IHE in Cardio

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					Integrating the Healthcare Enterprise

 Applying the IHE Framework to
           Cardiology
              Joseph Biegel
                  Mitra
         IHE Planning Committee
       Applying the IHE to
       Cardiology - Topics
• Quick IHE Overview
• Motivations for IHE in Cardiology?
• Common and distinct needs in
  Cardiology
• Data Complexity and Workflow
• Applying Scheduled Workflow in
  Cardiology
• Challenges and next steps…
                    2                  HIMSS 2002
       What is IHE about?
• It’s an initiative promoting and
  supporting the integration of systems in
  the healthcare enterprise.

• Integration Goal: Improve the efficiency
  and effectiveness of clinical practice by:
  – Improved Information Flow
  – Advanced Multi-System Functions

                     3                  HIMSS 2002
         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 inconsistent or unavailable

  Responsibility for information flow between systems,
   and between departments, is often unclear.
                             4                       HIMSS 2002
            Who is IHE?
• Participants:
  – Professional Societies (RSNA/HIMSS/…)
  – Vendors (over 30 companies)
  – Standards Group Committee Members


• RSNA and HIMSS sponsor IHE to
  provide a neutral forum for working on
  the Big Picture

                    5                 HIMSS 2002
        What Does IHE Do?
• 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 (RSNA/HIMSS)

                         6                     HIMSS 2002
 Aren’t DICOM / HL7 Sufficient?
• Standards are vital (HL7, DICOM, ICD, …)
  – They provide tools & technologies
• But Standards alone are insufficient
  – They are open to interpretation
  – There is room for optional variations
  – They avoid specifying how to apply them to
    particular real world scenarios




                       7                  HIMSS 2002
How is IHE related to Standards?
 • IHE attacks real world integration problems
 • HL7 and DICOM provide dictionaries
 • IHE defines a “phrasebook” that solves real
   world problems by assembling pieces
   provided by DICOM/HL7




                        8                   HIMSS 2002
  What are Key IHE Concepts?
• Generalized Systems                   -> Actors
• Interactions between Actors           -> Transactions
• Problem/Solution Scenarios            -> Integration
                                           Profiles
• For each Integration Profile:
   • the context is described (which real-world problem)
   • the actors are defined (what systems are involved)
   • the transactions are defined (what must they do)

                             9                      HIMSS 2002
         Scheduled Workflow Profile
                                                                                report
                                                                           report
  Registration                     report                    Report
                   HIS                                      Repository

        patient                                                              Diagnostic           Film
     information                                                             Workstation        Lightbox
                                                                                     images
                                                                  PACS              retrieved



     Orders Placed
                                               procedure
                                               scheduled                                         Film
                                                                              Image Manager
                                           Prefetch any relevant                                Folder
examination orders                                                               & Archive
                                           prior studies
                                                          Acquisition
                                     modality                         images
                                                            Modality
                   Orders Filled      worklist                         stored
       RIS                                                             acquisition
                                                                       completed
                                   acquisition                                                  Film
                                   in-progress
                                    completed                                images
                                                                             printed
                                               10   Modality                             HIMSS 2002
    That’s nice, but it is
       Radiology…
Cardiology
 ardiology

Radiology

             Henry Gray (1825–1861). Anatomy of the Human Body. 1918.
             http://www.bartleby.com/107/illus490.html


                   11                                            HIMSS 2002
    Simplified view of Cardiology
                                                     ECG




 Patient       Physician
Complaint
                                                     Nuclear Study
                               Cardiologist


               Hemo        Cath               Labs
      Echo



             Interventional Procedure



                                  12                         HIMSS 2002
    Why IHE in Cardiology?
• Cardiology workflow is complex
• Multiple diagnostic tests are very
  common
  – Large number of manual demographic
    input steps is common.
  – This leads to inefficiency, invalid data in
    clinical archives and can lower the quality
    of care

                       13                   HIMSS 2002
 Why IHE in Cardiology (2) ?
• The Cardiology position in the IT technology
  adoption cycle makes the IHE an ideal
  foundation
• The concepts of the IHE TF have broad
  general applicability, many can be directly
  leveraged in Cardiology
• Some of Cardiology’s special requirements
  can be well met by the IHE TF
• The TF could be adapted to meet Cardiology
  specific needs

                      14                  HIMSS 2002
           Common Needs
• Cardiology departments have needs similar
  to Radiology departments
  – Both are driven by imaging modalities
  – Workflow is similar at a very high level
  – Need to manage distributed departmental
    resources
  – Desire an integrated patient-centered view
  – Need for administrative reporting
  – Need to improve lab efficiency via workflow
    management

                         15                       HIMSS 2002
   Distinct Cardiology Needs
• Clinical data content is more complex
  – Procedural data with rich report content
     • Direct tie to billing
  – Clinical results data mining is a priority
• Cardio departments are often more
  driven/isolated by subspecialty
• Legacy installed base without clear
  connectivity path is large
• Strong individual patient focus than a system
  or procedure focus
• Cardio departments are revenue centers
                               16                HIMSS 2002
    Complexity of Core Data
• Radiology              • Cardiology
  – Diagnostic Imaging        – Diagnostic Imaging
     • CT,MR,US,NM…              • XA, US, NM, CT, MR
     • Scanned Film           – Waveforms
  – Text Reports                 • ECG, Hemo, EP, Stress
  – Measurements              – Extensive numeric
                                measurements
                              – Lab data
                              – Complex Reports
                                 • Stress,Holter, Cath


                         17                          HIMSS 2002
      Cardiology Workflow
           Elements
• Workflow elements in common with
  Radiology:
  – Patients are admitted
  – Demographics entered (often multiple
    times for the same patient)
  – Imaging studies are performed and read
  – Reports generated



                     18                 HIMSS 2002
      Cardiology Workflow
           Elements
• Additional Workflow elements:
  – Echo, ECG & lab data often prerequisites
    to treatment
  – Consumable materials and clinical data
    tied to procedures
  – Monitoring data is part of the Cath
    procedure
  – Echo as follow on to a Cath procedure
  – Interpretation generally uses multiple
    clinical inputs
                     19                  HIMSS 2002
Scheduled Workflow “Works”
      for Cardiology
• Minimizing redundant demographic
  input and producing valid header data in
  the clinical archive is important in
  Cardiology
  – Multiple modality inputs of Cardiology
    drives the value
  – Basic problem is well addressed by the
    Scheduled Workflow and Patient
    Reconciliation Integration Profiles in IHE
    Year 3
                       20                   HIMSS 2002
  Patient Information Reconciliation
   Profile “Works” for Cardiology
• Extends Scheduled Workflow
   – Handle unidentified patient (e.g. emergent)
   – Handle demographic information mistakes
   – Propagate changes to all affected systems,
     update all affected data
• Reduces incorrectly identified or “lost” studies
• Can reduce lost charge postings (billing)




                          21                       HIMSS 2002
       Can you “Just Do It”?
• We have done some investigations and
  prototype clinical testing to examine the utility
  of applying the concepts of Scheduled
  Workflow and Patient Reconciliation
• Key Pieces
   – HIS, “RIS”, Modality & PACS
• The HIS is the same
• So far this is easy…

                         22                   HIMSS 2002
    Modality Connectivity in
          Cardiology
• Imaging Modalities often have at least
  some DICOM services
  – DICOM Store SCU support common in
    new systems
  – Some legacy conversion solutions
  – DICOM MWL becoming common
  – DICOM MPPS and Storage Commitment
    “getting there”
• That was the good news…

                    23                HIMSS 2002
    Modality Connectivity in
          Cardiology
• Critical care monitoring is out of scope
  for now.
• Waveform systems are challenging.
  – Some Hemo systems and ECG information
    systems support HL7 ADT and ORM
    messaging allowing functionality similar to
    DICOM MWL.
  – Others have proprietary connectivity
    capabilities which could be “rigged” to
    enable MWL “style” modality messaging.
                      24                  HIMSS 2002
  The Cardiology “RIS” (CIS)
• Ask 10 people what a CIS is and you
  will get 9 answers…
• One of the key elements we need is an
  electronic source of order and schedule
  data that drive department workflow and
  support OP/OF and PPS Manager
  Actors
• This is often not readily available in
  Cardiology departments today
                   25                HIMSS 2002
          Scheduled Workflow in Cardiology

                                                            ECG


                                                              ECG LAB



                     CIS
                                        DMWL                CATH
                 (Performed                                                                    DICOM
      ADT,ORM                           MPPS                                                   Image
HIS               Procedure
                                       Patient
                                                                         Storage Commitment
                                                                                              Manager/
                  Step Mgr,
                                    Demographics,                                              Archive
              Order Placer/Filler     Schedules                                Waveform
                                                                                                 &
                    Actors)                                                    & Report
                                                         HEMODYNAMICS
                                                                                               Report
                                                                                              Repository

                                                              CATH LAB




                                                            ECHO


                                                              ECHO LAB



                                                    26                                               HIMSS 2002
       Easy Wins for IHE in
           Cardiology
• Workflow in the Cath lab can be streamlined
  – Minimize data re-entry
  – Automate pre-fetching
• Since Scheduled Workflow leverages DICOM
  MPPS, near real time updates on Cath
  procedure status are possible
• DICOM SR and Waveform allow the use of a
  common DICOM archive for waveform and
  imaging systems

                         27               HIMSS 2002
    Connectivity Challenges
• DICOM MPPS is a limiting capability for
  integrating Cardio modalities.
  – New Imaging modalities are starting to have IHE
    Modality Actor support, but the legacy installed
    base will be an integration challenge.
• Waveform modalities need to either adopt
  DICOM modality messaging and storage or
  the IHE TF needs to be extended to allow
  HL7 or “other” methods.
  – There are underlying standards (IEEE, SCP-ECG)
    that could be leveraged by the IHE in the future.

                         28                      HIMSS 2002
      Clinical Challenges in
      Cardiology for the IHE
• IS driven order creation in Cardiology is not
  generally available
• GSPS and Key Image Note have value, but
  are clearly limited today
  – Cardiologists use motion images and color data
    that depicts cardiac function
• Simple Image and Numeric Reports
  – Pictorial diagrams for anatomy, function and
    viability are needed for clinical reports
  – Extensions to manage specific frames of cine
    objects and waveform objects would be needed

                         29                    HIMSS 2002
Other Technology Challenges
• Some Cardiology tasks are still hard to
  “do digital”
  – Pediatric Echo is just now able to enter the
    digital era
     • Huge volume of data required to “do a search
       mission” on a tiny fast beating heart
     • Extensive measurements needed to
       understand the clinical situation
  – EP data volume
  – Real-time critical care monitoring

                         30                     HIMSS 2002
      IT, the CIO and That
            Archive…
• The IT department and the CIO should
  become strong advocates for moving
  the IHE into Cardiology
  – As IHE’s track record grows in Radiology
    integration projects, “doing it again down
    the hall” begins to form a value proposition
    for IT management
  – Leverage common archive infrastructure


                       31                   HIMSS 2002
               Conclusions
• The value is clear.
  – Applying and extending the IHE to Cardiology
    could save millions of dollars in product
    development costs
  – It could improve the quality and efficiency of care
• IHE Scheduled Workflow and Patient
  Reconciliation Integration Profiles are nearly
  ready to go in Cardiology.
• There are challenges.
• Need to extend the Technical Framework for
  some Cardiology specific needs.
                          32                       HIMSS 2002
  What Should You Do Now?
• Require support or at least a clear upgrade
  path to “Acquisition Modality Actor” for new
  imaging system RFP’s and purchase
  specifications
• Hug your Cardiologist and tell them a bit
  about why they need to know about the IHE…
• Help to build support within the key clinical
  professional societies
  – Have your CIO talk to the Cardiology chair and
    say, “I need your help so that I can help you”…
                         33                      HIMSS 2002
Questions?




    34       HIMSS 2002

				
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