Integrating the Healthcare EnterpriseIntegrating the Healthcare Enterprise

Applying the IHE Framework to Applying the IHE Framework to CardiologyCardiology

Joseph BiegelJoseph BiegelMitraMitra

IHE Planning CommitteeIHE Planning Committee

HIMSS 20022

Applying the IHE to Applying the IHE to Cardiology - TopicsCardiology - Topics

• QuickQuick IHE Overview IHE Overview

• Motivations for IHE in Cardiology?Motivations for IHE in Cardiology?

• Common and distinct needs in Common and distinct needs in CardiologyCardiology

• Data Complexity and WorkflowData Complexity and Workflow

• Applying Scheduled Workflow in Applying Scheduled Workflow in CardiologyCardiology

• Challenges and next steps…Challenges and next steps…

HIMSS 20023

What is IHE about?What is IHE about?

• It’s an initiative promoting and It’s an initiative promoting and supporting the integration of systems in supporting the integration of systems in the healthcare enterprise.the healthcare enterprise.

• Integration Goal: Improve the efficiency Integration Goal: Improve the efficiency and effectiveness of clinical practice by:and effectiveness of clinical practice by:– Improved Information FlowImproved Information Flow– Advanced Multi-System FunctionsAdvanced Multi-System Functions

HIMSS 20024

Why is IHE needed?Why is IHE needed?

• Serious Integration Challenges in Healthcare:Serious Integration Challenges in Healthcare:

• Systems need Information other systems haveSystems need Information other systems have

• But, systems communicate poorly or not at all But, systems communicate poorly or not at all

• Result: - tedious, inefficient workflows Result: - tedious, inefficient workflows - data that is inconsistent or unavailable - data that is inconsistent or unavailable

Responsibility for information flow between systems, Responsibility for information flow between systems, and between departments, is often unclear.and between departments, is often unclear.

HIMSS 20025

Who is IHE?Who is IHE?

• Participants:Participants:– Professional Societies (RSNA/HIMSS/…)Professional Societies (RSNA/HIMSS/…)– Vendors (over 30 companies)Vendors (over 30 companies)– Standards Group Committee MembersStandards Group Committee Members

• RSNA and HIMSS sponsor IHE to RSNA and HIMSS sponsor IHE to provide a neutral forum for working on provide a neutral forum for working on the Big Picture the Big Picture

HIMSS 20026

What Does IHE Do?What Does IHE Do?• Users and vendors work together to identify Users and vendors work together to identify

and design solutions for integration problemsand design solutions for integration problems

• Intensive process with annual cycles:Intensive process with annual cycles:– Identify key healthcare workflows and integration Identify key healthcare workflows and integration

problemsproblems– Research & select standards to specify a solutionResearch & select standards to specify a solution– Write, review and publish IHE Technical FrameworkWrite, review and publish IHE Technical Framework– Perform cross-testing at “Connectathon”Perform cross-testing at “Connectathon”– Demonstrations at tradeshows (RSNA/HIMSS)Demonstrations at tradeshows (RSNA/HIMSS)

HIMSS 20027

Aren’t DICOM / HL7 Sufficient?Aren’t DICOM / HL7 Sufficient?

• Standards are vital (HL7, DICOM, ICD, Standards are vital (HL7, DICOM, ICD, …)…)– They provide tools & technologiesThey provide tools & technologies

• But Standards alone are insufficientBut Standards alone are insufficient– They are open to interpretationThey are open to interpretation– There is room for optional variationsThere is room for optional variations– They avoid specifying how to apply them to They avoid specifying how to apply them to

particular real world scenariosparticular real world scenarios

HIMSS 20028

How is IHE related to Standards?How is IHE related to Standards?• IHE attacks real world integration problemsIHE attacks real world integration problems

• HL7 and DICOM provide dictionariesHL7 and DICOM provide dictionaries

• IHE defines a “phrasebook” that solves real IHE defines a “phrasebook” that solves real world problems by assembling pieces world problems by assembling pieces provided by DICOM/HL7provided by DICOM/HL7

HIMSS 20029

What are What are Key IHE ConceptsKey IHE Concepts??

• Generalized Systems Generalized Systems -> -> ActorsActors

• Interactions between Actors Interactions between Actors -> -> TransactionsTransactions

• Problem/Solution ScenariosProblem/Solution Scenarios -> -> IntegrationIntegration ProfilesProfiles

• For each Integration Profile:For each Integration Profile:

• the context is described (which real-world problem)the context is described (which real-world problem)

• the actors are defined (what systems are involved)the actors are defined (what systems are involved)

• the transactions are defined (what must they do)the transactions are defined (what must they do)

HIMSS 200210

imagesstored

patientinformation

RIS

examination orders

imagesretrieved

HIS

PACS

procedurescheduled

Prefetch any relevantprior studies

modalityworklist

report

report

Scheduled Workflow ProfileScheduled Workflow Profile

Registration

Orders Placed

Orders Filled

Film

FilmFolder

Image Manager& Archive

FilmLightbox

report ReportRepository

DiagnosticWorkstation

Modality

acquisitionacquisitionin-progressin-progressacquisitioncompleted

acquisitioncompleted

imagesprinted

AcquisitionModality

HIMSS 200211

RadiologyRadiology

That’s nice, but it is That’s nice, but it is Radiology…Radiology…

Henry Gray (1825–1861).  Anatomy of the Human Body.  1918.http://www.bartleby.com/107/illus490.html

ardiologyardiology

CardiologyCardiology

HIMSS 200212

Patient Patient ComplaintComplaint

Nuclear StudyNuclear Study

LabsLabsCathCathHemoHemo

Interventional ProcedureInterventional Procedure

EchoEcho

PhysicianPhysician

ECGECG

CardiologistCardiologist

Simplified view of CardiologySimplified view of Cardiology

HIMSS 200213

Why IHE in Cardiology?Why IHE in Cardiology?

• 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

HIMSS 200214

Why IHE in Cardiology (2) ?Why IHE in Cardiology (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

HIMSS 200215

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

HIMSS 200216

Distinct Cardiology NeedsDistinct Cardiology Needs

• Clinical data content is more complexClinical data content is more complex– Procedural data with rich report contentProcedural data with rich report content

• Direct tie to billingDirect tie to billing

– Clinical results data mining is a priorityClinical results data mining is a priority

• Cardio departments are often more Cardio departments are often more driven/isolated by subspecialtydriven/isolated by subspecialty

• Legacy installed base without clear Legacy installed base without clear connectivity path is largeconnectivity path is large

• Strong individual patient focus than a system Strong individual patient focus than a system or procedure focusor procedure focus

• Cardio departments are revenue centersCardio departments are revenue centers

HIMSS 200217

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, StressECG, Hemo, EP, Stress

– Extensive numeric Extensive numeric measurementsmeasurements

– Lab data Lab data – Complex ReportsComplex Reports

• Stress,Holter, CathStress,Holter, Cath

HIMSS 200218

Cardiology Workflow Cardiology Workflow ElementsElements

• 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

HIMSS 200219

Cardiology Workflow Cardiology Workflow ElementsElements

• 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

HIMSS 200220

Scheduled Workflow “Works” Scheduled Workflow “Works” for Cardiologyfor 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

HIMSS 200221

Patient Information Reconciliation Patient Information Reconciliation Profile “Works” for CardiologyProfile “Works” for Cardiology

• 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, update Propagate changes to all affected systems, update

all affected dataall affected data

• Reduces incorrectly identified or “lost” studiesReduces incorrectly identified or “lost” studies• Can reduce lost charge postings (billing)Can reduce lost charge postings (billing)

HIMSS 200222

Can you “Just Do It”?Can you “Just Do It”?

• We have done some investigations and We have done some investigations and prototype clinical testing to examine the utility prototype clinical testing to examine the utility of applying the concepts of Scheduled of applying the concepts of Scheduled Workflow and Patient ReconciliationWorkflow and Patient Reconciliation

• Key PiecesKey Pieces– HIS, “RIS”, Modality & PACSHIS, “RIS”, Modality & PACS

• The HIS is the sameThe HIS is the same

• So far this is easy…So far this is easy…

HIMSS 200223

Modality Connectivity in Modality Connectivity in CardiologyCardiology

• Imaging Modalities often have at least Imaging Modalities often have at least some DICOM servicessome DICOM services– DICOM Store SCU support common in DICOM Store SCU support common in

new systemsnew systems– Some legacy conversion solutionsSome legacy conversion solutions– DICOM MWL becoming common DICOM MWL becoming common – DICOM MPPS and Storage Commitment DICOM MPPS and Storage Commitment

“getting there”“getting there”

• That was the good news…That was the good news…

HIMSS 200224

Modality Connectivity in Modality Connectivity in CardiologyCardiology

• 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 messaging.enable MWL “style” modality messaging.

HIMSS 200225

The Cardiology “RIS” (CIS)The Cardiology “RIS” (CIS)

• Ask 10 people what a CIS is and you Ask 10 people what a CIS is and you will get 9 answers…will get 9 answers…

• One of the key elements we need is an One of the key elements we need is an electronic source of order and schedule electronic source of order and schedule data that drive department workflow and data that drive department workflow and support OP/OF and PPS Manager support OP/OF and PPS Manager ActorsActors

• This is often not readily available in This is often not readily available in Cardiology departments todayCardiology departments today

HIMSS 200226

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

Images & Reports

Waveform

& Report

Waveform & Report

Scheduled Workflow in CardiologyScheduled Workflow in Cardiology

CIS(Performed Procedure Step Mgr,

Order Placer/FillerActors)

ADT,ORMADT,ORM

HIMSS 200227

Easy Wins for IHE in Easy Wins for IHE in CardiologyCardiology

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

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

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

HIMSS 200228

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.

HIMSS 200229

Clinical Challenges in Clinical Challenges in Cardiology for the IHECardiology 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

HIMSS 200230

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

HIMSS 200231

IT, the CIO and That IT, the CIO and That Archive…Archive…

• The IT department and the CIO should The IT department and the CIO should become strong advocates for moving become strong advocates for moving the IHE into Cardiologythe IHE into Cardiology– As IHE’s track record grows in Radiology As IHE’s track record grows in Radiology

integration projects, “doing it again down integration projects, “doing it again down the hall” begins to form a value proposition the hall” begins to form a value proposition for IT managementfor IT management

– Leverage common archive infrastructureLeverage common archive infrastructure

HIMSS 200232

ConclusionsConclusions

• The value is clear.The value is clear.– Applying and extending the IHE to Cardiology Applying and extending the IHE to Cardiology

could save millions of dollars in product could save millions of dollars in product development costsdevelopment costs

– It could improve the quality and efficiency of careIt could improve the quality and efficiency of care

• IHE Scheduled Workflow and Patient IHE Scheduled Workflow and Patient Reconciliation Integration Profiles are nearly Reconciliation Integration Profiles are nearly ready to go in Cardiology.ready to go in Cardiology.

• There are challenges.There are challenges.• Need to extend the Technical Framework for Need to extend the Technical Framework for

some Cardiology specific needs.some Cardiology specific needs.

HIMSS 200233

What Should You Do Now?What Should You Do Now?

• Require support or at least a clear upgrade Require support or at least a clear upgrade path to “Acquisition Modality Actor” for new path to “Acquisition Modality Actor” for new imaging system RFP’s and purchase imaging system RFP’s and purchase specifications specifications

• Hug your Cardiologist and tell them a bit Hug your Cardiologist and tell them a bit about why they need to know about the IHE…about why they need to know about the IHE…

• Help to build support within the key clinical Help to build support within the key clinical professional societiesprofessional societies– Have your CIO talk to the Cardiology chair and Have your CIO talk to the Cardiology chair and

say, “I need your help so that I can help you”…say, “I need your help so that I can help you”…

HIMSS 200234

Questions?Questions?