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					           IHE Cardiology
          Profiles for Year 1


              Tom Dolan, Philips
Co-editor, IHE Cardiology Technical Committee


                                                1
     Presentation 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 2004   Dolan – p. 2
Three profiles selected for year 1
 Cardiac 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 2004   Dolan – p. 3
        Why these 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 2004   Dolan – p. 4
       Cath Lab




(A) room for improvement !
       IHE Educational Workshop 2004   Dolan – p. 5
     Cath Workflow Management
    Multi-Modality, Intra-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 2004   Dolan – p. 6
   Cath Workflow Management
           Extra-lab issues

Un-ordered cath exams (emergency)
Unidentified patients
Uncoordinated with Hospital Information
System
Diagnostic and interventional procedures
Ad hoc scheduling of cath labs
Change of rooms during procedure
… and interactions among these issues!
              IHE Educational Workshop 2004   Dolan – p. 7
Cardiac Catheterization Workflow
          - 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 2004   Dolan – p. 8
               Cardiac Catheterization Workflow
                  - What’s OUT?…for year 1
             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


                                                                                         But on the 5-
                                                   Amended      Export to
                                                     Report      Registry
                                         Report    (optional)   (optional)


                                                                      …                      year
   Pre-      Admission   Diagnostic Intervention  Post-          End of      Long-Term
Procedure
Evaluation
                to
              Facility
                         Procedure   (optional) Procedure
                                                 Events
                                                                Episode
                                                                 Event
                                                                             Follow-Up
                                                                                          roadmap!
      Addressed in Year 1

                                                  IHE Educational Workshop 2004                   Dolan – p. 9
 Cath actors and transactions
                                     ADT
 Pt. Registration [Rad-1] 
 Patient Update [Rad-12]                                      Pt. Registration [Rad-1]
                             Placer Order Management [Rad-2]  Patient Update [Rad-12]
          DSS/ Order Filler  Filler Order Management [Rad-3] Order Placer

    Modality PS in Progress [Card-1]
    Modality PS Completed [Rad-7]  Procedure Scheduled [Rad-4]
                                       Patient Update [Rad-12]
                                       Procedure Updated [Rad-13]
Many actors cooperating in a complete end-
                               Image Display
to-end workflow
Documented in the Technical Framework [Card-4]
    Performed
    Procedure
   Step Manager
                                    Query Images [Rad-14]
                                    Retrieve Images

                                                     Image    Image
                                                    Manager   Archive
         Modality PS in Progress [Card-1]
         Modality PS Completed [Rad-7]
                                                  Storage     Modality Image/Evidence
                                            Commitment        Stored [Card-2]
                                               [Card-3]
        Modality PS in Progress [Card-1]
        Modality PS Completed [Rad-7]
                                                        Acquisition
                                                        Modality
         Query Modality Worklist [Rad-5]

                                IHE Educational Workshop 2004                              Dolan – p. 10
Actors/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 2004   Dolan – p. 11
Cardiac Cath – 8 use cases
All 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 2004              Dolan – p. 12
                        Benefits
Simplify 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 2004   Dolan – p. 14
                          ACTORS
Acquisition 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 2004                      Dolan – p. 15
                        ACTORS
Image 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 2004                      Dolan – p. 16
                TRANSACTIONS
Patient 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 2004                               Dolan – p. 17
                TRANSACTIONS
Modality 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 2004                            Dolan – p. 18
Case 1 : Patient Registered at ADT and Ordered 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 2004        Dolan – p. 19
Case 2 : Patient Registered at ADT and Ordered 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 2004          Dolan – p. 20
Case 3 : Patient Registered at ADT and Procedure
       Not Ordered – 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 2004          Dolan – p. 21
Case 4 : Patient Registered at Department System
     Scheduler/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 2004           Dolan – p. 22
       Case 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 2004           Dolan – p. 23
 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 2004          Dolan – p. 24
 Case 7 : Change Rooms 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 2004                  Dolan – p. 25
          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 2004         Dolan – p. 26
                                                     Case 3 : again…..
Case 3: Patient Registered at ADT and Procedure Not Ordered – Schedule on MPPS
Case 3A: Unidentified Patient Registered at ADT and Procedure Not Ordered


                        Order               Department System       Image
ADT                                            Scheduler/          Manager/                    Acquisition             Acquisition
                        Placer
                                               Order Filler       PPS Manager                   Modality               Modality n
           Register J.Doe


      Patient
      Registration [RAD-1]


                                                    Modality Procedure    Modality Procedure
                                                    Step In Progress      Step In Progress
                                                    [CARD-1]              [CARD-1]
                                 Filler Order
                                 Management -             Auto-create
                                 New [RAD-3]              Procedure                                      Perform
                                                                                                         Acquisition
                                  Filler Order        Procedure
                                  Mgmt - Status       Scheduled [RAD-4]
                                  Update [RAD-3]
                                                                          Query Modality Worklist [RAD-5]                      Perform
                                                                          Modality Procedure                                   Acquisition
                                 Filler Order        Modality Procedure
   Patient Reconciliation        Mgmt - Status       Step Completed       Step Completed
                                 Update [RAD-3]      [RAD-7]              [RAD-7]
           J.Doe ->
           J.Smith
          Patient Update/
          Merge [RAD-12]                             Patient Update/
                                                     Merge [RAD-12]




                                                         IHE Educational Workshop 2004                                                       Dolan – p. 27
          Case 3 : Significant 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 2004               Dolan – p. 28
                      Case 3 : Highlights

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 2004          Dolan – p. 29
          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



             IHE Educational Workshop 2004   Dolan – p. 30

				
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