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					Imaging Integration SIG

Imaging Integration SIG ..........................................................................................................................................1
1. Introduction ......................................................................................................................................................1
   1.1 Scope..............................................................................................................................................................1
   1.2 Imaging orders ...............................................................................................................................................1
   1.3 Order Status....................................................................................................................................................2
   1.4 Results (Event) ...............................................................................................................................................2
   1.5 Imaging Characteristics ..................................................................................................................................2
2. Application Roles (AR)........................................................................................................................................3
   2.1 Application roles associated with images and reports ....................................................................................3
   2.2 Application roles associated with images ......................................................................................................3
   2.3 Application roles associated with reports .......................................................................................................4
3 Mapping of IHE Transactions and Story Boards ..................................................................................................7
   3. 1 Placer Order Management.............................................................................................................................7
   3.2 Filler Order Management ...............................................................................................................................8
   3.3 Procedure Scheduled ....................................................................................................................................10
   3.4 Procedure Update .........................................................................................................................................11
   3.5 Image Manager ............................................................................................................................................11
   3.6 Report Manager............................................................................................................................................11

1. Introduction

1.1 Scope
The scope of the imaging domain includes imaging intents, imaging orders and imaging
events. The notion of imaging covers signals acquired by imaging modalities, that is pixel
data, image header meta-data and associated reports.


1.2 Imaging orders
        The request for imaging procedures contains the procedure code or name of the
procedure, the body region examined, indication and an optional procedure plan. As an
option, detailed requests for reporting may be included (e.g. the reporting template ID,
template code or name).
        There are two types of imaging order messages: initial request and verified, active
order. The initial request is created by an external order placer and sent to the order filler,
while the verified order, which contains additional scheduling information, is transmitted
from the order filler to the image manager. The initial order request created by the order
placer will in most cases contain less detailed information about the imaging procedure being
ordered than the second type of imaging order message which is sent between imaging
information (sub-) systems (IIS).
        Imaging procedures, as initially requested, are not necessarily verified by the imaging
order filler who is responsible for performing appropriate imaging procedures. The initial
request is therefore subject to „negotiation“ between order placer and order filler. The order
becomes active upon verification by the order filler. The imaging intent respectively plan of
the order placer is sent to the order filler as an initial order request. If the order filler agrees to
the order request, an accept message is sent back to the order placer and this new imaging
order gets activated (active imaging order). If the order filler disagrees with the new imaging
order, a reject message is sent back to the order placer. The order may in turn be modified or
revised.
        Verification of the order is performed by the imaging order filler (i.e. the imaging
procedure is considered appropriate with regard to the clinical indication). The
appropriateness of the ordered imaging procedures is checked twice:
 New imaging order by order filler (e.g. By using the Radiology Information System, RIS)
  Scheduled imaging procedure at the point of care where the imaging procedure is
   performed (e.g. Modality connected to the Picture Archiving and Communication System,
   PACS)
These checks trigger the associated state transitions of the imaging order.

        The scheduled imaging procedure message contains additional scheduling information
(e.g. service location) which is relevant for the order filler resp. the „department system
scheduler“ (see IHE application role).


1.3 Order Status
Ways to communicate the order status:
 Unsolicited notification (e.g. order filler to order placer and vice versa, order filler to
    image manager and vice versa)
 Query order status (e.g. order filler queries image manager)


1.4 Results (Event)
An unsolicited event notification informs the issuer of the imaging order or other actors
interested in the results (e.g. Publish/subscribe mechanism) about relevant imaging events
(mood code = event).
These notifications are used to indicate events like:
  Images available
  Reports available

Pull and push mechanisms are used for results distribution.
 Pull: Query Imaging Order Status and subsequently retrieve results
 Push: Publish Imaging Results (e.g. Publish/subscribe mechanism)


1.5 Imaging Characteristics
One of the characteristics of the imaging domain is its inherent duality of imaging procedures
and associated reports.
 Imaging Order:
     Reports may be ordered explicitly along with the imaging procedure request or as a
       stand-alone reporting order for previously acquired image data. Depending on the
       standards of practice, the order filler may consider imaging procedure requests which
       don´t contain explicit reporting requests implicit reporting orders and report on the
       image data.
 Results:
     Imaging orders are considered complete, if either image acquisition or image
       acquisition plus reporting has been completed
     Service Relationships (RIM association class) are used to cover:
        Relationships between Imaging Procedures
        Relationships between Imaging Procedures and Reports

   Results distribution: Image Data Volume
     Rather than distribution of complete imaging studies, in most cases only images
       showing the relevant findings will be distributed. Complete studies are sent upon
       request.
2. Application Roles (AR)


2.1 Application roles associated with images and reports

   Imaging Order Placer (sub-role of order placer)
     A system that requests (places) one or more types of imaging orders. The types of
       orders supported are determined by what sub-role(s) is/are supported.

   Imaging Order Filler (sub-role of order filler)
     A system that fullfills one or more types of imaging orders. The types of orders
       supported are determined by what sub-role(s) are supported.
     Corresponding IHE Application Role (AR): Department System Scheduler / Order
       Filler
        A departmental information system (e.g. Radiology Information System, RIS) that
           provides functions related to the management of orders received from external
           systems or through the department system’s user interface.
     The imaging order filler tracks images and reports.

   Information System (HIS/DIS/EPR)
     Information system (IS) that receives imaging procedure results. The IS either gets a
        notification about the order status (availability of images and / or reports) or receives
        imaging order results. The information system is used as an application role, because
        the target information system may be different from the order placer or there may be
        additional information systems interested in getting the results (e.g. by using
        Publish/Subscribe Mechanisms).
     Sub-roles of Information System: Enterprise Image Repository, Enterprise Report
        Repository Access, Enterprise Report Repository


2.2 Application roles associated with images

   Acquisition Modality
     IHE Definition: A system that acquires and creates medical images, e.g. a Computed
       Tomography scanner or Nuclear Medicine camera. A modality may also create
       Grayscale Softcopy Presentation States for the consistent viewing of images and create
       Key Image Notes.
        Key Image Note IHE Definition: The Key Image Note allows a user to mark one
          or more images in a study as significant by attaching to them one or more notes
          managed together with the study. Each note includes a title stating the purpose of
          marking the images and a user comment. Physicians may attach Key Image Notes
          to images for a variety of purposes: referring physician access, teaching files
          selection, consultation with other departments, and image quality issues, etc. A
          single Key Image Note may be reference several images within a study. Multiple
          Key Image Notes may reference the same image.When a Key Image Note is
          associated with an image, it may also reference a specific Presentation State for the
          image thus ensuring that the significance of the Key Image Note includes the
          image presentation state (window width/window level, flip, zoom, rotate, graphical
          and textual annotations as defined in the Image Display ConsistencyConsistent
          Presentation of Images Integration Profile).
   Image Creator
     IHE Definition: A system that creates additional images and/or presentation states
       and/or Key Image Notes and transmits them to an Image Archive. It also makes
       requests for storage commitment to the Image Manager for the data previously
       transmitted and generates Performed Procedure Steps.

   Image Manager / Image Order Tracker (sub-role of order tracker)
     A system that tracks images associated with one or more types of imaging orders. The
       types of orders supported are determined by what sub-role(s) are supported.
     Corresponding IHE Application Role (AR): Image Manager
        IHE Definition: A system that provides functions related to safe data storage and
          image data handling. It supplies image availability information to the Department
          System Scheduler. -> Comment: availability of reports associated with image
          information has to be taken into account
     The Image Manager is the Image Tracker of the Departmental Information System
       (DIS) (e.g. Radiology Information System, RIS or Picture Archiving and
       Communication System, PACS).

   Image Archive
     IHE Definition: A system that provides long term storage of images, presentation
       states and Key Image Notes.

   Performed Procedure Step Manager
     IHE Definition: A system that re-distributes the Modality Performed Procedure Step
        information from the Acquisition Modality or Image Creator to the Department
        System Scheduler/Order Filler and/or Image Manager.
     Comment: Status changes for reports are handled by the report manager (IHE
        Application Role)


2.3 Application roles associated with reports

   Report Creator
     IHE Definition: A system that generates and transmits draft (and optionally, final)
       reports, presenting them as DICOM Structured Reporting Objects.

   Report Manager
     IHE Definition: A system that provides functions related to report management. This
       involves the ability to handle content and state changes to reports and to create new
       DICOM Structured Reporting Objects (amendment: or HL7 CDA conformant reports)
       based on these changes. In addition, the Report Manager generates and transmits
       verified, unsolicited text results to the Enterprise Report Repository

   Report Repository
     IHE Definition: A system that provides long-term storage of reports and their retrieval
       as DICOM Structured Reporting Objects.
     Comment: The Report Manager transforms DICOM Structured Report Objects to HL7
       compliant structured reports (e.g. HL V3 Clinical Document Architecture (CDA)
       compliant objects)
   Enterprise Report Repository
     IHE Definition: A system that receives Structured Report Export Transactions from
       the Report Manager and stores them.
     Comment: This Report Repository is external to the Radiology Department or Imaging
       Center. Structured Report Export Transactions, among others, use HL7 compliant
       structured report objects (e.g. HL7 V3 CDA).


2.4 Relevant IHE Transactions
   Image Manager
     Storage Commitment
     Images Availability Query
     Procedure Update
     Patient Update
     Notification needed for Order Status Tracking
        Modality Procedure Step in Progress
        Modality Procedure Step Completed
        Modality Images Stored (Images are sent directly to the Image Archive)
        Creator Images Stored
        Creator Procedure Step in Progress
        Creator Procedure Step Completed

   Report Manager
     Report Submission
     Report Issueing
     Structured Report Export
                                                                                                                                                Report
                                                    Order Placer                             Order Filler
                                                                                                                                               Repository
Information System (EPR / HIS / DIS)

   Enterprise                                                                                                                                  Report Issuing
    Image                                              sub-role                                 sub-role
   Repository
                                                                      Placer Order                                                               Report           Report
                                                                      Management
                                                    Imaging Order                          Imaging Order                                        Manager         Submission   Report
                                                       Placer         Filler Order             Filler                                           (Report                      Creator
                                       Enterprise                     Management                                                                Tracker)
                                      IS Manager                    Results Distribution            Procedure Scheduled
                                                                         / Export                   Procedure Update
                                                                                                    Image Availability Query

   Enterprise                                                                                                       Structured Report Export
    Report
   Repository


                                                                                                Image
                                                     Performed
                                                                                              Manager
                                                      Procedure                                                                           Image Archive
                                                                                            (Image Order
                                                    Step Manager
                                                                                               Tracker)

                Not defined by IHE
                                                                          sub-role
                                                                                           Storage Commitment
                Status Notification


                                                                                              Acquisition
                                                                                               Modality

                                                                                                            Image Creator


                                                    Order Tracker



Fig. 1 Application Roles and Transactions
3 Mapping of IHE Transactions and Story Boards
Subset of relevant IHE transactions for HL7 V3 Imaging Orders & Observation Messages.


3. 1 Placer Order Management

    IHE Definition: The Order Placer informs the Order Filler of the initiation or
     cancellation of an order.
    Extension: Imaging Order Placer sends an imaging order query message (i.e. a query
     for the status of imaging procedures and / or reports) to the Imaging Order Filler.
    Mapping to HL7 V3 messages
      Story boards
          Name: Imaging Order Placer sends new imaging order message to the
             imaging order filler
          ID: tbd.
          Purpose: The imaging order placer sends a new imaging order (service mood
             code = order) to the imaging order filler. The active imaging order is verified
             by the imaging order filler who sends a response message back to the order
             placer.
          Diagram:
          Storyboard Examples:
                  External Imaging Order Placer sends HL7 V3 Imaging Order Message.
                     This order in turn has to be negotiated between order placer and order
                     filler. If the order is accepted, the imaging order filler then forwards a
                     second order message including the approved imaging procedures and
                     additional scheduling information to the image manager resp. report
                     manager.
                  Imaging Order is directly entered into Imaging Information System
                     (e.g. Radiology Information System). The imaging order has been
                     verified, so there is no need for a subsequent negotiations between
                     order filler and order placer.
                  New imaging order accepted by order placer.
                  New imaging order rejected by order filler. The order filler responds by
                     sending an intent which indicates the required order modifications.

             Name: Modification of existing imaging order (imaging order placer sends
              unsolicited notification to imaging order filler)
             ID: tbd.
             Purpose: The imaging order placer notifies the imaging order filler of the
              modification of an imaging order.
             Diagram:
             Storyboard Examples:
                   The intent resp. plan of the order filler for the modification of the non-
                      verified imaging request of the order placer doesn´t change the status of
                      the new order. The new order doesn´t get activated.
                   Stop Imaging Order: The active order is stopped before the start of the
                      ordered procedures. Example: A routine chest x-ray is scheduled for the
                      next 3 days. Patient is discharged on second day and exam for third day
                      is canceled.
                     Abort Imaging Order: Abort request message is sent while the imaging
                      procedures ordered are performed. Example: A nuclear medicine
                      procedure spanning two days is begun. Based on Day 1 results, the
                      remainder of the procedure is canceled.
                     Replace Imaging Order: Replace active order by modified order.
                      Example: A non-contrast CT examination is ordered. Prior to start of
                      the examination, a decision is made to change to a contrast-enhanced
                      examination.
                     Supercede Completed Imaging Order



              Name: Query imaging order status
              ID: tbd.
              Purpose: The imaging order placer queries the order status from the imaging
               order filler.
              Diagram:
              Storyboard Examples:
                Queries for single imaging procedures and/or reports:
                    Simple Image Procedure Order Status Query: The requesting physician
                       queries the imaging order filler (RIS) for the status of a Thorax CT he
                       has ordered by providing the (Filler Order) Act ID (mood code =
                       order) and additional service information. He gets back the status of
                       the order instance, which is one of the enumerated values for Act
                       status_cd. (The imaging order placer may subsequently decide to
                       retrieve the results).
                    Simple Reporting Order Status Query Similiar to the above, but
                       applicable to reporting of existing images, such as overreads or
                       interpretation of outside exams.
                    Complex Imaging Order Status Query: Multiple imaging procedures
                       and / or associated report may exist of a filler order, but only a single
                       aggregate status is returned. For example, the order is designated as „in
                       progress“ as soon as the first imaging procedure step has begun, and is
                       „completed“ when all the final results (images and/or reports) are
                       available. In certain circumstances , it may be desirable to designate a
                       procedure as „in progress with partial results available“.
                Queries for multiple imaging procedures and/or reports:
                    Query imaging procedures (period: start date/time – end date/time,
                       including imaging procedure status) -> images available?
                    Query imaging reports (period: start date/time – end date/time,
                       including imaging report status) -> reports available?
                    Complex query for imaging procedures and associated reports (period:
                       start date/time – end date/time, including imaging procedure and report
                       status)


3.2 Filler Order Management
     IHE Definition: The Order Filler informs the Order Placer of the initiation,
        cancellation, or change in the status of an order.
   Accept and reject responses of Imaging Order Filler to request of Order Placer. These
    generic accept and reject messages are used by the receiving facility.
        Accept Imaging Order
        Reject Imaging Order (The external imaging order is rejected by the order filler
           -> reason code example: false indication, that is there is either no appropriate
           imaging procedure at all or the order has to be changed. The intent of the
           imaging order filler is sent to the imaging order placer.)

   Mapping to HL7 V3 messages
     Story boards
       Deferred notification of order placer about modification of existing order
          initiated by order filler
           Non-deferred response messages are covered by Accept/Response
              Messages mentioned above (refer to Filler Order Management section of
              this document)
       ID: tbd.
       Purpose: The imaging order filler sends an unsolicited notification of
          modifications of a previously placed order to the order placer. This notification
          is deferred opposed to immediate accept / reject responses (the imaging order
          has been initially accepted).
       Diagram:
       Storyboard Examples:
               Modification due to deferred verification results (e.g. consultation,
                  second opinion, laboratory results) by imaging order filler
               Modification due to condition at service location i.e. modality

       Unsolicited notification of imaging order placer about imaging order statuses
         ID: tbd.
         Purpose: The imaging order filler sends an unsolicited notification of imaging
           order statuses to the order placer.
         Diagram:
         Storyboard Examples:
            Images Available
            Reports available
            Common order statuses for imaging orders
                RIM order statuses: new, cancelled, active (in progress), suspended,
                   aborted, completed, superceded
                    Consideration of DICOM General Purpose Worklist (Suppl. 52)
                      statuses


       Unsolicited notification of imaging procedures that were not ordered
         ID: tbd.
         Purpose: The imaging order filler sends an unsolicited notification of imaging
           procedures which have been performed without being previously ordered by
           the imaging order placer to the order placer or information system.
         Diagram:
         Storyboard Examples:
            Emergency case
                  Walk-in patients
                  For notifications of existing orders refer to story board: Deferred
                   notification of imaging order placer about modification of existing order
                   initiated by order filler

          Distribution / Export of Results (Results Distribution)
            ID: tbd.
            Purpose: The imaging order filler sends a results distribution message to the
              imaging order placer. To that purpose, the imaging order filler integrates status
              messages from the image manager and report manager (availability of images
              and reports). The results distribution message contains references to the results
              object instances (e.g. Uniform Resource Identifier, URI)


              Diagram
              Storyboard Example:
                Results distribution message containing references to the original results
                  object instances ( e.g. URI) -> results distribution by reference
                Results distribution message containing copies of the relevant images and /
                  or associated report(s) -> results distribution by value
                Distribution of DICOM object instances (potential use MIME types: refer
                  to Draft DICOM Suppl. 54: DICOM MIME Type)
                Distribution of rendered image objects (e.g. JPEG)
                Distribution of structured reports (DICOM SR to HL7 CDA conversion is
                  performed by Report Manager)
                For complex imaging orders results might get distributed by using multiple
                  messages in order to ease processing by avoiding overly complicated result
                  distribution messages.


3.3 Procedure Scheduled
     IHE Definition: Schedule information is sent from the Department System Scheduler
       (DSS)/Order Filler to the Image Manager.
     This is an Inter-IIS (Imaging Information System) „Order Message“ (refer to the
       contents of the IIS-Segment draft for scheduling information)
     Mapping to HL7 V3 messages
        Story boards
           Name: Imaging Order Filler informs Image Manager of ordered imaging
              procedures (active orders). Imaging scheduling data has been added.
           ID: tbd.
           Purpose: In addition to orders placed by the Imaging Order Placer this message
              contains scheduling information (refer to IIS Segment). Scheduling data has
              been added to the active order by the imaging order filler.
           Diagram:
           Storyboard Examples:
               Simple Imaging Procedure Scheduled
               Simple Reporting Procedure (without image acquisition) Scheduled
               Complex Imaging Procedure Scheduled
             Name: Imaging Order Filler informs Report Manager of completed
              imaging procedure(s)
               ID: tbd.
                  Purpose: To notify Report Manager of availability of images and that
                    reporting can begin.
               Diagram:
               Storyboard Example:
                  The completed imaging procedure(s) is/are ready for reporting. The
                    image manager notifies the report manager of these procedures (mood
                    code = event) which constitute observations without associated reports.


3.4 Procedure Update
     IHE Definition: The Department System Scheduler/Order Filler sends the Image
       Manager updated order or procedure information.
        Storyboards:
           Name: Modification of existing scheduled imaging and/or reporting
              procedure (imaging order filler sends unsolicited notification to image
              manager and/or report manager)
           ID: tbd.
           Purpose: The Imaging Order Filler notifies the image manager and/or report
              manager of the modification of an scheduled imaging and/or reporting
              procedure (refer to the contents of the IIS-segment draft for scheduling
              information).
           Diagram:
           Storyboard Examples:
                   Stop Scheduled Imaging Order
                   Abort Scheduled Imaging Order
                   Replace Scheduled Imaging Order
                  

				
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Description: Domain filler