patient Registered at ADT and Procedure Ordered at the Patient Registered at ADT and Procedure Ordered at the Order PlacerOrder Placer

• Case C2:Case C2: Patient Registered at ADT and Procedure Ordered at Patient Registered at ADT and Procedure Ordered at DSS/OFDSS/OF

• Case C3:Case C3: Patient Registered at ADT and Procedure Not Ordered Patient Registered at ADT and Procedure Not Ordered

• Case C4:Case C4: Patient Registered at DSS/OF and Procedure Ordered Patient Registered at DSS/OF and Procedure Ordered

• Case C5:Case C5: Patient Not Registered Patient Not Registered

• Case C6:Case C6: Patient Updated During Procedure Patient Updated During Procedure

• Case C7:Case C7: Change RoomsChange Rooms During Procedure During Procedure

• Case C8:Case C8: Cancel Procedure Cancel Procedure

• Case C9:Case C9: Post-Procedure Evidence Creation Post-Procedure Evidence Creation

EchoEcho Use Cases Use Cases

• Case E1:Case E1: Patient Registered at ADT and Procedure Ordered Patient Registered at ADT and Procedure Ordered

• Case E2:Case E2: Intermittently Connected ModalityIntermittently Connected Modality

• Case E3:Case E3: Intermittently Connected ModalityIntermittently Connected Modality with Ad Hoc Procedure, with Ad Hoc Procedure, Patient Registered, Scheduled ProcedurePatient Registered, Scheduled Procedure

• Case E4:Case E4: Intermittently Connected ModalityIntermittently Connected Modality with Ad Hoc Procedure, with Ad Hoc Procedure, Patient Registered, Unscheduled ProcedurePatient Registered, Unscheduled Procedure

• Case E5Case E5: : Intermittently Connected ModalityIntermittently Connected Modality with Ad Hoc Procedure, with Ad Hoc Procedure, Patient Unregistered, Unscheduled ProcedurePatient Unregistered, Unscheduled Procedure

• Case E6:Case E6: Stress Echo Staged Protocol Stress Echo Staged Protocol

• Case E7:Case E7: Echo Measurements Echo Measurements

Displayable Reports (DRPT) Displayable Reports (DRPT)

• Case R1:Case R1: Report manager provides local storage and distribution of Report manager provides local storage and distribution of reportsreports

• Case R2:Case R2: Image manager/archive provides storage and distribution of Image manager/archive provides storage and distribution of reportsreports

• Case R3:Case R3: Multiple Reports on one Requested Procedure Multiple Reports on one Requested Procedure

• Case R4:Case R4: Preliminary, Final and Corrected Reports Preliminary, Final and Corrected Reports

ECG Profile Transaction DiagramECG Profile Transaction Diagram

Display InformationSource

Retrieve Specific Info for Display [ITI-11]Retrieve ECG List [CARD-5]

Retrieve ECG Document for Display [CARD-6]

ECG NeedsECG Needs

• ECGs Accessible Everywhere!ECGs Accessible Everywhere!• Need broad distribution of ECGs using Need broad distribution of ECGs using

ubiquitous technology (Web).ubiquitous technology (Web).– Allow medical applications to easily retrieve and Allow medical applications to easily retrieve and

display ECGs in a platform/vendor neutral way.display ECGs in a platform/vendor neutral way.• High-quality ECG documents. Avoid artifacts High-quality ECG documents. Avoid artifacts

on zoomed ECGs and arbitrary display on zoomed ECGs and arbitrary display geometries.geometries.– Vector images required (not rasterized)Vector images required (not rasterized)

• Facilitate apps for serial comparison (side-by-Facilitate apps for serial comparison (side-by-side synchronized display).side synchronized display).

MFERMFER

ECG Profile Abstract / ScopeECG Profile Abstract / Scope

• Provide ECGs and related documents to Provide ECGs and related documents to enterpriseenterprise

• Reuse IHE-ITI RID Reuse IHE-ITI RID – Retrieve list of documents; retrieve single Retrieve list of documents; retrieve single

documentdocument– ECGs served in ready-to-display format (MFER,ECGs served in ready-to-display format (MFER,

[PDF, SVG [PDF, SVG **IHE-J optionIHE-J option])])

• Limited extension for ECG-specific needsLimited extension for ECG-specific needs– Add requirements on display format and qualityAdd requirements on display format and quality– [Include XML-based ECG report list [Include XML-based ECG report list **IHE-J optionIHE-J option]]

Out of ScopeOut of Scope

• ECG acquisition and reading workflow.ECG acquisition and reading workflow.

• ECG raw data interchange.ECG raw data interchange.

• Export of reports to external repository.Export of reports to external repository.

• Central management and configuration Central management and configuration of ECG devicesof ECG devices

ECG Profile Value PropositionECG Profile Value Proposition

• Use ubiquitous HTTP Get mechanism as Use ubiquitous HTTP Get mechanism as defined in IHE-ITI RIDdefined in IHE-ITI RID– Standardized URLsStandardized URLs

• USE MFER(ISO11073-92011) for ECG USE MFER(ISO11073-92011) for ECG display display **IHE-J national extentionIHE-J national extention

• [Use PDF for easy integration with existing [Use PDF for easy integration with existing display applications display applications **IHE-J optionIHE-J option]]

• [PDF vector graphics supports scalable [PDF vector graphics supports scalable waveforms waveforms **IHE-J optionIHE-J option]]

• [XML list of ECGs for serial comparison apps [XML list of ECGs for serial comparison apps **IHE-J optionIHE-J option]]

MFER:ISO/11073-92001 MFER:ISO/11073-92001 (measuring R-R interval with caliper)(measuring R-R interval with caliper)

MFER zoom-in view (measuring with scale)MFER zoom-in view (measuring with scale)

CDA report with MFERCDA report with MFER

Example ECG in (vector)PDF FormatExample ECG in (vector)PDF Format

Example ECG in SVG FormatExample ECG in SVG Format

ECG Profile ActorsECG Profile Actors

• DisplayDisplay – A system that can request and – A system that can request and display preformatted (“presentation-ready”) display preformatted (“presentation-ready”) data using Web technologies.data using Web technologies.

• Information SourceInformation Source – A system that – A system that responds to requests for patient-related ECG responds to requests for patient-related ECG data by encoding it in a presentation-ready data by encoding it in a presentation-ready format using Web technologies.format using Web technologies.

• Same actors as RID ProfileSame actors as RID Profile

ECG Profile TransactionsECG Profile Transactions

• Retrieve Specific Info for Display [ITI-11]Retrieve Specific Info for Display [ITI-11]– Uses HTTP Get query parameters “SUMMARY” or Uses HTTP Get query parameters “SUMMARY” or

“SUMMARY-CARDIOLOGY”“SUMMARY-CARDIOLOGY”– [Response list of documents (including ECGs) in ready-to-[Response list of documents (including ECGs) in ready-to-

display format (XHTML) display format (XHTML) **IHE-J optionIHE-J option]]

• Retrieve ECG List [CARD-5]Retrieve ECG List [CARD-5]– Uses HTTP Get query parameter “SUMMARY-Uses HTTP Get query parameter “SUMMARY-

CARDIOLOGY-ECG”CARDIOLOGY-ECG”– [Response list of ECGs in processable format (HL7 RIM-[Response list of ECGs in processable format (HL7 RIM-

derived XML) derived XML) **IHE-J optionIHE-J option]]

• Retrieve Retrieve ECG ECG Document for Display Document for Display [CARD-6][CARD-6]– MFERMFER– [Response ECG served in PDF [Response ECG served in PDF **IHE-J optionIHE-J option]]– [SVG allowed if Display actor asks for it and Information [SVG allowed if Display actor asks for it and Information

Source supports it Source supports it **IHE-J optionIHE-J option]]

Use Case D1: Simple DisplayUse Case D1: Simple Display

• Display actor requests list of ECG documents Display actor requests list of ECG documents for a specific patient ID.for a specific patient ID.– RID profile SUMMARY-CARDIOLOGY request returns list RID profile SUMMARY-CARDIOLOGY request returns list

as HTML.as HTML.– [ECG profile SUMMARY-CARDIOLOGY-ECG request [ECG profile SUMMARY-CARDIOLOGY-ECG request

returns list as XML with stylesheet. returns list as XML with stylesheet. **IHE-J optionIHE-J option]]

• Display actor requests a specific ECG Display actor requests a specific ECG document using a unique document ID.document using a unique document ID.– The ID of the requested document may not have The ID of the requested document may not have

been obtained from the previously retrieved list.been obtained from the previously retrieved list.

MFER:ISO/11073-92001 MFER:ISO/11073-92001 (measuring R-R interval with caliper)(measuring R-R interval with caliper)

Use Case D2: Advanced DisplayUse Case D2: Advanced Display

• Display actor requests list of ECG documents Display actor requests list of ECG documents for a specific patient ID using ECG profile for a specific patient ID using ECG profile request type.request type.– [List of ECGs returned as structured XML. [List of ECGs returned as structured XML. **IHE-J optionIHE-J option]]

• Display actor parses structured document list Display actor parses structured document list to select related ECGs for serial comparison, to select related ECGs for serial comparison, for example.for example.

• Display actor requests the specific ECG Display actor requests the specific ECG documents using the unique document IDs documents using the unique document IDs obtained in structured list above.obtained in structured list above.

• Display actor displays the ECGs in a Display actor displays the ECGs in a meaningful waymeaningful way

Advanced MFER ECG display (3x4)Advanced MFER ECG display (3x4)

Advanced MFER ECG display (6x2)Advanced MFER ECG display (6x2)

IHE exhibition show IHE exhibition show in Japanese Circulation Society conferencein Japanese Circulation Society conference

Future profilesFuture profiles

• HemodynamicsHemodynamics

• IVUSIVUS

• Data harvestingData harvesting

• Stress ECG/EchoStress ECG/Echo

• Holter ECGHolter ECG