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Integrating the Healthcare Enterprise Emmanuel Cordonnier, ETIAM (slides from Rita Noumeir) IHE-Europe IHE Technical and Planning Committees Cross-enterprise Document Sharing for Imaging (XDS-I) Abstract / Scope Sharing of Imaging Information across health enterprises

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integrating the healthcare enterprise

Integrating the Healthcare Enterprise

Emmanuel Cordonnier, ETIAM (slides from Rita Noumeir)

IHE-Europe

IHE Technical and Planning Committees

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

abstract scope
Abstract / 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 images in a regional health information network
Sharing Radiology Reports and Imagesin a Regional Health Information Network

Regional Health Information Network

Radiology Enterprise B

PACS B

Radiology-to-radiology

Radiology-to-Physicians

PACS A

Physician Office

Radiology Enterprise A

sharing radiology reports and images in a regional health information network4
Sharing Radiology Reports and Imagesin a Regional Health Information Network

Regional Health Information Network

Radiology Enterprise B

PACS B

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

Cross-Enterprise Registry

PACS A

Physician Office

Radiology Enterprise A

physicians and systems within a regional health network routine imaging referral

Register Imaging Information for sharing

Priorimaging Reports & Studies

Register Imaging Information for sharing

Query for Documents

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

Regional Health Information Network

Radiology Enterprise B

Cross-Enterprise Registry

Patient Id= 3547F45

  • Report 5/21/1998 : CT Head B
  • Study 5/21/1998 : CT Head B

Physician Office

Radiology Enterprise A

physicians and systems within a regional health network routine imaging referral6

Register Imaging Information for sharing

Register Imaging Information for sharing

Notification of Doc Availability

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

Regional Health Information Network

Radiology Enterprise B

Cross-Enterprise Registry

Physician Office

Radiology Enterprise A

physicians and systems within a regional health network for a routine imaging referral

Prior Imaging Report & Study

Query for documents

Notification of Doc Availability

Imaging Report & Study

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

Regional Health Information Network

Radiology Enterprise B

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

Cross-Enterprise Registry

Physician Office

Radiology Enterprise A

value proposition
Value 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 proposition9
Value 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.
xds i dependencies
XDS-I Dependencies
  • XDS-I depends on IT Infrastructure Cross-Enterprise Document Sharing (XDS)
  • Same Actors as in XDS
    • Document Source
    • Document Consumer
    • Document Registry
    • Document Repository
  • Added extension to support imaging data (images and reports)
xds i actors and transactions
XDS-I Actors and Transactions

Retrieve Images

Image Manager

Image Archive

Retrieve Presentation States

Retrieve Key Image Note

Retrieve Evidence Documents

WADO Retrieve

Patient

Identity Source

Patient Identity

Feed

Query

Document

Documents

Document

Consumer

Registry

Register

Document Set

Retrieve

Provide & Register

Document

Document Set

Document

Document

Repository

Source

xds i new transaction requirements
XDS-I New Transaction requirements
  • XDS Actors:
    • Document Consumer
      • at least one Retrieve (DICOM C-Move or WADO)
    • Document Source
      • Provide and Register Document Set
  • Radiology Actors
    • Image Manager / Image Archive
      • WADO Retrieve
xds i profile options 1
XDS-I Profile Options (1)
  • Document Source must support at least one of the following options:
    • Extensive Set of DICOM Instances
    • PDF Report
    • Text Report
    • Multipart Text/PDF Report
slide18

Register Manifest

Query Registry

DICOM Manifest

DICOM Manifest

Retrieve Manifest

Reference to image 1

Reference to image 1

Reference to image 2

Reference to image 2

Reference to image 3

Reference to image 3

Retrieve Images

Manifest

Manifest

Manifest

Manifest

Manifest

Clinical IT System

Clinical Encounter

Document Registry

Document Repository

sharing of extensive dicom instance set19
Sharing of Extensive DICOM Instance Set
  • The shared Document is a manifest
    • a Key Object Selection DICOM Instance
  • Image Manager/Image Archive is required
    • to ensure that the referenced images from within a published manifest are available to be retrieved
  • Document Source is responsible
    • for replacing a previously submitted manifest Document when a change occurs to the manifest content (eg. Change of the DICOM SOP instances referenced within the manifest)
slide21

Radiology Report

Header:

Report Type:

OB / Gyn

BPD

…..

...

Findings:

…..

Gestational

Impressions:

Age

...

Text Report

PDF Report

Text +PDF Report

Radiology system

Report Source

slide22

Register Report

Query Registry

Radiology Report

Header:

Report Type:

OB / Gyn

BPD

Retrieve Report

…..

...

Findings:

…..

Gestational

Impressions:

Age

Report

Report

Report

...

Clinical IT System

Clinical Encounter

Document Registry

Document Repository

Radiology system

Report Source

sharing of report
Sharing of Report
  • The shared Report Document format is
    • PDF, Text, or multipart PDF + Text
  • A report can
    • embed selected images in its PDF format
    • include fully resolved hyperlinks (interactively clickable) that point to the selected images
  • Document Source is responsible
    • for formatting the hyperlink to reference relevant images as a DICOM WADO URI or as IHE RID Request for Document
  • Document Source is required
    • to ensure that image references are valid links
xds i actors grouping
XDS-I Actors / Grouping
  • Sharing of an Extensive DICOM set
    • Document Source shall be grouped with an Image Manager/Image Archive
  • Sharing of a report that references selected images
    • Document Source shall be grouped with an Image Manager/Image Archive
  • Sharing of a report that references selected images from previously published extensive DICOM set
    • Document Source can be grouped with a Document Consumer
linking report to complete set of images

SubmissionSet

DocumentEntry

DocumentEntry

Study

Manifest

Report

Linking Report to Complete Set of Images

Document Registry

Document Repository

linking report to complete set of images26

SubmissionSet

1

SubmissionSet

2

DocumentEntry

Report

Study

Manifest

Linking Report to Complete Set of Images

Document Registry

DocumentEntry

Document Repository

linking report to prior images and prior report

SubmissionSet

3

SubmissionSet

1

SubmissionSet

2

SubmissionSet

4

DocumentEntry

DocumentEntry

DocumentEntry

Prior Study Manifest

Prior Report

Report

Study

Manifest

Linking Report to Prior Images and Prior Report

Document Registry

DocumentEntry

Document Repository

linking report to selected images

BPD

...

…..

Linking Report to Selected Images

Radiology Report

Header:

Report Type:

OB / Gyn

…..

Findings:

Gestational

WADO URI

Link

to image

Age

...

Relevant Image

Radiology system

Report Source

examples of wado implementation
Examples of WADO implementation

Web Client System

Web Access to Dicom Persistent Objects

Web Access to Dicom Persistent Objects

DirectInterface

Web Gateway

Gateway

DICOM Q/R

DICOM Interface

Web Interface

DICOM Q/R

DICOM Interface

DICOM Objects Database

DICOM Objects Database

Flexibility for the client

to be implemented either

as new system

or on existing system

wado interaction diagram
WADO Interaction Diagram

Web Client

System

Web Enabled DICOM Server

Object(s) request (HTTP GET)

Object(s) send

(HTTP response header and body)

syntax of the wado http get method
Syntax of the WADO HTTP GET method
  • Syntax defined by the RFC2396 (URI)
  • http://<authority><path>?<query>
  • e.g:
      • http://www.hosp.fr/dicom/wado.asp?studyUID=1…
  • The « Web Access to DICOM Persistent Object » standard defines only the <query>

Path of the Web Enabled DICOM Server

WADO Parameter(s)

wado selection parameters
WADO Selection Parameters
  • studyUID&seriesUID&objectUID[&frameNumber]
    • studyUID => UID of the study containing the object(s)
    • seriesUID=> UID of the series containing the object(s)
    • objectUID => UID of the single object (Service Object Pair SOP)
    • frameNumber => number of the selected frame (multiframe image objects) – if NOT retrieved as application/dicom
wado mime type of return object
WADO MIME type of return object
  • The MIME type of the object contained in the contentType parameter, compatible the<accept>parameter of the GET method
  • application/dicomfor all objects, or a different MIME type for converting the DICOM object, depending of the nature of the object:
    • image/jpeg for still image object
    • text/html or text/plain for text object, or
    • other optional formats
wado mime type of a structured report
WADO MIME type of a Structured Report
  • application/dicom
  • application/x-hl7-cda-level-one+xmlfor converting the SR into CDA (see HL7 Imaging SIG /DICOM WG20)
  • text/plain for « minimal » version of document
  • text/rtf for « Word » version of document
  • application/pdf for « stable » version of document, potentially containing images
  • text/html a priori without the images (to contained into only one file). The reference to the images can used the WADO syntax.
wado parameters when the object is return as application dicom
WADO Parameters when the object is return as application/dicom

[transferSyntax][anonymize][charset]

  • transferSyntax => DICOM UID of the transferSyntax to be applied to the image (lossy/lossless compression). Implicit and Big Endian TS shall not be used.
  • anonymize => “=yes” for blanking all the personal healthcare information (patient name, study date…) as described in Sup. 55. Potentially the server can refuse to deliver an object if there are some risk the personal information is burned into the image (secondary capture…)
  • charset => for converting the text fields in a different character set (available also if object return as text/xxx)
parameters when the object is return as image xxx 1
Parameters when the object is return as image/xxx (1)

[imageQuality]

[presentationUID & presentationSeriesUID |[windowCenter & windowWidth]]

  • imageQuality => controls the level of compression (from 1 to 100)
  • presentation => UIDs of the Presentation State SOP and of its series to be applied on the image (P-values, and display size set to the original size if undefined)
  • windowCenter / windowWidth => controls the luminosity and the contrast of the B&W image
parameters when the object is return as image xxx 2
Parameters when the object is return as image/xxx (2)

[region][rows][columns][annotation]

  • region=> part of the image to be displayed, in relative coordinates (top left hand corner and bottom right hand extent)
  • rows => maximum number of pixels (vertical)
  • columns => maximum number of pixels (horizontal)
  • annotation => text to be superimposed of the image (“patient” and / or “technique” for demographic information and technical information, respectively)
security aspects
Security aspects
  • It is clear that the information contained within DICOM objects may be considered as protected healthcare information (PHI). The protocol used, that is HTTP, can be replaced by HTTPs, which is its secure extension, for that purpose.
  • Two optional parameters, anonymize and annotation, control respectively the absence of patient identification in a retrieved DICOM object and the presence of patient identification burned in to the pixel data of images.
providing a image as image xxx

Select the object

studyUID&…

presentationUID&…or windowCenter…

Apply the presentation

Select a region

region

Build the pixel area

CT WC-800 WW200

rows…&columns…

Burn the annotations

annotation

Content-Type: image/jpeg;

name="Image.jpg"

Content-Transfer-Encoding: base64

Content-Disposition: attachment;

filename="Image.jpg"

/9j/4AAQSkZJRgABAQEASABIAAD/2wBDAAYEBQYFBAYGBQYHBwYIChAKCgkJChQODwwQFxQYGBcU

FhYaHSUfGhsjHBYWICwgIyYnKSopGR8tMC0oMCUoKSj/2wBDAQcHBwoIChMKChMoGhYaKCgoKCgo

KCgoKCgoKCgoKCgoKCgoKCgoKCgoKCgoKCgoKCgoKCgoKCgoKCgoKCgoKCj/wgARCABkAGQDASIA

AhEBAxEB/8QAGwABAQEBAQEBAQAAAAAAAAAAAAUEAwECBgf/xAAYAQEAAwEAAAAAAAAAAAAAAAAA

AQIDBP/aAAwDAQACEAMQAAAB/qgAAAAAAABNpnSTVc6Sbpm2lO6RG0a7gAcZWztzcORR8tef9+6a

09xdPZncOjtAfH3Opls+oOrHlq8+Eubfoc3LpfXRn4ZaZUtOTXr0BfVPoKZxud1lzRdFJN5PSklI

8sIjJrNegLXAAAAAAAAAAAAAA//EACEQAAMAAQQCAwEAAAAAAAAAAAECAwQREhMUACAQNFAk/9oA

CAEBAAEFAvyksxxl7DILsYJ2GVSyIrXoJVbf6zoKeT+lPscTS48WUWM8lSMQHWSPTs+r42rcI4EG

Generate the MIME type

contentType

DOE 2003-9-22

Providing a image as image/xxx
client flexibility
Client flexibility
  • The WADO functionality supports access to
    • Native (un-rendered) DICOM data
    • Associated rendering data e.g. Gray Scale Presentation State
    • “Rendered” information e.g. JPEG image
  • So client design can be
    • Simple, relying on basic features of the web browser
    • Complex, providing advanced functionalities by taking ‘raw’ DICOM data and deciding the processing and rendering to be applied
xds i metadata
XDS-I Metadata
  • Radiology specific
    • Acquisition Modality (e.g. CT, MR)
    • Anatomic Region (e.g. Arm, Elbow, Hand)
    • Requested procedure (e.g. MRI Knee with contrast)
  • Query example
    • find all “CT of the Head” of patient John Doe for the last 2 years
more information
IHE Web site: http://www.ihe.net

http://www.himss.org/IHE

http://www.rsna.org/IHE

http://www.acc.org/quality/ihe.htm

Technical Frameworks

Technical Framework Supplements – Trial Implementation

Non-Technical Brochures :

Calls for Participation

IHE Fact Sheet and FAQ

IHE Integration Profiles: Guidelines for Buyers

IHE Connect-a-thon Results

Vendor Products Integration Statements

More information….

Questions?