What’s New in IHE Integrating the Healthcare Enterprise Kevin O’Donnell Toshiba Medical Systems...

What’s New in IHEWhat’s New in IHE

Integrating the Integrating the Healthcare EnterpriseHealthcare Enterprise

Kevin O’Donnell

Toshiba Medical SystemsRita Noumeir Ph.D.

Softmedical

IHE Radiology ActivitiesIHE Radiology Activities New Supplements in 2005

– Teaching File and Clinical Trial Export(TCE)

– Cross-enterprise Document Sharing for Imaging (XDS- I)

– Radiology Option for Audit Trail and Node Authentication (ATNA)

IHE Radiology Users Handbook

PDI Demonstration and Success Stories at RSNA 2005

IHE Radiology Integration ProfilesIHE Radiology Integration Profiles

Do you we have a new updated radiology profile diagram ??

IHE IT Infrastructure ActivitiesIHE IT Infrastructure Activities Sponsored by HIMSS

9 Profiles deployed including:– ATNA: Audit Trail & Node Authentication– PIX: Patient ID Cross-Referencing– XDS: Cross-Enterprise Document Sharing

New Supplements being finalized(Public Comment June 15 - July 15)– Digital Signatures– Cross-Enterprise User Authentication– Patient Management– Notification of Document Availability

HIMSS 2005– Interoperability Showcase– Brailer Press Conference

IHE Cardiology ActivitiesIHE Cardiology Activities Sponsored by ACC, ESC, GMSIH

3 Profiles deployed:– CATH: Cardiac Cath Workflow– ECHO: Echocardiography Workflow– ECG: Retrieve ECG for Display

New Supplements being published– Displayable Reports Profile– Cath & Echo Evidence Documents

ACC 2005– First Demo very successful– ~1,300 Attendees

ASE 2005– Demo Planned – June 8-15, Boston

IHE Lab ActivitiesIHE Lab Activities

Sponsored by GMSIH, HPRIM, JAHIS

1 Profile deployed– LWF: Laboratory Scheduled Workflow

New Supplements being finalized (Public Comment June 15 – July 15)– Laboratory Point of Care– Laboratory Device Automation– Laboratory Code Set Distribution– Laboratory Information Reconciliation

New IHE DomainsNew IHE Domains IHE Radiation Oncology

– Sponsored by AAPM / ASTRO– Working on initial profiles

IHE Patient Care Coordination– Sponsored by HIMSS– New profile – “Cross Enterprise Document Sharing Content

profile : Medical Summary Document”

IHE Point of Care Devices– Sponsored by ACCE / HIMSS– Forming committees

IHE Eyecare– Sponsored by AAO– Forming domain

IHE RegionsIHE Regions New national IHE initiatives; governmental interest

IHE-North America– U.S., Canada– Demonstrations at RSNA, HIMSS, ACC– Additional Presentations at SCAR, SPIE

IHE-Europe– France, Germany, Italy, UK, Norway, Netherlands,

Spain & Denmark– Presentations/Demos at ECR, DRK, SIRM, Hopital Expo

& UKRC

IHE-Asia– Japan, South Korea, Taiwan & China– Demo at JRC

IHE ConnectathonIHE Connectathon Massive Cross-vendor Testing

– One week; dozens of vendors; thousands of tests– Opportunity to find/resolve issues

Participation is Voluntary– Litmus test not a pre-requisite or certification

Engineering event– Project Management by Mallinckrodt– Pre-Validation Tools (MESA)– Defined Test Protocols with Verification

Annual IHE ConnectathonsAnnual IHE Connectathons

IHE-North America– Connectathon in January 2005 (Chicago, IL)

45 Vendors, 110 Systems, 300 Engineers, 22 Profiles

IHE-Europe– Connectathon in April 2005 (Noordwijkerhout, Netherlands)

62 Vendors, 98 Systems, 230 Engineers, 23 Profiles

IHE-Asia– Connectathon in Feb 2005 (Yokohama, Japan)

30 Vendors, 70 Systems, 8 Profiles

IHE Radiology – Users HandbookIHE Radiology – Users Handbook SCAR 2005 – Debut of first Edition

“Using IHE” for purchasers, system integrators & users Real-world scenarios: acquiring a modality, RIS or PACS

Selecting IHE Profiles; Making the Business Case

– Based on goals (e.g. reducing errors; increasing throughput)– Identify Profiles that contribute to each goal– Find products that support those Profiles– Specify Profiles in an RFP

Installing & Operating IHE Systems

– Leverage electronic workflows– Install & Configure the systems– Do Acceptance Testing– Interface with non-IHE systems

Teaching File and Clinical Teaching File and Clinical Trial ExportTrial Export

(TCE)(TCE)

Teaching File and Clinical Trial Teaching File and Clinical Trial ExportExport

TCE Abstract/ScopeTCE Abstract/Scope

DICOM-based mechanism for connecting clinical systems to:– External teaching file systems – External clinical trial systems

Meets de-identification requirements for:– Teaching files (HIPAA)– Clinical trials (pseudonymization)


Value Proposition for CustomersValue Proposition for Customers

Brings digital imaging to traditionally film-based activities

Facilitates clinical research and grant acquisition Standardizes clinical trial data collection Improves the efficiency of teaching file production Supports meeting the Accreditation Council on

Graduate Medical Education requirements for teaching files


Value Proposition for CompaniesValue Proposition for Companies

You can add TF and CT capability to your products just by implementing the TCE profile

MIRC is available as a TF and CT Receiver– Teaching File and Clinical Trial system– In use at many universities– Selected by the NCI for clinical trial image transport– Developed, supported and promoted by the RSNA– Free & open source (mirc.rsna.org)– Supported by other CT and TF systems


Export Selector– a system that identifies information to be sent to a teaching file or clinical

trial system– example: a user at a PACS diagnostic workstation

Export Manager– de-identifies and re-identifies the images, reports, evidence documents,

presentation states and additional information with pseudonymous values– supports the Remap Identifiers option to pseudonymize the images with

the trial-specific identifiers and to populate the clinical trial specific attributes.

– sends the pseudonymized DICOM objects and an updated manifest to a Receiver.

Receiver– a local teaching file or clinical trial system– a clinical trial system responsible for transferring images to the central

review facility

Teaching File and Clinical Trial ExportTeaching File and Clinical Trial Export Example Teaching File Use CaseExample Teaching File Use Case

- Part 1: Selection -- Part 1: Selection -

Radiologist views images for primary diagnosis on Image Display grouped with Export Selector.

Export Selector allows images, series and studies to be selected “For Teaching File Export”.

Export Selector may also provide a UI allowing the user to enter text notes and select additional items (SR, KIN, GSPS, etc.) for inclusion in exported objects.

Teaching File and Clinical Trial ExportTeaching File and Clinical Trial ExportExample Teaching File Use CaseExample Teaching File Use Case

- Part 2: Export -- Part 2: Export -

User action triggers Export Selector to send objects and a Key Image Note manifest to Export Manager. – Document Title of the KIN specifies “For Teaching File Export”.

– Export Manager de-identifies objects.

Export Manager collects objects selected and sends to Receiver.– Receiver may be part of a Teaching File system.

TF system receives objects and manifest and stores them for later use by radiologist when authoring the teaching file case.

…other use cases are in the Technical Framework


Example Clinical Trial Use CaseExample Clinical Trial Use Case- Part 1: Selection -- Part 1: Selection -

A clinical trial administrator views images on Image Display grouped with Export Selector.

The Export Selector allows images, series and studies to be selected “For Clinical Trial Export”.

The administrator identifies the trial. The Export Selector sends images and a KIN

manifest to the Export Manager.– The Document Title of the KIN specifies “For Clinical Trial Export”.

– Export Manager de-identifies objects.

Teaching File and Clinical Trial ExportTeaching File and Clinical Trial ExportExample Clinical Trial Use CaseExample Clinical Trial Use Case

- Part 2: Export -- Part 2: Export -

The Export Manager collects all the objects selected and sends them to the Receiver which may be part of a Clinical Trial communication system.

The CT system receives the objects and the manifest and forwards the relevant data to the central facility of the Clinical Trial.

…other use cases are in the Technical Framework


Export SelectionExport Selection

Key Image Note used as a manifest of exported objects:– List of images and other DICOM objects– Coded Document Title

“For Clinical Trial Export” “For Teaching File Export”

– Text “disposition”– Information about the requesting user

Sent via conventional C-STORE– Not a new SOP Class


Export Selector Export Manager Receiver

Export Instances [Rad 53]

Store Export Selection [Rad 51]

Store Instances [Rad 50]

Store Additional TF Info [Rad 52]

Delay for pathology

De-identify attributes

De-identify pixel data

Re-map identifiers


Export Selector

Export Manager

Receiver

Export Instances [Rad 53]

Store Export Selection [Rad 51]

Store Instances [Rad 50]

Store Additional teaching File Information [Rad 52]

ImageArchive/Manager

PortableMedia

Creator

ImageManager/Archive

ReportManager

ReportRepository

ImageDisplay

EvidenceCreator

ReportCreator

AcquisitionModality

Cross-enterprise Document Cross-enterprise Document Sharing for Imaging (XDS- I)Sharing for Imaging (XDS- I)

Abstract / ScopeAbstract / Scope

Sharing of Imaging Information across health enterprises

Imaging Information includes – extensive sets of DICOM instances including

images, evidence documents and presentation states

– diagnostic reports provided in a "for display" form

– selection of diagnostically significant images associated with the report content

Sharing Radiology Reports and ImagesSharing Radiology Reports and Imagesin a Regional Health Information Networkin a Regional Health Information Network

Radiology Enterprise A

Radiology Enterprise B

Physician Office

Regional Health Regional Health Information Information NetworkNetwork

PACS B

PACS A

Radiology-to-radiology

Radiology-to-Physicians

Sharing Radiology Reports and ImagesSharing Radiology Reports and Imagesin a Regional Health Information Networkin a Regional Health Information Network



Physician Office


Cross-Cross-Enterprise Enterprise RegistryRegistry

Patient Id= 3547F45• Report 5/21/1998 : CT Head B• Study 5/21/1998 : CT Head B• Report 2/18/2005 : Chest Xray A• Study 2/18/2005 : Chest Xray A

PACS B

PACS A

Physicians and Systems within a Regional Health Physicians and Systems within a Regional Health Network - Routine Imaging ReferralNetwork - Routine Imaging Referral



Physician Office


Query for Query for Documents Documents

Register Imaging Register Imaging Information for Information for

sharingsharing

Priorimaging

Reports & Studies


Register Imaging Register Imaging Information for Information for sharingsharing

Patient Id= 3547F45• Report 5/21/1998 : CT Head B• Study 5/21/1998 : CT Head B

Physicians and Systems within a Regional Health Physicians and Systems within a Regional Health Network - Routine Imaging ReferralNetwork - Routine Imaging Referral



Physician Office


Register Imaging Register Imaging Information for Information for

sharingsharing


Notification of Notification of Doc AvailabilityDoc Availability

Register Imaging Register Imaging Information for Information for sharingsharing

Physicians and Systems within a Regional Health Physicians and Systems within a Regional Health Network for a Routine Imaging ReferralNetwork for a Routine Imaging Referral



Physician Office

Prior Imaging Report & Study


Query for Query for documents documents

Imaging Report Imaging Report & Study& Study


Patient Id= 3547F45• Report 5/21/1998 : CT Head B• Study 5/21/1998 : CT Head B• Report 2/18/2005 : Chest Xray A• Study 2/18/2005 : Chest Xray A

Notification of Notification of Doc AvailabilityDoc Availability

Value PropositionValue Proposition Imaging component of the Electronic Health Record:

Shared imaging Record, in a community, region, etc.

Effective means to contribute and access imaging documents across health enterprises. – Without XDS-I, access to the radiology report across health

enterprises is difficult

Scalable sharing of imaging documents between radiology departments, private physicians, clinics, long term care, acute care with different clinical IT systems.

Easy access: Care providers are offered means to query and retrieve imaging documents (images and reports) of interest – with the same mechanisms used to query other documents

Value PropositionValue Proposition Distributed: Each Care delivery organization

“publishes” imaging information for others. Actual images remain in the source/Image Manager.

Cross-Enterprise: A Registry provides an index for published information to authorized care delivery organizations belonging to the same clinical affinity domain.

Document Centric: Published clinical data is organized into “clinical documents”. using agreed standard document types (DICOM KOS, PDF and/or text report)

Document Content Neutral: Document content is processed only by source and consumer IT systems.

Standardized Registry Attributes: Queries based on meaningful attributes ensure deterministic document searches.

Document Consumer

Retrieve Document

Query Documents

Patient Identity Source

Patient Identity Feed

Document Source

Document Registry

Document Repository

Provide & Register Document Set

Register Document Set

XDS-I Actors and TransactionsXDS-I Actors and Transactions

Image ManagerImage Archive

Retrieve Images

Retrieve Presentation StatesRetrieve Key Image NoteRetrieve Evidence DocumentsWADO Retrieve

Sharing of Sharing of Extensive DICOM Extensive DICOM

Instance SetInstance Set

Document Registry

Document Repository

Manifest

Reference to image 1

DICOM Manifest


Reference to image 3Manifest Manifest

Clinical Encounter

Clinical IT System

Query Registry

Manifest

Retrieve Manifest


DICOM Manifest



Retrieve Images

Register Manifest

Manifest

Sharing of Sharing of Imaging ReportImaging Report

Radiology systemReport Source

…..

Findings:

Header:

Report Type: OB / Gyn

BPD ...…..

Radiology Report

Impressions: GestationalAge

...

Text Report

PDF Report

Text +PDF Report


Document Registry

Document Repository

Report Report

Clinical Encounter

Clinical IT System

Query Registry

Retrieve Report

Register Report

Report

…..

Findings:

Header:


BPD ...…..

Radiology Report

Impressions: GestationalAge

...

Linking Report to Selected Linking Report to Selected ImagesImages


…..

Findings:

Header:


BPD ...…..

Radiology Report

Relevant Image

GestationalAge

...WADO URI

Link to image

Radiology Option for Audit Radiology Option for Audit Trail and Node Trail and Node

Authentication (ATNA)Authentication (ATNA)

Audit Trail and Node Authentication (ATNA) + Audit Trail and Node Authentication (ATNA) + Radiology OptionRadiology OptionAbstract / ScopeAbstract / Scope

Defines basic security features for an individual system for use as part of the security and privacy environment for a healthcare enterprise.– Provides host level authentication, which is used

in conjunction with the user authentication from EUA and XUA.

– Provides audit trail mechanism for monitoring activities related to security and patient privacy

Audit Trail and Node Authentication (ATNA) + Audit Trail and Node Authentication (ATNA) + Radiology OptionRadiology Option

Compatibility with Basic SecurityCompatibility with Basic Security

“But, what if I already have systems that support Basic Security?”– ATNA + Radiology Option is backward

compatible with Basic Security– Integration Statements should change support

claim from “Basic Security” to “Radiology Option for ATNA”

ATNAATNAValue PropositionValue Proposition

Protect Patient Privacy and System Security:– Meet ethical and regulatory requirements

Enterprise Administrative Convenience:– Unified and uniform auditing system– Common approach from multiple vendors simplifies

definition of enterprise policies and protocols.– Common approach simplifies administration

Development and support cost reduction through Code Re-use:– Allows vendors to leverage single development effort to

support multiple actors– Allows a single development effort to support the needs of

different security policies and regulatory environments.

ATNA vs Basic SecurityATNA vs Basic SecurityValue PropositionValue Proposition

Why Change? Use an Audit Repository that supports more

than just imaging domains like Radiology. Use a reliable, error correcting, secure

transport for audit messages

ATNAATNASecurity MeasuresSecurity Measures

Authentication:Authentication: Establish the user and/or system identity, answers question: “Who are you?”

ATNA defines: How to authenticate network connections. ATNA Supports: Authentication mechanisms, e.g. Enterprise

User Authentication (EUA) or Cross Enterprise User Authentication (XUA)..

Authorization and Access control:Authorization and Access control:Establish user’s ability to perform an action, e.g. access to data, answers question: “Now that I know who you are, what can you do?”

ATNA defines: How to authorize network connections. ATNA requires: System internal mechanisms for both local and

network access.

ATNAATNASecurity MeasuresSecurity Measures

Accountability and Audit trail:Accountability and Audit trail:Establish historical record of user’s or system actions over period of time, answers question:

“What have you done?” ATNA Defines: Audit message format and

transport protocol

ATNAATNANode AuthenticationNode Authentication

X.509 certificates for node identity and keys TCP/IP Transport Layer Security Protocol (TLS) for

node authentication, and optional encryption Secure handshake protocol of both parties during

Association establishment:– Identify encryption protocol– Exchange session keys

Actor must be able to configure certificate list of authorized nodes.

ATNA presently specifies mechanisms for HTTP, DICOM, and HL7

ATNAATNAAuditing SystemAuditing System

Designed for surveillance rather than forensic use. Two audit message formats

– IHE Radiology interim format, for backward compatibility with radiology

– IETF/DICOM/HL7/ASTM format, for future growth DICOM Supplement 95 IETF Draft for Common Audit Message ASTM E.214 HL7 Audit Informative documents

Both formats are XML encoded messages, permitting extensions using XML standard extension mechanisms.

UPDATEUPDATE Where Is More Where Is More Information Available?Information Available?

www.ihe.net – IHE Radiology Technical Framework V5.5– IHE IT Technical Framework V1.1– IHE Lab Technical Framework V1.1– IHE Cardiology Technical Framework V1.0

– IHENews Mailing List– IHE Primer and IHE FAQ– IHE Integration Profiles: Guidelines for Buyers– IHE Presentations– IHE Connectathon Results– IHE Integration Statement Links

Ask your vendors:

Which IHE Profiles do they support on which systems?

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