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Integrating the Healthcare Enterprise. IHE 2003: Meeting Clinical Goals and Technical Challenges. Authors & Presenters. Paul Vegoda, FHIMSS Malvern Group IHE Strategic Development Committee Kevin O’Donnell Toshiba America, Inc. IHE Planning Committee Co-chair David S. Channin, MD CPHIMS

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integrating the healthcare enterprise

Integratingthe Healthcare Enterprise

IHE 2003:Meeting Clinical Goals and Technical Challenges

authors presenters
Authors & Presenters

Paul Vegoda, FHIMSS

Malvern Group

IHE Strategic Development Committee

Kevin O’Donnell

Toshiba America, Inc.

IHE Planning Committee Co-chair

David S. Channin, MD CPHIMS

Northwestern University

IHE Strategic Development Committee

HIMSS 2003

the problem
The Problem

Poor Information System Support for Healthcare Delivery

  • Information not available when and where needed for medical, research, education or administrative decision support
  • Errors, both manual and electronic
  • Inefficient
  • Paper based and clogged

HIMSS 2003

why is ihe needed
Why is IHE needed?
  • Serious Integration Challenges in Healthcare:
    • Systems need Information other systems have
    • But, systems communicate poorly or not at all
  • Result: - tedious, inefficient workflows - data that is redundant, inconsistent or unavailable

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

HIMSS 2003

a cio s dream
A CIO’s dream
  • A fully integrated healthcare information system
    • Best of breed systems working together to facilitate efficient workflow
  • Documented improvement of efficiency and quality of delivered care
  • Easy to deploy and manage
  • Good, fast and cheap (pick two)

HIMSS 2003

slide6
RIS

PACS

What my CIO sees:

120 Server Systems

62 point to point

HL7 connections

  • includes 3 to PACS

Dreams of ‘Best of Breed’?!

HIMSS 2003

slide7
What some would like to see:

Dreams of ‘Single Vendor’

‘Mangy Mutt’

HIMSS 2003

slide8
Alas….

Best of Breed vs. Integrated

… “tis a consummation devoutly to be wished.”

Will Shakespeare, Hamlet

HIMSS 2003

then suddenly
Then suddenly…

“What light from yonder window breaks?”

Will Shakespeare, Romeo and Juliet

It is IHE!

HIMSS 2003

what is ihe
What is IHE?

IHE is an initiative to speed the integration of information systems in the healthcareenterprise to achieve better workflow

HIMSS 2003

goals of ihe
Goals of IHE
  • Speed up the rate and quality of integration in healthcare environments
  • Foster communication among vendors
  • Prove that integration is attainable based on standards

HIMSS 2003

ihe penetration in radiology
IHE Penetration in Radiology
  • Now entering Year 5!!
  • 50+ vendors worldwide
  • 100+ systems in annual Connectathons
  • Geographic spread
    • U.S., France, Germany, Japan, Italy, U.K.

HIMSS 2003

ihe expansion into new areas
IHE Expansion into New Areas
  • New IT Infrastructure Committee Formed
    • (EMPI, Query-Display, Synchronized Patient Views, and Advanced Security)
  • Cardiology Group forming in March (ACC)
  • Work progressing in:
    • Lab
    • Pharmacy/Medication Management

HIMSS 2003

ihe participants
IHE Participants
  • Societies Representing Healthcare Segments
    • ( RSNA, HIMSS, ACC, … )
  • Users
    • ( Clinicians, Medical Staff, Administrators, CIOs, … )
  • Information Systems Vendors
  • Imaging Systems Vendors
  • Standards Development Organizations (SDOs)
    • DICOM
    • HL7
    • Others …

HIMSS 2003

benefits to ihe participants
Benefits to IHE Participants
  • Clinicians
    • Improved workflow
    • Information when and where needed
    • Fewer opportunities for errors
    • Fewer tedious tasks/repeated work
  • Administrators
    • Improved efficiency
    • Best of breed opportunities
    • Decreased cost and complexity of interface deployment and management

HIMSS 2003

benefits to ihe participants1
Benefits to IHE Participants
  • Vendors
    • Decreased cost and complexity of interface installation and management
    • Validation of integration at Connectathon
    • Focus competition on functionality/service space not information transport space
  • SDOs
    • Rapid feedback to adjust standards to real-world

HIMSS 2003

ihe process
IHE Process
  • Users and vendors work together to identify and design solutions for integration problems
  • Intensive process with annual cycles:
    • Identify key healthcare workflows and integration problems
    • Research & select standards to specify a solution
    • Write, review and publish IHE Technical Framework
    • Perform cross-testing at “Connectathon”
    • Demonstrations at tradeshows (HIMSS/RSNA/…)

HIMSS 2003

ihe deliverables
IHE Deliverables
  • Venues for discussion between users and vendors
  • Common vocabulary; Common view of the world based on:
    • HL7 and DICOM Model of the real world
    • Pieces of information and their meaning
  • Technical Framework - INTEGRATION PROFILES
    • ACTORS in Roles performing TRANSACTIONS to accomplish Specific Processes
  • Connect-a-thon
  • Public Demonstrations / Education Exhibits

HIMSS 2003

ihe concepts and vocabulary
IHE Concepts and Vocabulary
  • Actors
  • Transactions
  • Integration Profiles

HIMSS 2003

actors
Actors
  • Represent a role performed by a system
  • Collect a subset of related responsibilities 

Examples:

    • Order Placer
    • Order Filler
    • Acquisition Modality
    • Image Display
    • Report Creator

HIMSS 2003

transactions
Transactions
  • Unambiguously defines how several actors communicate
  • Using existing standards such as HL7 or DICOM to accomplish a specific task.

Examples: 

    • Procedure Scheduled
    • Modality Worklist Provided

HIMSS 2003

integration profiles
Integration Profiles

IHE Integration Profiles define a collection of real world functionality and group together the necessary Actors and Transactions to make it work.

  • Examples: 
    • Scheduled Workflow
    • Patient Information Reconciliation
    • Presentation of Grouped Procedures

HIMSS 2003

ihe technical framework
IHE Technical Framework
  • Defines enterprise Integration Profiles
  • Defines what to do to support the Integration Profiles
  • 3 volumes, 450+ pages
  • Version controlled
    • 5.4 is latest revision (www.rsna.org/IHE)
  • May be incorporated by reference into contract documents

HIMSS 2003

the annual connectathon
The Annual “Connectathon”
  • Unprecedented Cross-Vendor Testing
  • Voluntary Participation
  • Neither a Demo nor a Certification
  • Well Designed End-to-End Scenarios
  • Advanced Testing Tools
  • Unprecedented Pool of Technical Talent

HIMSS 2003

public demonstrations education exhibits
Public Demonstrations / Education Exhibits
  • RSNA Annual Meeting (November)
  • HIMSS Annual Meeting (Here and NOW!!)
    • Check your program books for a large number of IHE related presentations and exhibits

HIMSS 2003

ihe integration profiles
Scheduled Workflow

Post- Processing Workflow

Patient Information Reconciliation

ChargePosting

Admit, order, schedule, acquire & store images with notification of completed steps

Schedule, perform, & notify image processing & CAD steps

Collection of billable procedure details

Unknown patients and unscheduled orders

Consistent Presentation of Images

Key ImageNotes

Simple Image and Numeric Reports

Simple reports with image links and measurements

Hardcopy and softcopy grayscale presentation state

Flag & search for significant images

Presentation of Grouped Procedures

Manage subsets of a single acquisition

Access to Radiology Information

Retrieve & view images and reports

Basic Security

Audit Trail Consolidation & Node Authentication

IHE Integration Profiles

HIMSS 2003

scheduled workflow integration profile
Scheduled Workflow Integration Profile
  • Real World Problem:
    • Patient-centric, service oriented care delivery
    • Multiple actors, multi-vendor, multi-system
  • Registration
  • Order Placer
  • Order Filler
  • Modality
  • Image Manager / Image Archive
  • Image Display
  • Report Creator
  • Etc.

HIMSS 2003

slide28
Scheduled Workflow Profile

report

Registration

Film

Lightbox

Image Manager

& Archive

Orders Filled

Film

Folder

Diagnostic

Workstation

Film

Report

Repository

Orders Placed

AcquisitionModality

acquisitioncompleted

acquisitionin-progress

imagesprinted

Modality

acquisitioncompleted

HIMSS 2003

year 4 enhancements to scheduled workflow
Year 4 Enhancements to Scheduled Workflow
  • Reduce variance on how procedures are performed
    • Imaging protocols
    • Assisted Acquisition Protocol Setting (option)
  • Exception management
    • When errors are made on the modalities how can these be corrected
    • PPS Exception Management (option)

HIMSS 2003

patient information reconciliation integration profile
Patient Information Reconciliation Integration Profile
  • Real World Problem:
    • ‘To err is human, but to really mess things up you need a computer’

5 scenarios of patient/order/images reconciliation addressed:

      • Unidentified Patient registered at ADT and ordered at Order Placer
      • Unidentified Patient registered at ADT and ordered at Dept Scheduler/Order Filler
      • Unidentified Patient registered at ADT but completed at Modalityprior to Order
      • Unidentified Patient assigned Temporary Departmental ID andScheduled at Dept Scheduler/Order Filler
      • Image Acquisition Completed without Scheduling at Dept Scheduler/OrderFiller

HIMSS 2003

post processing workflow integration profile
Post-Processing WorkflowIntegration Profile
  • Clinical Problem:
    • How do I know when there is post-processing (3D, CAD, etc.) to be done?
    • How do I know when the post-processing is done and ready to be billed, distributed, and interpreted?
    • How do I make sure the post-processed images / objects get associated with the correct study?

HIMSS 2003

post processing workflow profile
Source Data

Worklist

PACS System

CAD

*Workstation

3-D

*Workstation

Review

Workstation

ReportRepository

Work Status

Results

AcquisitionModality

Post-Processing Workflow Profile

Post-Proc.

Workflow

Manager

Work Status

Results

HIMSS 2003

charge posting integration profile
Charge Posting Integration Profile
  • Clinical Problem:
    • Can my information systems send consistent messages to a ‘charge processor’ for timely technical and professional fee billing?
    • Can my billing / coding process more accurately reflect what was actually done?
    • Can I shrink my back office?

HIMSS 2003

charge posting profile
Account

Management

ADT Terminal

Report Generated /

Signed

CAD

*Workstation

3-D

*Workstation

ReportRepository

3-D

Performed

CAD

Performed

AcquisitionModality

Charge Posting Profile

Post

Charges

*Billing System

Charge

Poster

Study

Performed

/ Materials

Used

HIMSS 2003

consistent presentation of images integration profile
Consistent Presentation of Images Integration Profile
  • Real World Problems:
    • Is my referring clinician seeing the same picture as I am?
    • Can I avoid calibrating every imaging device to every display device?
    • Why do I have to repeat image manipulations that the technologist already performed?
    • Can I view the images the way Dr. X did?

HIMSS 2003

consistent presentation of images profile
Original Image &

Presentation State

Area Of

Interest

Area Of

Interest

The Radiologist’s Transformations

Are Saved

Flip

Zoom

Prepared Image

Annotate

Original Image

Original Image

Window Level

Original Image

The Radiologist’s Transformations

Are Lost

Consistent Presentation of Images Profile

What the Radiologist Displays:

What the Reviewing Physician Sees:

HIMSS 2003

presentation of grouped procedures integration profile
Presentation of Grouped Procedures Integration Profile
  • Clinical Problem:
    • Single physical acquisition of images must be ‘split’ for interpretation, viewing or billing
      • E.g., Spiral CT of Chest, Abdomen, Pelvis
      • E.g., One order, two procedures, one data set, two reports
    • How can I optimize both patient experience (time and comfort) and throughput?
    • How can I make sure images are grouped and sorted correctly and ready for display

HIMSS 2003

presentation of grouped procedures profile
Report:CHEST

Report:AB/PELVIS

Ab/Pelvis View

Chest View

Chest View

MODALITY

Performs a single exam

Operator

groups

2 procedures

Ab/Pelvis View

Presentation of Grouped Procedures Profile

Requested Procedure:CHEST

RIS / PACS

Requested Procedure:AB/PELVIS

HIMSS 2003

key image note integration profile
Key Image Note Integration Profile
  • Clinical Problem:
    • How can I flag images in a procedure for various purposes:
      • To clarify findings for referring physicians or teaching
      • QA
      • Technical inadequacy
      • Etc.

HIMSS 2003

key image notes profile
Note1

Note2

For referring

physician:

This image shows

the renal rupture.

For referring

physician:

This image has

the hematoma.

Study &

Key Image Notes

Note2

Note1

for refering physician

This image shows

the renal rupture.

Note1

Note2

for refering physician

This image has the hematoma.

for refering physician

This image has the hematoma.

for refering physician

This image shows

the renal rupture.

Key Image Notes Profile

Radiologist

Flags Images:

Referring PhysicianSees Key Images First:

HIMSS 2003

simple image numeric report integration profile
Simple Image & Numeric Report Integration Profile
  • Clinical Problem:
    • How can I start to use DICOM Structured Reporting for my reports?
    • How can I capture report information other than as blobs of text?
    • How can I mine my report data?
    • How can I disseminate reports to all downstream systems?

HIMSS 2003

example simple image and numeric report
Example: ‘Simple Image and Numeric Report’

Discussion

Comparison is made to the prior study of 4/11/99. The left paratracheal lymph node (image 8, image 11) now measures 2.5x2.7x3.1 cm increasing from 2.0x2.1x2.6 previously. No other mediastinal, upper abdominal or axillary adenopathy is identified. No focal pulmonary lesions are seen. The yadda, yadda, yadda are normal.

Impression

Worsening L Paratracheal adenopathy.

HIMSS 2003

simple image numeric reports profile
Images and Examdata presented fordiagnosis

Verified Report

Preliminary Report

Image Manager

& Archive

ReportVerification

Reports storedforNetwork Access

Report & ImageReview forPatient Care

Report & Images

Retrieved

Images

Retrieved

Simple Image & Numeric Reports Profile

HIMSS 2003

access to radiology information integration profile
Access to Radiology InformationIntegration Profile
  • Clinical Problem:
    • How can other information systems get information from me without interrupting me?
      • Images
      • Gray Scale Presentation States
      • Key Image Notes
      • Simple Image and Numeric Reports

HIMSS 2003

slide45
Emergency Department

Referring Physician

Radiology Department – Images and Reports

Remote Clinics

Other Departments:- Oncology- Surgery- Neurology- Pediatrics- etc.

Electronic Medical Record

Access to Radiology Information Profile

HIMSS 2003

basic security integration profile
Basic Security Integration Profile
  • Clinical Problem:
    • How can I begin to coordinate HIPAA / security requirements between systems?
      • Secure communications between nodes
      • Common audit repository
      • Common date and time across systems

HIMSS 2003

basic security profile
Image Manager

& Archive

Diagnostic

Workstation

ReportRepository

Report & ImageReview

Basic Security Profile

Audit

Record

Repository

“Images Queried /

Retrieved”

“Reports Retrieved”

“Reports Printed”

“Images Printed”

“Reports Stored”

“Reports Queried /

Retrieved”

HIMSS 2003

what is available
What is Available?
  • IHE Integration Statements
    • Vendor claims of IHE Profile support on specific products
    • Simple format
    • backed up by Technical Framework
  • Connectathon Results
    • what types of systems, which companies are testing at the Connectathons

See links at www.rsna.org/IHE

HIMSS 2003

clinical ihe success progress
Clinical IHE Success Progress

IHE at Northwestern

HIMSS 2003

goals
Goals
  • Define the PACS / modality environment:
    • Northwestern Memorial Hospital
  • Measure a specific PACS / modality workflow metric in the absence of IHE transactions
  • Deploy coreIHE Scheduled Workflow Integration Profiletransactions (MPPS) between modalities and PACS
  • Re-measure the metric in the presence of the IHE transactions

HIMSS 2003

nmh environment
Patient Reg. Actor (ADT)

Plus 2000 (McKesson)

Order Placer Actor (CIS)

PowerChart (Cerner)

Order Filler Actor (RIS)

Classic RadNet (Cerner)

Image Manager / Image Archive

Centricity 1.0 PACS (GEMS)

Acquisition Modality: MR

Syngo MR (Siemens)

Acquisition Modality: CT

LightSpeed CT (GEMS)

NMH Environment

Systems Supporting IHE Transactions

Non-IHE Compliant Systems

HIMSS 2003

process to be measured
Process to be measured
  • Order received by PACS:
    • Procedure is in ‘Ordered’ status
  • Images received by PACS:
    • Procedure transitions to ‘Arrived’ status
  • Procedure closed for acquisition:
    • Procedure transitions to ‘Verified’ status
  • Procedure dictated:
    • Procedure transitions to ‘Dictated’ status
  • Dictation transcribed:
    • Procedure transitions to ‘Transcribed’ status
  • Electronically signed report received:
    • Procedure transitions to ‘Complete’ status

HIMSS 2003

the problem i
The Problem (I)
  • ‘Verification’ as defined above can occur:
    • Manually
    • By dictation (jumps over ‘verified’ status)
    • Automatically at 5 hours
    • On receipt of complete message from RIS
      • Not used due to unreliable usage by technologists
  • Time to ‘Verification’ is variable and inconsistent

HIMSS 2003

the problem ii
The Problem (II)
  • Timely verification is critical because it triggers:
    • Closing a procedure for further acquisition signifying procedure is done.
    • Writing of the images to permanent long-term storage
      • Which triggers DICOM Storage Commitment back to the Modality
    • Procedure is ready to be interpreted

HIMSS 2003

the promise
The Promise
  • Use of DICOM Modality Performed Procedure Step Transaction as defined by IHE Framework can automatically trigger ‘Verification’

HIMSS 2003

so what
So What?

Radiology at NMH is big business

  • If:
    • 40,000 CT studies per year
    • CT exam slot is 20 minutes
    • Reimbursement of 50¢ on the dollar
    • One minute of CT slot time is worth $14 in Gross Revenue!

HIMSS 2003

lessons learned
Lessons Learned
  • IHE functionality can be purchased / deployed in select commercial products
  • IHE functions at the ‘least common denominator’ level
  • Connect-a-thon success does not guarantee clinical success:
    • test, test, then test some more
  • Upgrading legacy equipment to support IHE may be expensive and take a long time (and involve forklifts and other heavy machinery)

HIMSS 2003

clinical conclusion
Clinical Conclusion
  • The promise of efficiencies from implementation of IHE Integration Profiles is so great that it merits continued dedication and commitment from the user community.
  • The perils of IHE deployment indicate that vendors must continue their dedication and commitment to improving implementations and understanding details of clinical operations

HIMSS 2003

what can you do
What can you do?
  • Learn about IHE
  • Find problems at your institution that can benefit from the IHE Initiative
  • Participate in IHE committees
  • Ask vendors about IHE when ‘shopping’
  • Stress to your vendors the importance of connectivity and integration in your next purchase!
  • Require IHE participation and compliance in your contracts!

HIMSS 2003

resources
Resources
  • www.rsna.org/IHE
    • FAQs
    • Buyer’s guidelines
    • IHE Technical Framework
    • Primer on IHE
    • Presentations
  • www.himss.org
    • IHE monograph

HIMSS 2003

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