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IHE: INTEROPERABILITY AT WORK THE USA PILOT RADIOLOGY
NATIONAL IMAGE-SHARING PROGRAM
Based on presentation at the Radiological Society of North America Annual meeting in Chicago, December 2013
Written by: David S. Mendelson, M.D.
Professor of Radiology
The Icahn School of Medicine at Mount Sinai
Senior Associate - Clinical Informatics
The Mount Sinai Medical Center
Co-chair IHE International Board
Adapted and presented for the IHE Colombia IHE Workshop by:
Elliot B. Sloane, PhD, CCE, FHIMSS
Co-chair IHE International Board
President, Center for Healthcare Information Research and Policy
(CHIRP)
Image sharing- Why?
Benefit of historical exam during interpretation
Rapidly growing cost of healthcare especially growing utilization of imaging
Overutilization- Inappropriate Utilization
Prevent duplicate exam because a recent exam is inaccessible
Radiation exposure- reduction
Quality
Expedites clinical care through easy availability of imaging examination
Sharing Healthcare Information in the Cloud
Hospital
Imaging Center
Primary Doctor
Consultant
PatientPatient
Surrogate
2nd
Radiologist
2nd
Hospital
Clinical Trial
Challenges to exchange
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
Development - IHE Domains
• Anatomic Pathology
• Cardiology
• Dental
• Eye Care
• IT Infrastructure (ITI)
• Laboratory
• Patient Care Coordination
• Patient Care Devices
• Pharmacy
• Quality, Research and Public Health
• Radiation Oncology
• Radiology• Mammography
www.ihe.net
Ihe.wiki.net
ITI Profiles
XDS, XDS- I Cross Enterprise Document Sharing
XCA, XCA-I Cross Community Access
XDR, XDR-I Cross-Enterprise Document Reliable Interchange Document sharing in the absence of a registry and repository
XDM Cross-enterprise Document Media Interchange
XUA Cross Enterprise User Assertion Integration Profile
XDS-SD Cross-Enterprise Sharing of Scanned Documents
BPPC Basic Patient Privacy Consents
ATNA Audit Trail and Node Authentication
ITI- Trial implementation
Cross-Community Fetch (XCF) - Published 2011-08-19
Cross-Community Patient Discovery (XCPD) -Revised 2012-08-31
Cross-Enterprise Document Workflow (XDW) - Revised 2013-09-20
Interoperability Profiles-Radiology specific
PDI Portable Documents for Imaging IRWF Import Reconciliation Workflow TCE Teaching File and Clinical Trial Export
Trial Implementation IOCM Imaging Object Change Management MIMA Multiple Image Manager/Archive IID Invoke Image Display
Development Mobile Access to Health Documents - Imaging
Importing an Exam
Establish a standard viewing environment for clinicians for outside exams.
Allow them to designate exams for import from this environment
Import into local PACS
IHE solutions [PDI] Portable Data for Imaging provides reliable interchange of
image data and diagnostic reports on CDs for importing, printing, or optionally, displaying in a browser.
[IRWF] Import Reconciliation Workflow manages importing images from CDs, hardcopy, etc. and reconciling identifiers to match local values.
Image Share: Rationale
Medical imaging is a high-value, high-cost, rapidly expanding medical service
Current method of sharing via CDs is beset with inefficiencies and frustration
Studies show significant rates of redundant imaging procedures due to inaccessible priors
Patient empowerment is a key goal of current federal initiatives
16
NIBIB/RSNA Image Sharing Project
Consumer controls the flow of information –Patient Engagement Diminishes the need for BAAs
between enterprises Imaging Site to Clearinghouse Clearinghouse to PHR
Bootstrap an IHE based network IHE generally has not focused on
consumer driven solutions but rather on institutional and enterprise workflow
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
5 Academic Institutions
Develop a solution for all Radiology Sites
Establish a clearinghouse
Engage PHRs
A Standards Based Solution
Industry Participants
Clearinghouse
EdgeServer- in progress
lifeIMAGE
Dell
DICOMGRID
eHealthTechnologies
19
• PHRs
itMD
Image Sharing/Elements of Solution
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
Advantages of Approach
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?
RSNA Image Share- Current State 4 Academic sites are live
Mount Sinai, UCSF, University of Maryland, Mayo Clinic
Last sites are navigating local issues and hope to be live within a few months
3 Community practices are live- Oct 2013
Active discussions with approximately 15 additional sites An additional 15-20 under preliminary discussion
Version 2.1; version 3.0 just released
RSNA Image Share- Initial Patient experience Patients enrolled in production environment-
6400
Nov 23, 2013
Approximately 30% have closed the loop and used the PHR
Patient Responses
Love it!
Its about time
This is great
My doctor was really pleased to have access to my images
Problems
Couldn’t access my images
Got my images- but difficult
My doctor couldn’t see my images
Edge Server Release 3.0
New Features in Edge Server 3.0 (compared to prior version 2.1)
Site-to-site Transfer of Images for Clinical Use - Previous versions of the Edge Server support transfer of image studies only from the originating site to the Clearinghouse for retrieval into a patient’s PHR. Edge Server 3.0 adds support for retrieval of the Clearinghouse, enabling site-to-site transfer of images for clinical care.
Clinical Trials Support - Edge Server 3.0 enables anonymization of research imaging data set at field centers, which are then sent to the Clearinghouse for retrieval by a primary investigation site.
Edge Server 3.0 incorporates a unified GUI appearance for all three functional modules: system administration, clinical administration, and research administration.
Edge Server Release 3.1
More flexible sending function to address a broader range of clinical use cases
Release 3.1 adds options for sending patient information- flexible send time: Normally, after the radiologist report is final, with a delay for communication with the patient
that is configurable and set to 72 hours by default Urgently, as soon as the report is final Immediately, without waiting for the radiologist's report
Improved user convenience for patients Enables the use of patient email in place of system-generated security token Enables the reuse of a submission set ID for subsequent records of the same patient Sets password requirements at a minimum of eight characters, allowing any combination of
letters and symbols
Improved user convenience and system reliability for site personnel and administrators Provides automated resending of failed submissions Provides the option to include canceled exams in patient search results for troubleshooting
and exception resolution
Next steps - New NIBIB (NIH) contract New Funding awarded by NIH for 2 years + 2 option
years Expansion of network
Vendor Adoption of Edge Server (Open Source) Vendor migration to XDS for all services New use cases
Leverage XDS infrastructure/ network PHR HIE XDR
Edge Server as a platform QA, Comparative Effectiveness, CDS…..
Office of Civil Rights (OCR) HIPAA discussion about Privacy and Security -8/21/13
General Flow of Information is correctly implemented
OCR uggested the Clearinghouse vendor disclose dual role to patients
Validated use of email as a logon ID
Next steps and Future Direction - New NIBIB (NIH) contract
DICOM evolution Restful services Separation of Metadata from pixel data
Enables discovery Viewer
Refine Workflow Initial workflow is to replace a CD Exam updates Download DICOM data and archive in a local PACS EHR Integration
Edge server as a platform Radiation Monitoring Peer Review Quality Metrics