XDS (Cross-Enterprise Document Sharing)

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					                       Image Sharing

                                   Review and Update

   David S. Mendelson, M.D.
    Professor of Radiology
  Chief of Clinical Informatics
The Mount Sinai Medical Center
Co-chair IHE International Board
      Image sharing- Why?

• Benefit of historical exam during interpretation
• Rapidly growing cost of healthcare especially
  growing utilization of imaging
   – Overutilization
   – Prevent duplicate exam because a recent exam is
• Radiation exposure
• Quality
   – Expedites clinical care through easy availability of
     imaging examination
      Issues that govern sharing Imaging Exams

•   What is our product?
•   Who are our customers?
•   What are the mechanisms of sharing?
•   What are the impediments?
    – Technology
    – Policy
       Our Product – Information!
• Imaging Exam
   – Order
   – Direct patient history
   – Prior exams
• Report
   – Demographics
       • Referring Clinician
       • Reporting Team
   – Indication
   – Narrative
       • Procedure
   – Impression
   – Structured report
      Issues that govern sharing Imaging Exams

•   What is our product?
•   Who are our customers?
•   What are the mechanisms of sharing?
•   What are the impediments?
    – Technology
    – Policy
                            Radiology              Physician


               Consulting               Clinical
                Physician                Trial
      Issues that govern sharing Imaging Exams

•   What is our product?
•   Who are our customers?
•   What are the mechanisms of sharing?
•   What are the impediments?
    – Technology
    – Policy

• Are you old enough to remember film?
• Still exists
  – Clinical offices
      The “CD”- “better than sliced bread” or “be
      careful what you ask for – you may get it”

•   Portable
•   Compact
•   Can hold thousands of images
•   Inexpensive ($0.50 or less)

• What’s wrong here?
        CDs- Problems
• Different data formats
    – Non-Dicom
• Different viewers
    – End-user confusion
•   Defective Discs
•   Disc must be in your possession
•   Patient Identity
•   Wrong Patient on Disc
•   Time consuming
•   Clinician’s are confused
    – They share their confusion with their Radiologist
      CD- Opportunities to improve

• Importing a disc provides the opportunity to correct
• Robust import solutions -commercial
   – Standard import interface
      • Reconciliation process
   – Trained personnel
• Standards
   – DICOM
   – PDI extensions (IHE- Portable Documents for Imaging)
   – BIR- (IHE- Basic Image Review)
      • Minimum requirement for review
       Mechanisms of Sharing- Reports

•   Mail
•   RIS
•   FAX
•   E-Mail
•   PACS
    – VPN
• Internet
    – EMR-Patient Portal
    – PHR
    When to release a Report vs. Image?

                     • Immediate use to
• The patient is entitled
   – Legal             clinician
   – Practical       • May be meaningless to
   – Is the patient    most patients other than
     prepared for the a curiosity
     information in
     the report?
     Network/Internet base sharing

• Replace the CD (SneakerNet) with the
• Convenience vs. Security
• New opportunities
  – Shared Image processing
• Efficiencies
     Network/Internet base sharing

• Proprietary applications
  – Usually used within an enterprise or a limited
    domain with legal agreements
• Health Information Exchange (HIE)
  – Multiple enterprises with a set of legal
  – Often have selected their own standards-
    not truly open standards based
  – Sustainability
• VPN/Enterprise Portal
    – Clinical Staff
    – Patient
    – Temporary credentials
• Enterprise- multi-sites; proprietary solution
    – Multiple PACS and RIS feed one central archive
    – All credentialed can view that archive
• Point to Point networks
    – Standards based or proprietary sharing network
        • IHE model
• Patient Centric model / PHR
        Challenges to exchange
•   Who pays for an exchange infrastructure
•   What is the persistence of the information in the exchange
•   Are images different from other forms of healthcare data
•   Easy secure access is good for the patient
    – Does it endanger the provider?- is this an impediment?
    – Economic adjustments and evolution are likely to occur
        • Balance of cost control vs. Quality
        • Reduction in Radiation exposure
    – Not all patients agree
     Point to Point

• A limited number of entities establish
  direct connections
• Usually requires a direct formal
  relationship (legal)

• Can be successful to address very
  specific interoperability problems
• Doesn’t scale

• Requires legal relationships between participants
• Requires patient identity management
• Enables a greater number of entities to participate
   – May be scalable
   – HIE to HIE
• Consent issues
   – Commonly all or nothing rather than episode or event based
   – Patients may wish to only expose limited pieces of
Sharing Healthcare Information in the Cloud


Imaging                          Specialist


   Cloud Computing

• WHO          • WHAT

• Enterprise   • Services
• HIE          • Transactions
• Consumer     • Archive
     IHE-XDS (Cross-Enterprise Document Sharing)

• XDS.a
• XDS- I.a
• XDS.b
  – ?? XDS-I.b

• a vs. b
  – Related to web standards and transactions
Canada Health Infoway
A Standards Based Solution

     Goals of Contract

• NIBIB contract
• Bootstrap an IHE based network
  – Primary emphasis is Consumer Control
    through PHRs
  – Can be extended to other forms of sharing
     • HIE
• Security and Confidentiality are drivers
• Replacement / Alternative to CD
    NIBIB contract summary

• Consumer Control                 • 5 Academic Institutions
• Employ IHE solutions                – Mayo Clinic
  whenever possible                   – Mount Sinai Medical
   – IHE generally has not              Center
     focused on consumer              – University of California
     driven solutions but               San Francisco
     rather on institutional and      – University of Chicago
     enterprise workflow              – University of Maryland
                                   • Establish a clearinghouse
                                   • Engage PHRs
                                   • 300,000 patients over 2
     Image Sharing/Elements of Solution

• Edge Server
   – Register a patient
   – Listens to a Radiology Information System (RIS)- looking for a
     complete exam
   – Retrieves Image set from PACS and Report from RIS
   – Send both to clearinghouse
        • PHI hidden; an RSNA ID and 2nd factor security token are used to identify
          the patient
• Clearinghouse (XDS-I) – functions as a secure router
   – Transiently hold encrypted patient data
   – Consumer controls upload and future access
        • Must have RSNA ID available and know answer to 2nd factor question
   – Develop web based viewers
   – Download full DICOM data set
• Misc Consumers
Software architecture
                                                                                    Protocol Flow
                                                                                                                 R   A
                                                                                                                 S   D
                                                                                                                 R   M
                                                                                                                 C   I
                                                                                                                 H   N
                                                                               From RIS                                        XDS.b &
                                                                                               HL7        Web/                            Clearing
                                                                                                   MIRTH Java                  token       House
                                                                                             DICOM        Srv


Prepare content    Poll database, get report, get            Background java srvlet                              25 days
                   exam,prepare big fat file
Transfer content   Poll database for transfer out, package   Background java srvlet                              35 days
                   content into xds.b
HL7 receiver       Receive HL7 A04 messages, extract         Mirth HL7 Channel. Let Mirth create its             65 days for 5 sites
                   reports and store them in database        default database, all script work-but may
                                                             have to customize per site
Token App          Create new tokens based on two parts,     Ajax based web front-end ,JavaServlet               30 days
                   associate token with accession            for CFIND using dcm4che, creating job in
                   numbers, update database, user            the RSNA database, creating tokens
                   interface with login, get patient         using kerberos – tokens generated locally
                   info,create job
Database           Store reports, logs, audit trails, user   Mirth instance for HL7 & DICOM, RSNA                50 days – 2 databases
                   accounts, etc.                            instance for everything else
Management App     Create users, monitor logs, check         Ajax gui front end, backend servlet,                45 days
                   health                                    dicom targets etc.
     Project design assumptions

• Security is paramount
  – Restrictive policy
  – PHI is never unsecured
• Consumer controls the flow of
  information by placing it in the PHR
  – Diminishes the need for BAAs between
     • Imaging Site to Clearinghouse
     • Clearinghouse to PHR
Image Enabled PHR
       Advantages of Approach
• Push model
   – No Query of PACS from outside the firewall
• Full DICOM data set is available
   – Web viewers
   – Download and Import to PACS
• Report is available
• Historical exams can be sent simultaneously
• Consumer controls flow of information
   – Affords the patient the ability to select what information to
       • Is this good?
    Future Directions

• Refine Workflow
  – Initial workflow is to replace a CD
  – Exam updates
  – Download DICOM data and archive in a
    local PACS
• Edge server as a platform
  – Radiation Monitoring
  – Peer Review
  – Quality Metrics
              Research CTP- The RSNA Clinical Trial Processor

•   CTP is a stand-alone program that provides all the processing features of a MIRC site for clinical trials in a highly configurable and
    extensible application. It connects to FieldCenter applications and can also connect to MIRC sites when necessary. CTP has the
    following key features:
•   Single-click installation.
•   Support for multiple pipelines.
•   Processing pipelines supporting multiple configurable stages.
•   Support for multiple quarantines for data objects which are rejected during processing.
•   Pre-defined implementations for key components:
      –    HTTP Import
      –    DICOM Import
      –    DICOM Anonymizer
      –    XML Anonymizer
      –    File Storage
      –    Database Export
      –    HTTP Export
      –    DICOM Export
      –    FTP Export
•   Web-based monitoring of the application's status, including:
      –    configuration
      –    logs
      –    quarantines
      –    status
      Issues that govern sharing Imaging Exams

•   What is our product?
•   Who are our customers?
•   What are the mechanisms of sharing?
•   What are the impediments?
    – Technology
    – Policy
• We live in a heterogeneous world needing multiple solutions
• CDs and portable media have both advantages and drawbacks
    – Compliance with standards helps
• We are transitioning to network/internet solutions
    – Security and confidentiality are even more difficult
    – ONC and State policies will foster these solutions
    – Solutions are evolving
        • Proprietary solutions are often easier to implement
        • Solutions based on open standards will provide the patient with greater
        • Interoperability will require an adjustment to the way we all think of healthcare

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