IHE Educational Workshop 2005 1
IHE Cardiology IHE Cardiology Profiles for Year 1Profiles for Year 1
Tom Dolan, Philips
Co-editor, IHE Cardiology Technical Committee
IHE Educational Workshop 2005 Dolan – p. 2
Presentation structurePresentation structure
IHE Cardiology profile context– What we are covering and why
Cardiology Catheterization Workflow– Overview, benefits, actors/transactions,
highlights
ASSUMPTIONS– Basic understanding of IHE concepts from
earlier sessions
IHE Educational Workshop 2005 Dolan – p. 3
Three profiles selected for year 1Three profiles selected for year 1Cardiac Catheterization Workflow– Based on IHE Radiology Scheduled Workflow and
Patient Information Reconciliation Profiles
Echocardiography Workflow– Based on IHE Radiology Scheduled Workflow and
Patient Information Reconciliation Profiles
Retrieve ECG for Display– Based on IHE IT Infrastructure Retrieve
Information for Display Profile
IHE Educational Workshop 2005 Dolan – p. 4
Why Why thesethese profiles? profiles?
High return on investment - important integration
problems
Standards in place (DICOM, HL7)
Leverage IHE Radiology and IT Infrastructure
No “political” challenges – just technical
Restricted scope for “quick win”
IHE Educational Workshop 2005 Dolan – p. 5
Cath LabCath Lab
(A) room for improvement !(A) room for improvement !
IHE Educational Workshop 2005 Dolan – p. 6
Cath Workflow ManagementCath Workflow Management Multi-Modality, Multi-Modality, IntraIntra-Lab issues-Lab issues
Multiple re-entry of Patient ID
Error prone
Results fragmented across systems
Custom solutions needed for data sharing
Difficult to manage
IHE Educational Workshop 2005 Dolan – p. 7
Cath Workflow Cath Workflow Management Management ExtraExtra-lab issues -lab issues
Un-ordered cath exams (emergency)Unidentified patientsUncoordinated with Hospital Information SystemDiagnostic and interventional proceduresAd hoc scheduling of cath labsChange of rooms during procedure… and interactions among these issues!
IHE Educational Workshop 2005 Dolan – p. 8
Cardiac Catheterization WorkflowCardiac Catheterization Workflow- What’s in?- What’s in?
Management of cath exams (in-lab portion)– Similar to IHE-Radiology SWF
– Multi-modality, multiple procedure steps
Reconciliation of patient information– Similar to IHE-Radiology PIR
– Unscheduled cath is the norm, not the exception
Time synchronization– Modalities must support IHE-ITI Consistent Time
IHE Educational Workshop 2005 Dolan – p. 9
Pre-cath and post-cath activity
Hemo waveforms and reports*
Procedure logs
QCA/QVA*
Final cath reports*
Supply chain*Archives must support storage, but no actors specified for display
Cardiac Catheterization WorkflowCardiac Catheterization Workflow- What’s OUT?…for year 1- What’s OUT?…for year 1
But on the 5-But on the 5-year year
roadmap!roadmap!
Diagnostic Procedure
Post- Procedure
Events
End of Episode
Event
Long-Term Follow-Up
Intervention (optional)
…
Addressed in Year 1
Admission to
Facility
Pre- Procedure Evaluation
Report
Amended Report
(optional)
Export to Registry
(optional)
IHE Educational Workshop 2005 Dolan – p. 10
Actors/Transactions take-awayActors/Transactions take-away
NO new actors– Same actors as Radiology scheduled
workflow
4 “modified” transactions– Existing Radiology-based transactions
have been modified to accommodate cardiology specifics
IHE Educational Workshop 2005 Dolan – p. 11
Cardiac Cath – 8 use casesCardiac Cath – 8 use casesAll use cases must be supported
Case C1: Patient Registered at ADT and Procedure Ordered at the Order Placer
Case C2: Patient Registered at ADT and Procedure Ordered at DSS/OF
Case C3: Patient Registered at ADT and Procedure Not Ordered
Case C4: Patient Registered at DSS/OF and Procedure Ordered
Case C5: Patient Not Registered
Case C6: Patient Updated During Procedure
Case C7: Change Rooms During Procedure
Case C8: Cancel Procedure
IHE Educational Workshop 2005 Dolan – p. 13
BenefitsBenefitsSimplify Management of Cath exams (In Lab)– High-value, high-complexity workflow addressed
Basic lab-centric workflow addressed Worklist-driven for speed and accuracy Solid basis for extension in future
Reuse of existing standards – Similar to IHE-Radiology SWF means savings in training,
development and reduced risk– But cath-specific issues addressed
Aim to remove the integration-barriers compromising efficiency and safety between cath-modalities/vendors
IHE Educational Workshop 2005 Dolan – p. 14
ACTORSACTORSAcquisition Modality – A system that acquires and creates medical images or waveforms while a patient is present, e.g., an X-ray angiography or hemodynamic measurement system. A modality may also create other evidence objects such as Structured Report Documents containing measurements.
ADT – A system responsible for adding and/or updating patient demographic and encounter information (Admission/Discharge/Transfer). In particular, it registers a new patient with the Order Placer and Department System.
Department System Scheduler/Order Filler – A department-based (for instance, Cardiology or Radiology) information system that provides functions related to the management of orders received from external systems or through the department system’s user interface.
Image Archive – A system that provides long term storage of evidence objects such as images, presentation states, Key Image Notes and Evidence Documents.
IHE Educational Workshop 2005 Dolan – p. 15
ACTORSACTORSImage Display – A system that offers browsing of patients’ studies. In addition, it may support the retrieval and display of selected evidence objects including sets of images, presentation states, Key Image Notes, and/or Evidence Documents.
Image Manager – A system that provides functions related to safe storage and management of evidence objects. It supplies availability information for those objects to the Department System Scheduler.
Order Placer – A hospital or enterprise-wide system that generates orders for various departments and distributes those orders to the correct department.
Performed Procedure Step Manager – A system that re-distributes the Modality Performed Procedure Step information from the Acquisition Modality to the Department System Scheduler/Order Filler and Image Manager.
Time Client – A system unit that synchronizes its time of day clock to the correct time provided by a time server
IHE Educational Workshop 2005 Dolan – p. 16
TRANSACTIONSTRANSACTIONSPatient Registration – The ADT system registers and/or admits a patient and forwards the information to other information systems. [RAD-1]
Placer Order Management – The Order Placer informs the Order Filler of the initiation or cancellation of an order. The Placer/Filler Order Management transaction will sometimes be referred to as “-New” when a new order is being initiated, or as “-Cancel” when an existing order is canceled. [RAD-2]
Filler Order Management – The Order Filler informs the Order Placer of the initiation, cancellation, or change in the status of an order. The Placer/Filler Order Management transaction will sometimes be referred to as “-New” when a new order is being initiated, or as “-Cancel” when an existing order is canceled. [RAD-3]
Procedure Scheduled – Schedule information is sent from the Department System Scheduler/Order Filler to the Image Manager. [RAD-4]
Query Modality Worklist – Based on a query entered at the Acquisition Modality, a modality worklist is generated listing all the items that satisfy the query. This list of Scheduled Procedure Steps with selected demographic information is returned to the Acquisition Modality [RAD-5].
Modality Procedure Step In Progress – An Acquisition Modality notifies the Performed Procedure Step Manager of the start of a new Procedure Step and the PPS Manager informs the Department System Scheduler/Order Filler and Image Manager. [CARD-1, derived from RAD-6]
IHE Educational Workshop 2005 Dolan – p. 17
TRANSACTIONSTRANSACTIONSModality Procedure Step Completed – An Acquisition Modality notifies the Performed Procedure Step Manager of the completion of a Procedure Step and the PPS Manager informs the Department System Scheduler/Order Filler and Image Manager. [RAD-7]
Modality Images/Evidence Stored – An Acquisition Modality sends acquired or generated images, waveforms, or other evidence documents to the Image Archive. [CARD-2, derived from RAD-8 and RAD-43]
Storage Commitment – A requestor (Acquisition Modality) requests that the Image Manager confirm ownership for the specified DICOM objects (images, waveforms, evidence documents, or any combination thereof) that the requestor stored in the Image Archive, thus allowing the sender to delete those objects now owned by the Image Manager. [CARD-3, derived from RAD-10]
Patient Update – The ADT Patient Registration System informs the Order Placer and the Department System Scheduler/Order Filler of new information for a particular patient. The Department System Scheduler may then further inform the Image Manager. [RAD-12]
Procedure Update – The Department System Scheduler/Order Filler sends the Image Manager updated order or procedure information. [RAD-13]
Query Images – An Image Display queries the Image Archive for a list of entries representing images by patient, study, series, or instance. [RAD-14]
Retrieve Images – An Image Display requests and retrieves a particular image or set of images from the Image Archive. [CARD-4, derived from RAD-16]Maintain Time – Synchronize the local time with the time maintained by the Time Server. [ITI-1]
IHE Educational Workshop 2005 Dolan – p. 18
Case 1 : Patient Registered at ADT and Ordered Case 1 : Patient Registered at ADT and Ordered at the Order Placer at the Order Placer
Clinical Context– Corresponds to traditional Radiology workflow– Order placed in central system– Also deals with case where emergency identifier has been
created– Common identifiers known ahead of time
IHE Context– MPPS in Progress from first modality used to update
worklists for others
IHE Educational Workshop 2005 Dolan – p. 19
Case 2 : Patient Registered at ADT and Ordered Case 2 : Patient Registered at ADT and Ordered at DSS/OF at DSS/OF
Clinical Context– Slight difference to Case 1– Order placed NOT in central system but in department– Department system provides info to Central ordering system – Typical of many institutes, relieves need for HIS terminal in
lab
IHE Context– Filler Order Management (New Order) transaction [RAD-3]
is sent from Department System Scheduler/Order Filler to the Order Placer.
IHE Educational Workshop 2005 Dolan – p. 20
Case 3 : Patient Registered at ADT and ProcedureCase 3 : Patient Registered at ADT and Procedure
Not OrderedNot Ordered – Schedule on MPPS – Schedule on MPPS
Clinical Context– Procedure not ordered at hospital/dept. e.g. due to time-
constraints.– A modality initiates creation of common identifiers on
Departmental system – Allows multiple modalities participating in the case to be
synchronized
IHE Context– DSS/OF creates a Requested Procedure/Scheduled
Procedure Steps in response to the first MPPS-In-Progress – Requested Procedure created without waiting for response
from Order Placer. This improves speed of cross-modality synchronization
TO BE CONTINUED……
IHE Educational Workshop 2005 Dolan – p. 21
Case 4 : Patient Registered at Department System Case 4 : Patient Registered at Department System Scheduler/OF and Procedure OrderedScheduler/OF and Procedure Ordered
Clinical Context– Variation on Case 2 (procedure ordered in Department)– Patient registered NOT in central system but in department– Covers emergency case or when HIS is unavailable – Temporary Patient identifier used, – Manual reconciliation with official HIS ID later is used to update
department records and ordering system
IHE Context– Temp ID is used to schedule procedure steps to modalities as
normal. – Filler Order management is not invoked until after the reconciliation
with official ID occurs. This is trigger to update DSS/OF, Image Manager and Order Placer with official patient, and order numbers
IHE Educational Workshop 2005 Dolan – p. 22
Case 5 : Patient NOT RegisteredCase 5 : Patient NOT Registered
Clinical Context– Combination of Case 3 and Case 4– No information/time to create patient/order identifiers at HIS or
Department system– Patient ID entered at first modality is adopted for other
modalities (as in Case 4)– procedure triggered by first modality shared across other
modalities (as in Case 3)
IHE Context– DSS/OF creates a Requested Procedure/Scheduled Procedure
Steps in response to the first MPPS-In-Progress– Filler Order management is not invoked until after the
reconciliation with official ID occurs. This is trigger to update DSS/OF, Image Manager and Order Placer with official patient, and order numbers
IHE Educational Workshop 2005 Dolan – p. 23
Case 6 : Patient Update During Procedure Case 6 : Patient Update During Procedure
Clinical Context– unidentified patient registered at the ADT system and brought into
the cath lab with temporary patient demographics – Patient is identified and official ID/demographics sent by HIS while
procedure is in progress.– Some data in the procedure is produced with temporary info and
some with official.– This must be reconciled across the procedure
IHE Context– Modality may continue to transmit data with temporary identifiers– DSS/OF and Image Manager must continue to automatically
reconcile such incoming data with the official data throughout procedure.
IHE Educational Workshop 2005 Dolan – p. 24
Case 7 : Change RoomsCase 7 : Change Rooms During Procedure During Procedure Clinical Context– Not uncommon – diagnostic interventional, equipment failure,…– procedure is halted in one room, with one set of modality
equipment, and resumed in another room with different equipment– For continuity of clinical data, it is critical that this be treated as a
single Procedure
IHE Context (no comparable case in Radiology TF)– Each modality in the first room will issue a Modality Procedure
Step Completed or Discontinued Note – not required prior to moving, can be done later, but needed to
complete the step at end of procvedure.
– DSS/OF used to can reassign the Requested Procedure to a new room and create Scheduled Procedure Steps for those modalities who use WLM to restart procedure
– IF no re-assignment - new modalities can issue broad (not own AE Title) query to get original SPS and then append an MPPS to that
IHE Educational Workshop 2005 Dolan – p. 25
Case 8 : Cancel Procedure Case 8 : Cancel Procedure
Clinical Context– When cases are cancelled it’s important that information
systems reflect same so that staff are informed and can respond appropriately.
– Case covers procedure cancelled prior to start
IHE Context– DSS/OF notifies the Order Placer system and Image
Manger. – All three systems may maintain information about the
cancelled Order and Requested Procedure for a pre-determined length of time.
IHE Educational Workshop 2005 Dolan – p. 26
Case 3 : Case 3 : Significant TransactionsSignificant Transactions
– MWLM query (not shown) will not return a response for current patient
(from card/wristband)
– Unscheduled Performed Procedure Step created
– DSS/OF recognizes patient and room from data in MPPS-In-Progress
[CARD-1] (i.e. Patient ID and AE Title)
– DSS/OF creates a (generic/specific) Requested Procedure/Scheduled
Procedure Steps for other modalities in room using info above.
Different than Radiology !
– Order Placer and Image Manager informed of new, active procedure.
– Requested Procedure created without waiting for response from Order
Placer. This improves speed of cross-modality synchronization.
– Subsequent MWLM queries [RAD-5] from equipment in this cath lab
will receive the appropriate scheduled procedure steps including the
necessary patient/study identifiers
IHE Educational Workshop 2005 Dolan – p. 27
Case 3 : Case 3 : HighlightsHighlights
Contributions– Multi-modality synchronization supported– Modality-initiated, ad-hoc, cases become “managed”
Time delays between first MPPS and shared SPS are seconds/minutes
Avoids trying to synch multiple studyUID’s later (not addressed)
Different…. not Deviant – Auto create of Requested Procedure contradicts “letter” of IHE-
R – but not “spirit” Goal is to reconcile and unscheduled PPS with a Requested
Procedure
IHE Educational Workshop 2005 Dolan – p. 28
For more info:For more info:
IHE Cardiology Technical Framework version 1.0 for Trial Implementation at:– www.rsna.org/ihe– www.acc.org/quality/ihe.htm
Submit questions and comments to:– http://forums.rsna.org
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IHE Scheduled Workflow Concepts
PROCEDURE STEP : The smallest unit of managed workin the workflow:
Scheduled Procedure Step: ‘A unit of work to do’Performed Procedure Step: ‘A unit of work done’
IHE has addressed the definitional problem of workflow processes by
selecting three UNAMBIGUOUS HL7/DICOM TERMS :
ORDER : A request for departmental
service
REQUESTED PROCEDURE : Unit of work resulting in one Reportwith associated codified, billable acts
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3 level workflow structuring concept is user oriented
ORDER:A request for departmental service
(Accession Number)
REQUESTED PROCEDURE : Unit of work resulting in one Reportwith associated codified, billable acts
(Requested Procedure ID)
PROCEDURE STEP :The smallest unit of managed work
in the workflow(modality worklist entry)
CLINICIANOR REFERING DOC:
The Imaging Dept Customer
CARDIOLOGIST : In Charge of producing
the Report
TECHNOLOGIST(and CARDIOLOGIST)In charge of acquiring
images, etc.
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Simple Workflow
One Order – One Procedure – One Study – One Report
ORDERA request for DepartmentalService
RequestedProcedure
Imaging Department
One or more series of images
ReportSet of
Codifiable,Billable,
ActsAcquisition Modality
Study is the container for the series of image/evidence objects(denoted I-Study in IHE Rad TF Vol. II Fig. A-1)
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Study UIDs in Simple Workflow
Requested Procedure identifies Order Filler-specified Study UID
Modality uses that Study UID to store its images/evidence
Both Requested Procedure and I-Study (the object container) use same Study UID
•Classic DICOM did not distinguish between these two concepts
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AcquisitionModality
AcquisitionModality
Multiple Modality Steps
ORDERA request for DepartmentalService
Imaging Department
Set of Codifiable,
Billable, ActsOne or more series of images
PerformedProcedure
Step P1
ScheduledProcedure
Step B
RequestedProcedure
1
ScheduledProcedure
Step A
Report
One or more series of images
PerformedProcedure
Step P2
DICOMModality Worklist
DICOMModality Worklist
One Order – One Procedure – One Study – One Report
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Study UIDs in Multi-Modality
Requested Procedure identifies Order Filler-specified Study UID
Each Modality uses that Study UID to store its images/evidence
All images/evidence stored under same I-Study
•Again, Study UID shared between Requested Procedure and I-Study