Berthold Wein, Dept. Diagnostic Radiology University Hospital Aachen

1. Berthold Wein,Dept. Diagnostic RadiologyUniversity Hospital Aachen The Clinical Benefits of IHE The first 7 IHE Integration Profiles, for a Better Practice

2. Selected Problems: (Overview) • Seamless workflow • Data consistency • Image presentation • Spiral CT examinations • Information distribution • Image notification • Parametric access to images and reports

3. Workflow • Most critical issue in a Radiology Environment • Inter- or corrupted information chain • Paper based informations -> multiple re-entry of data • Different non adapted subsystems don‘t cooperate • Error correction takes huge amount of time • Stale information • Brandnew information not known (cancellation, change) • Status update information • Exam registered, finished, archived, reported, delivered

4. ADT Patient Registration Patient Registration Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps Patient Update Image Creator Order Placer Storage Commit Image Display Images Stored Filler Order Management Placer Order Management Q /R Key Image Note Present. State Stored Q /R Presentation Sates Q /R Images Department System Scheduler – Order Filler – Patient Update Key Image Note Stored Image Archive Procedure Update Procedure Scheduled Image Manager Key Image Note Stored Images Availability Query Images Stored Storage Commit Present. State Stored PPS In-Progress / Completed Performed Procedure Step Manager PPS In-Progress / Completed Acquisition Modality PPS In-Progress / Completed Modality Worklist IHE Integration Profiles Workflow

5. Worklist Modality Worklist Procedure Scheduled Store Images StorageCommitment Storage Commitment List of Images Modality Performed Procedure Step Performed Step: Status = Completed Performed CT Head Pat Name/ID, Dose, Accession #, Study UID Complete List of Images IHE Scheduled Workflow in Radiology RIS PACS &Archive • A Closed Loop • Update IS Scheduling • Match Procedure with Order • Support Billing Based on MPPS • Avoid Reading Incomplete Procedures

6. Data Consistency • Trauma patient • Manual wrong data entry at the modality • System crashed • VIP person

7. Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders IHE Integration Profiles

8. Image presentation • Viewing on different monitors / systems • Ensuring print quality outside of the department • Radiologist discussing images with remote physicians • Capture image manipulation to avoid redundant work (coronal CT, MR reading, etc.)

9. Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders ConsistentPresentation of Images ConsistentPresentation of Images Hardcopy and softcopy grayscale and presentation state Hardcopy and softcopy grayscale and presentation state IHE Integration Profiles

10. Achieving Consistent Presentation Original Image Window Level Flip Zoom Without Consistent Presentation Area Of Interest Area Of Interest Annotate Consistent Presentation of Images Referring Physician or Reviewing Radiologist Reporting Radiologist Presentation State Presentation LUT Grayscale Standard

11. Re-arranging Series • CT/MR: Head bone / brain separation (external/internal) • CR: Foot/ankle - hand/wrist • E.g., lateral image of foot shared between AP of ankle and AP of foot • DR: Trauma patient AP / Lat re-grouping • I.e., do all the Aps then rotate the patient once then do Lats • MR: MRI/MRA • To be viewed and billed separately • IR: Diagnostic run and therapeutic run • Performed contemporaneously, viewed/billed separately • US: Abdomen and kidneys / retroperitoneum and lymphnodes

12. Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders Presentation ofGrouped Procedures Presentation ofGrouped Procedures Subset a single acquisition Subset a single acquisition ConsistentPresentation of Images Hardcopy and softcopy grayscale and presentation state IHE Integration Profiles

13. Report:CHEST Report:ABDOMEN Abdomen View Chest View Chest View MODALITY Abdomen View Performs a single exam Operator groups 2 procedures IHE – Presentation of Grouped Procedures Requested Procedure:CHEST Requested Procedure:ABDOMEN RIS / PACS

14. Information distribution • Therapy related imaging • Radiation therapy • Computer assisted surgery (orthopaedic, neurosurgery, ...) • Secure image distribution within the enterprise and to the outside world

15. Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps Access toRadiologyInformation Access toRadiologyInformation Patient Information Reconciliation Consistentaccess to images andreports Consistentaccess to images andreports Unknown patients and unscheduled orders Presentation ofGrouped Procedures Subset a single acquisition ConsistentPresentation of Images Hardcopy and softcopy grayscale and presentation state IHE Integration Profiles

16. Report Reader Image Display Query and Retrieve Key Image Notes Query and Retrieve Images Query and Retrieve PresentationStates Query and RetrieveReports Image Archive Report Repository Image Manager Access to Radiology Information • Providing Access to Radiology Information: • Internally to Radiology • From Other Departments Surgery, Oncology, Pediatrics, etc. DICOM Based Transactions

17. Image notification • Flag images within a huge CT-series • Informations from radiographer to radiologist • Dedicated image descriptions • ....

18. Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps Key ImageNotes Key ImageNotes Access toRadiologyInformation Patient Information Reconciliation Exchange flaggingsignificant images Exchange flaggingsignificant images Consistentaccess to images andreports Unknown patients and unscheduled orders Presentation ofGrouped Procedures Subset a single acquisition ConsistentPresentation of Images Hardcopy and softcopy grayscale and presentation state IHE Integration Profiles

19. Note3 Note1 Note2 for referring physician Here you can see the renal rupture. for referring physician This is the hematoma. for referring physician Hematoma everywhere Note1 Note2 for refering physician This is the hematoma. for refering physician Here you can see the renal rupture. Note3 Note3 Note3 Note3 for refering physician Hematoma everywhere for refering physician Hematoma everywhere for refering physician Hematoma everywhere for refering physician Hematoma everywhere Different notes on different images Same note on different images

20. Parametric access to images and reports Discussion Comparison is made to the prior study of 11.04.1999. 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 left paratracheal adenopathy. Signature

21. Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps Key ImageNotes Access toRadiologyInformation Patient Information Reconciliation Exchange flaggingsignificant images Consistentaccess to images andreports Unknown patients and unscheduled orders Simple Image andNumeric Reports Simple Image andNumeric Reports Exchange simplereports with image links and, optionally, measurements Exchange simplereports with image links and, optionally, measurements Presentation ofGrouped Procedures Subset a single acquisition ConsistentPresentation of Images Hardcopy and softcopy grayscale and presentation state IHE Integration Profiles

22. Pattern – Simple Image & Numeric Report Simply Adds Measurements to Simple Image Reports

23. Simple ImageandNumeric Reports

24. IHE Year 4 Integration Profiles Scheduled Workflow Post- Processing Workflow Patient Information Reconciliation ChargePosting Admit, order, schedule, acquire images, notify 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, optionally, measurements Hardcopy and softcopy grayscale presentation state Flag significant images Presentation of Grouped Procedures Subset of a single acquisition Access to Radiology Information Consistent access to images and reports Basic Security Audit Trail Consolidation & Node Authentication

25. Clinical Benefits by IHE • The power of IHE to improve productivity and reduce errors is really great • Clinical workflow will re-gain resources • Systems connectivity increases • => Daily work will become worthwhile again