RADIOLOGY & ITRADIOLOGY & ITMerger or Collision ?Merger or Collision ?
David P. Mayer, MD,MS,FACRDavid P. Mayer, MD,MS,FACRClinical Professor of RadiologyClinical Professor of Radiology
Drexel University College of MedicineDrexel University College of Medicine
RADIOLOGY & ITRADIOLOGY & ITOUTLINEOUTLINE
What is Radiology? What is Radiology? Connectivity & Image Connectivity & Image
ManagementManagement Alphabet Soup: DICOM;PACS Alphabet Soup: DICOM;PACS
and IHE et al.and IHE et al. The Future of IT & RadiologyThe Future of IT & Radiology SummarySummary
Diagnostic RadiologyDiagnostic RadiologyRe-Defined:Re-Defined: The use of various The use of various
imaging tools to examine the bodyimaging tools to examine the body
in order to guide patient treatmentin order to guide patient treatment
There is an There is an information chaininformation chain that that connects the patient and referring connects the patient and referring Doctor to the Radiology Department Doctor to the Radiology Department which responds with useful diagnosticwhich responds with useful diagnosticinformationinformation
““Radiology is an applied IT field”Radiology is an applied IT field”
Email & Fax
Diagnosis?
rDigital Image:
A Dx Puzzle
Results
““You’ve got You’ve got Questions,Questions,We’ve got answers!”We’ve got answers!”
Imaging Tools:Imaging Tools:CT Scanning (CAT Scan)CT Scanning (CAT Scan)MRI (Magnetic Resonance Imaging)MRI (Magnetic Resonance Imaging)UltrasoundUltrasoundAngiography & InterventionalAngiography & InterventionalX-ray & FluoroscopyX-ray & FluoroscopyMammography & etc. Mammography & etc.
Ultrasound
CT Scanning MRI
Diagnostic Radiology: IT IssuesDiagnostic Radiology: IT Issues
Imaging Challenges:Imaging Challenges:Xs Digital Data (225K Cases/yr=3Tb/yr)Xs Digital Data (225K Cases/yr=3Tb/yr)Future = Video Display (Film is “dead”)Future = Video Display (Film is “dead”)Digital transmission via Inter and IntraNetDigital transmission via Inter and IntraNetDisseminated Access is RequiredDisseminated Access is RequiredDemandsDemands Xs Bandwidth; Redundancy; 3-5 Xs Bandwidth; Redundancy; 3-5 Megapixel Display @ >500:1 contrast; Long Megapixel Display @ >500:1 contrast; Long term Image & Data Archival; Rapid Access term Image & Data Archival; Rapid Access with report info & Demographics; with report info & Demographics; Standardized format- i.e. DICOM; Image Standardized format- i.e. DICOM; Image Manipulation tools; etc.Manipulation tools; etc.
Computer DataComputer Data
ByteByte == 8 bits or 256 shades of gray8 bits or 256 shades of gray
KilobyteKilobyte == 1024 Bytes1024 Bytes
Megabyte =Megabyte = 1024 Kbytes (KB)1024 Kbytes (KB)
GigabyteGigabyte = = 1024 Mbytes (MB)1024 Mbytes (MB)
TerabyteTerabyte = = 1024 Gbytes (GB)1024 Gbytes (GB)
Average Average Word processing DocWord processing Doc < 100KB < 100KB
Average Average (Digital) Radiology Exam(Digital) Radiology Exam =25MB =25MB
SingleSingle Digital X-Ray = Digital X-Ray = 10 MB10 MB
Network StandardsNetwork Standards
PACS data loads are PACS data loads are hugehuge
Requires high speed/high capacity Requires high speed/high capacity networknetwork
@ 100 – 1000Mb/sec@ 100 – 1000Mb/sec
MHSMHS data volume/year ~ data volume/year ~ 3TBytes/yr3TBytes/yr
Data Multiplication:Data Multiplication: exams move exams move many times across the networkmany times across the network
Diagnostic Radiology: IT IssuesDiagnostic Radiology: IT Issues
Read-to-write ratioRead-to-write ratio:: In healthcare because many different In healthcare because many different medical professionals repeatedly access the same data. medical professionals repeatedly access the same data.
Data lifecycle:Data lifecycle: Process by which you can move data from online Process by which you can move data from online storage, to near online, to tape, to archive—is specific to storage, to near online, to tape, to archive—is specific to healthcare. healthcare. RRecall dataecall data: Captured years earlier & Accessed very quickly.: Captured years earlier & Accessed very quickly.
Disparate data:Disparate data: Generated, captured, and stored in different Generated, captured, and stored in different locations & different applications, with different Dx modalities. locations & different applications, with different Dx modalities.
Requirement:Requirement: Link the images with the patient's chart, pharmacy Link the images with the patient's chart, pharmacy records, billing information, etc..records, billing information, etc..
Health Insurance Portability and Accountability Act Health Insurance Portability and Accountability Act (HIPAA):(HIPAA): 1.1. Providers must communicate information between different Providers must communicate information between different
stakeholders in the system including doctors, stakeholders in the system including doctors, hospitals, insurance companies, and the Federal hospitals, insurance companies, and the Federal
governmentgovernment2.2. Information Information mustmust be secure at every step in the process. be secure at every step in the process.
Diagnostic RadiologyDiagnostic RadiologyPACS:PACS: “Picture Archival & “Picture Archival & Communication System”Communication System”
DICOM:DICOM: A Digital Communication A Digital Communication Standard between DiagnosticStandard between Diagnostic
Modalities & PACSModalities & PACS
IHE:IHE: “Integrating the Healthcare “Integrating the Healthcare
Enterprise”Enterprise”
““Radiology is an applied IT field”Radiology is an applied IT field”
PACSPACS & Diagnostic Radiology & Diagnostic RadiologyPACSPACS:: “Picture Archival & “Picture Archival & Communication System”Communication System”Provides a means to Provides a means to move, display move, display and store imagesand store images generated by generated by radiology or other hospital depts.radiology or other hospital depts.Radiology Radiology “product”:“product”: The The interpretationinterpretation of an image of an imageInterpretations Interpretations MUSTMUST be timely! be timely!
PACSPACS““Any image, anywhere, Any image, anywhere,
anytime – and fast”anytime – and fast”Northwestern Memorial Hospital, Northwestern Memorial Hospital,
Chicago, IllinoisChicago, Illinois
PACSPACSKey Components:Key Components: Modality InterfacesModality Interfaces Network BackboneNetwork Backbone Database Management Database Management
SystemSystem Image Management SystemImage Management System Long term ArchiveLong term Archive DiagnosticDiagnostic Workstations Workstations Clinical WorkstationsClinical Workstations Web server Access to Web server Access to
imagesimages
PACSPACSAdvantages:Advantages: Redundant Archives; Cost savings: Film, Redundant Archives; Cost savings: Film, Chemicals, Storage Space; Manpower, & Time !!!Chemicals, Storage Space; Manpower, & Time !!!PotentialPotential Increased productivity Increased productivity
Reduced Turnaround timeReduced Turnaround timeReduced Retakes & Lost FilmsReduced Retakes & Lost FilmsEasier consultation & Stat reportingEasier consultation & Stat reporting
Disadvantages:Disadvantages: Large Capital $ outlay; Requires new Large Capital $ outlay; Requires new work paradigm; Clinician cooperation?; Reinvestment work paradigm; Clinician cooperation?; Reinvestment are requiredare required
Cultural shift:Cultural shift: Age and Medical Specialty Age and Medical Specialty dependentdependent
PACS: PACS: 2006-72006-7
Hospitals w/o PACS:Hospitals w/o PACS:The question shifts from “if” to “when”The question shifts from “if” to “when”
Approx. 50% of US HospitalsApprox. 50% of US HospitalsHospitals w/ PACS:Hospitals w/ PACS:Upgraded systems: Upgraded systems:
IHE Networking IHE Networking Upgraded data handling capabilitiesUpgraded data handling capabilitiesUpgraded computers & monitors to Upgraded computers & monitors to
LCD’sLCD’s
PACS: PACS: 2006-72006-7
Upgraded systems:Upgraded systems:
99.99% Network & PACS Uptime99.99% Network & PACS Uptime::
Redundancy; “self healing”Redundancy; “self healing”
99% uptime = 1 failed day/100d99% uptime = 1 failed day/100d
RequirementsRequirements::
HL7; DICOM; IHE standardsHL7; DICOM; IHE standards
HIS+RIS+PACS: HIS+RIS+PACS:
““seamless” & “bidirectional”seamless” & “bidirectional”
Modality “worklist” (MWL) etc.Modality “worklist” (MWL) etc.
Wireless systems??Wireless systems??
PACS: PACS: 2006-72006-7
Upgraded systems:Upgraded systems:
PACS is “Not just for Radiology”:PACS is “Not just for Radiology”:
Cardiology & PathologyCardiology & Pathology E.M.A. E.M.A.
[“-ologies” : common data storage][“-ologies” : common data storage]
Data Storage requirements:Data Storage requirements:e.g. MD-CT: 64+ slices; Digital Mammo;e.g. MD-CT: 64+ slices; Digital Mammo;
ultrasound video clips; High res. MRI;ultrasound video clips; High res. MRI;
FasterFaster Spinning media archive access Spinning media archive access
3D renderings3D renderings
PACS: PACS: 2006-72006-7
Upgraded systems:Upgraded systems:
““Off the shelf” hardwareOff the shelf” hardware
““Software only” solutionsSoftware only” solutions
Mergers:Mergers:
Images with Voice Recognition Images with Voice Recognition generated reportsgenerated reports
Hospital-wide Image & DataHospital-wide Image & Data
Clinical Data w/ ImagesClinical Data w/ Images
Surgical templates w/ imagesSurgical templates w/ images
Healthcare IT IssuesHealthcare IT IssuesIT Government Oversight:IT Government Oversight:
HIPAA: HIPAA: Audit trails requiredAudit trails requiredFDAFDAState & Local Health RegulationsState & Local Health Regulations
HIPAA:HIPAA:1. 1. Electronic Data format standards:Electronic Data format standards:2. 2. Privacy:Privacy: Integrity & Confidentiality of Integrity & Confidentiality of patient info. patient info. Flexibility vs. privacyFlexibility vs. privacy3. 3. Security:Security: Storage, Transmission and Storage, Transmission and Display Data protection. Display Data protection.
*PHI (Protected Health Information) *PHI (Protected Health Information) requires User Authentication requires User Authentication*Every data access must be logged*Every data access must be logged*Secure Storage & Transmission*Secure Storage & Transmission
PACS: PACS: 2006-72006-7
Upgraded systems:Upgraded systems:
HIPAA Compliant security systemsHIPAA Compliant security systems
Site requirements:Site requirements:
PACS administratorPACS administrator
Voice recognition AdministratorVoice recognition Administrator
Teamwork:Teamwork:
Healthcare IT DilemmaHealthcare IT DilemmaSecuring clinical Information systemsSecuring clinical Information systems
““CIA Triad”:CIA Triad”: ConfidentialityConfidentiality; ; IntegrityIntegrity & & AvailabilityAvailability
Confidentiality:Confidentiality: Staff & Pt. Data must be Staff & Pt. Data must be protectedprotected
IntegrityIntegrity:: Correct & Complete data; Correct & Complete data; Legal & HIPAA: sanctionsLegal & HIPAA: sanctions
Availability:Availability: Timely and secure access; Timely and secure access; Mission criticality: 24/7/365Mission criticality: 24/7/365
Tradeoff:Tradeoff:
Protected Info. vs. Ease-of-useProtected Info. vs. Ease-of-use
HIPAA – Its Impact on RadiologyHIPAA – Its Impact on Radiology
Cost estimates: $2B-43BCost estimates: $2B-43B
Security for Radiology Reports & ImagesSecurity for Radiology Reports & Images
Digital environment: Digital environment:
Authentication: “Who are you” ? Authentication: “Who are you” ?
Encryption: “Encode the data”Encryption: “Encode the data”
Access: “Need to know” basisAccess: “Need to know” basis
DICOMDICOM (Digital Image Communication in Medicine):(Digital Image Communication in Medicine):A A standard forstandard for imageimage communication in the communication in the medical field, that is supported by most medical field, that is supported by most vendors of digital imaging devices (CT, vendors of digital imaging devices (CT, MR, MR, digital X-Ray, ultrasound, etc.). digital X-Ray, ultrasound, etc.).
DICOMDICOM standard includes a detailed description standard includes a detailed description of the of the patient information withpatient information with the imagesthe images and and the way the images are sent the way the images are sent
between different devices:between different devices: e.g. between a CT scanner and a PACS e.g. between a CT scanner and a PACS
(Picture Archival and Communication System)(Picture Archival and Communication System)
DICOM 3DICOM 3 (Current level):(Current level):
ACR & NEMAACR & NEMA: Formed joint committee : Formed joint committee to develop Digital Imaging to develop Digital Imaging standardsstandards
Other participating organizationsOther participating organizations: : IEEE, HL7, ANSI, JIRA, etc.IEEE, HL7, ANSI, JIRA, etc.
Allows Gateway to HL7, wwwAllows Gateway to HL7, www
HIS/RIS – PACS Communication:HIS/RIS – PACS Communication: Optimal: Bidirectional interface Optimal: Bidirectional interface between HIS/RIS & PACSbetween HIS/RIS & PACS Minimizes data entry errorsMinimizes data entry errors
Est. 15% of medical data entries have errors !!!Est. 15% of medical data entries have errors !!! Faster reporting and image availabilityFaster reporting and image availability Pre-fetching of old reports & examsPre-fetching of old reports & exams Modality Work List: Data Modality Work List: Data Scanner Scanner
DICOM DICOM http://medical.nema.org/http://medical.nema.org/
Many Capabilities are included under the Many Capabilities are included under the “DICOM” name “DICOM” name [e.g. [e.g. 1212 DICOM “Classes”] DICOM “Classes”]DICOM Verification Service Class DICOM Verification Service Class DICOM Storage Service Class DICOM Storage Service Class DICOM Query/Retrieve Service Class DICOM Query/Retrieve Service Class DICOM Study Content Notification Service Class DICOM Study Content Notification Service Class DICOM Patient Management Service Class DICOM Patient Management Service Class DICOM Study Management Service Class DICOM Study Management Service Class DICOM Results Management Service Class DICOM Results Management Service Class DICOM Print Management Service Class DICOM Print Management Service Class DICOM Media Storage Service Class DICOM Media Storage Service Class DICOM Storage Commitment Service Class DICOM Storage Commitment Service Class DICOM Basic Worklist Management Service Class DICOM Basic Worklist Management Service Class DICOM Queue Management Service ClassDICOM Queue Management Service Class
RISRISRRadiology adiology IInformation nformation SSystemystem
1.1. Patient registration order entryPatient registration order entry
2.2. Data analysisData analysis
3.3. Management reportingManagement reporting
4.4. Scheduling & Billing dataScheduling & Billing data5.5. Exam & Patient tracking Exam & Patient tracking (incl. Mammo)(incl. Mammo)
6.6. TranscriptionTranscription
7.7. Integration: IHE; HIPAA; PACSIntegration: IHE; HIPAA; PACS
RISRISRRadiology adiology IInformation nformation SSystemystem
8. Patient info merges w/ Images:8. Patient info merges w/ Images:
Allergies; lab values & HxAllergies; lab values & Hx
9.9. Internet linkageInternet linkage
10.10. Mammography: Mammography: (Unfunded federal (Unfunded federal mandate)mandate) MQSA Regulations MQSA Regulations
DICOMDICOMNote:Note: All new imaging modalities (e.g. CT, All new imaging modalities (e.g. CT, Ultrasound, MRI, Digital X-Ray etc.) are Ultrasound, MRI, Digital X-Ray etc.) are availableavailable with DICOM compatibility with DICOM compatibilityOlder imaging equipment Older imaging equipment require ($$$)require ($$$) upgrades or interfaces to the DICOM std.upgrades or interfaces to the DICOM std.There are numerous “levels” or There are numerous “levels” or ““classesclasses” to DICOM compatibility” to DICOM compatibilityDICOM DICOM continuescontinues to evolve to evolve IHE IHE
What is IHE?What is IHE?"Integrating the Healthcare Enterprise" (IHE), "Integrating the Healthcare Enterprise" (IHE), is a multi-year initiative, sponsored by the is a multi-year initiative, sponsored by the Radiological Society of North America (RSNA) Radiological Society of North America (RSNA) and the Healthcare Information and and the Healthcare Information and Management Systems Society (HIMSS), whose Management Systems Society (HIMSS), whose single purpose is to bring together medical single purpose is to bring together medical equipment and information products from equipment and information products from different manufacturers for different manufacturers for developing an developing an efficient and seamless workflow between efficient and seamless workflow between multiple products from multiple vendors multiple products from multiple vendors while improving the clinical and while improving the clinical and economic efficiencies of hospital-wide economic efficiencies of hospital-wide connectivityconnectivity..
Note that the IHE is not a Note that the IHE is not a Standards organization. The IHE Standards organization. The IHE uses existinguses existing standardsstandards, such as , such as DICOM and HL-7, for developing DICOM and HL-7, for developing workflow solutions for the workflow solutions for the healthcare enterprisehealthcare enterprise
PartnersPartners Supporting organizations providing Supporting organizations providing
expertise, technology and guidanceexpertise, technology and guidance• American College of PhysiciansAmerican College of Physicians• Centers for Disease Control & PreventionCenters for Disease Control & Prevention• CDISCCDISC• Duke University Medical CenterDuke University Medical Center• Food & Drug AdministrationFood & Drug Administration• OASISOASIS• Massachusetts Medical SocietyMassachusetts Medical Society• National Institute for Standards & TechnologyNational Institute for Standards & Technology• UC David, Medical InformaticsUC David, Medical Informatics
IHEIntegrating the Healthcare Enterprise
• Multi-year initiative• Creates framework for seamless passage of
health information• Provides framework for implementing
relevant standards: e.g. “Connectathon”• 1998: RSNA & HIMSS provides leadership• Drives the adoption of standards to address
specific clinical needs• Does NOT create new standards• Ensures higher level of practical
interoperability• Clinical Domain Expansion: Cardiology,
Medication Mgnt. And Clinical Engineering
Brokered Claim; Registry DiscoveryBrokered Claim; Registry DiscoveryFor patient chart and Tumor Registry; CCR back to PCPFor patient chart and Tumor Registry; CCR back to PCP
PCP
From Continuity of Care scenarioFrom Continuity of Care scenarioImaging Integration, Tumor Reporting, Claims ProcessingImaging Integration, Tumor Reporting, Claims Processing
Surgery
Server
EMR
Hospital
Repository
Pathology
Dictation
Tumor Registry
Registry
eForms
Broker
Broker
Payer
Workstation
ImagingRIS
EMREMR
eFormseForms
EMREMR
EMREMR
Secure Secure transporttransport
TransforTransformm
ImagingImaging
DictationDictationLabLab
ImagingImaging
Virtual EHRVirtual EHR
Virtual EHRVirtual EHR
Tumor Tumor Registry/repositoryRegistry/repository
PCPPCP
HospitHospitalal
Continuity of Care (Continuity of Care (e.g.e.g. TumorsTumors))Imaging Integration, Tumor Reporting, Claims ProcessingImaging Integration, Tumor Reporting, Claims Processing
HighlightsHighlightsFirsts:Firsts: Annotated Electro-cardiogram, submissionsAnnotated Electro-cardiogram, submissions CDA College of American Pathology tumor report, CDA College of American Pathology tumor report, CDA Continuity of Care Record (CCR)CDA Continuity of Care Record (CCR) Clinical Document Architecture Release 2 (ballot draft)Clinical Document Architecture Release 2 (ballot draft) DistributedDistributed, standards-based decision support, standards-based decision support Document-based HIPAA Document-based HIPAA claims attachmentsclaims attachments End-to-end, standards-based electronic clinical End-to-end, standards-based electronic clinical
trial data submissiontrial data submission End-user Authentication profileEnd-user Authentication profile Hyperlink between electronic document and Hyperlink between electronic document and
PACS imagePACS image Nationally Notifiable Disease reportNationally Notifiable Disease report Open-source metadata registry for ubiquitous Open-source metadata registry for ubiquitous
access to distributed informationaccess to distributed information Patient Information Patient Information Cross-reference profileCross-reference profile Patient Synchronized ApplicationsPatient Synchronized Applications Retrieve Information for DisplayRetrieve Information for Display profile profile Re-useRe-use of electronic clinical documents to support a of electronic clinical documents to support a
claimclaim Structured Product LabelingStructured Product Labeling Third-party brokered claims attachmentsThird-party brokered claims attachments Version 3/CDA TemplatesVersion 3/CDA Templates
The HL7-IHE Demo…The HL7-IHE Demo…
Creates the future of Creates the future of machinemachine interoperability through interoperability through humanhuman interoperabilityinteroperability• We identify barriers to Interoperability We identify barriers to Interoperability
andand• And we engineer breakthroughs.And we engineer breakthroughs.
Scheduled Workflow :Scheduled Workflow : flow of information for flow of information for the key steps (registration, ordering, the key steps (registration, ordering, scheduling, acquisition, distribution and scheduling, acquisition, distribution and storage) storage)
Patient Information ReconciliationPatient Information Reconciliation method for method for reconciliation of information for unidentified or reconciliation of information for unidentified or mistakenly identified patients mistakenly identified patients
Consistent Presentation of ImagesConsistent Presentation of Images ensures a ensures a consistent view of images and annotations consistent view of images and annotations across different displays and media across different displays and media
Presentation of Grouped ProceduresPresentation of Grouped Procedures management of images for multiple procedures management of images for multiple procedures in a single acquisition step (e.g. spiral CT: in a single acquisition step (e.g. spiral CT: chest & abdomen) chest & abdomen)
Access to Radiology InformationAccess to Radiology Information mechanism for mechanism for sharing radiological images and information sharing radiological images and information across department boundaries across department boundaries
IHE Components (1)
Key Image NoteKey Image Note addition of textual notes and addition of textual notes and pointers to key images in a series pointers to key images in a series
Simple Image and Numeric ReportsSimple Image and Numeric Reports standard standard way of creating, managing, storing and viewing way of creating, managing, storing and viewing reports that include images, text and reports that include images, text and numerical values numerical values
Charge PostingCharge Posting information about procedures information about procedures available to billing systems allows consistent available to billing systems allows consistent and timely billing of technical and professional and timely billing of technical and professional charges charges
Basic SecurityBasic Security establishes enterprise-wide establishes enterprise-wide security infrastructure for meeting privacy security infrastructure for meeting privacy requirements (such as HIPAA) requirements (such as HIPAA)
Post-processing WorkflowPost-processing Workflow supports workflow supports workflow steps such as Computer-Aided Detection (CAD), steps such as Computer-Aided Detection (CAD), Imaging Processing, and Image ReconstructionImaging Processing, and Image Reconstruction
IHE Components (2)
TeleradiologyTeleradiologyTeleradiology programs allow the sending Teleradiology programs allow the sending of pictures between different stations in of pictures between different stations in
different locations. different locations. MR Image from the brain
TeleradiologyTeleradiologyTeleradiology programs allow the sending Teleradiology programs allow the sending of pictures between different stations in of pictures between different stations in
different locations.different locations.
CT
MRIX-Ray
Productivity in Radiology:Productivity in Radiology: Why?Why?
Procedure volume increasing by 3.5-5%/yrProcedure volume increasing by 3.5-5%/yr
Supply of radiologists increasing by 2%/yrSupply of radiologists increasing by 2%/yr
Between 1995 - 2000Between 1995 - 2000
MRI Exams increased by 19%:MRI Exams increased by 19%:
CT Exams increased by 10%:CT Exams increased by 10%:
Case complexity & Slices: Case complexity & Slices: 64 slice CT !!!64 slice CT !!!
Clinical expectations are also increasing !!Clinical expectations are also increasing !!
Diagnostic RadiologyDiagnostic Radiology
SUMMARY: SUMMARY: The Future of MedicineThe Future of Medicine
Digital based image acquisition, Digital based image acquisition, interpretation and distribution interpretation and distribution Continued integration of imaging Continued integration of imaging with demographic & clinical datawith demographic & clinical data
Computer Assisted Diagnosis (CAD):Computer Assisted Diagnosis (CAD):
[the real “Tricorder”][the real “Tricorder”]
Diagnostic RadiologyDiagnostic RadiologySUMMARY: SUMMARY: The Future of MedicineThe Future of Medicine
Computer Assisted Diagnosis (CAD):Computer Assisted Diagnosis (CAD):
[the [the firstfirst real “Tricorder”??] real “Tricorder”??]
Working CAD systems:Mammography
Clinical Trials:CT Scanning: ChestChest X-Rays
The Tricorder Site, 2001, www.tricorder.cjb.net