Waveform Workflow Archiving Assessment of Standard Interfaces Opportunities

Waveform, Workflow, Archiving… Assessment of Standard Interfaces Opportunities for Cooperation

Three Levels for Connectivity Standards Device Connectivity Cardiology Captors, Actuators Cardiac Monitors Hemodynamics ICU Bed-Side Monitors 1073 Cluster Monitor RIS R-PACS DICOM Cardiac IS, CPACS SCP ? HL 7 ? DICOM ? 1073 ? ADT Order Placer EMR, … Rest, Stress, Holter ECG DICOM Enterprise Archive Imaging Modalities Image proc. CAD, … Radiology Hospital/Ambulatory Workflow EMR Integration Departmental Integration ICU IS HL 7 Three Examples Overlap Coordination Needed

Three Topics, Three Opportunities ? 1. Persistent Waveform Objects 2. Departmental Workflow Integration 3. Enterprise Archiving of Images & Waveforms

DICOM Waveforms Quick Refresher

Key Aspects of DICOM • DICOM domain is communications for imaging-based care • DICOM is an Object-based standard – Persistent objects • Inter-object referential capability – Binary tagged data element format – Objects are hierarchically organized • Patient / Study / Series (modality) “folders” • DICOM: Persistent Object workflow services over TCP/IP – Generally in client-server architecture – Object transfer, storage commitment, query and retrieval • Media-Interchange (CD, DVD, Floppy, etc. ) with clinical directory. • Network Archiving – Departmental workflow management (worklist, performed steps) • Broadly used and accepted world-wide for many years.

DICOM Waveforms • Supplement 30: Waveform – in DICOM 2001 • Introduces general structure for waveform composite (persistent) objects – Waveform channels identified by coded-entry triplet • • Coding Scheme / Code Value / Code Meaning Allows externally defined terminology (e. g. , SCP-ECG for leads) Triplets also used in HL 7 and DICOM Structured Reporting Triplet values may be constrained by Templates defined in Part 16 • Specific waveform Object Definitions (particularly for cardiology) – – – Hemodynamics Cardiac Electrophysiology Electrocardiography (12 -lead, ambulatory, general) Basic Voice Audio In progress, Ultrasound Doppler Waveform (Suppl 56)

DICOM Waveform Object • Waveform object encodes digital data from a discrete time period – Multiple channels; all channels have common time base – Flexible waveform sample format • 8 or 16 bit data; Signed, unsigned, u-law, A-law • Separate sampling frequencies for each channel, or multiplexed channels at common frequency – Objects may be temporally contiguous, or temporally selective – “Store and forward” (not for real time monitoring) • Waveform object encodes full definition of each channel – Quality being sampled, Sensor location (anatomic), Function (measurement or stimulus), Resolution and range, Technique (e. g. , pull-back) – Based on HL 7 V 2 definition Streams of • Waveform object encodes Waveform Samples DICOM + HL V 2 context information in header – Equipment information (manufacturer, serial number, location) – Temporal frame of reference (synchronization with other objects, in particular images) • Waveform object encodes optional annotation – Identify features or regions of interest – Generated by acquisition unit – Constructed of label and time or sample reference

Waveforms Standardization for Departemental Integration -Key Objectives-

Waveforms: why integrated & separated ? • Integrated with other persistent objects – Images • Supporting the waveforms (e. g. , for documentation of EP catheter location) • Supported by waveforms (e. g. , simultaneous ECG for IVUS post processing) – Various categories of Structured Reports with waveform references. • • Clinical reports Measurement reports (e. g. , hemodynamics, or ECG) Procedure Log documents (full procedural context for waveform acquisition) Key object selection (electronic “Post-It”) • Workflow integration: – worklists and status monitoring of scheduled tasks • including distribution of patient demographics – Object archiving and retrieval – Key for archiving of recorded vitals signs – Web accessible as persistent objects (presented or original data) • Focused on Full Fidelity Acquired Data: – – No Presentation: to be addressed independently. Compression: compact encoding, separate from the object definition Clearly distinguished from derived measurements and reports Patient/Visit/Order context driven by HL 7

Departmental Workflow Integration DICOM and HL 7…. . Much more than combining standards !

IHE Scheduled Workflow Patient Registration/Update Order Management (HL 7) Worklist RIS Modality Worklist Procedure Scheduled (HL 7) Store Images Storage Commitment List of Images Storage Commitment Performed Step: Modality Performed Procedure Step PACS & Archive Status = Completed Performed CT Head Pat Name/ID, Dose, Accession #, Study UID Complete List of Images A Closed Loop • Update IS Scheduling • Match Procedure with Order • Support Billing Based on MPPS • Avoid Reading incomplete Procedures

Structuring the Departmental Workflow with an Enterprise perspective ORDER A request for Radiologic Service DICOM Modality Worklist Radiology Department Scheduled Procedure Step A Requested Procedure 1 Scheduled Procedure Step B DICOM Modality Worklist Performed Procedure Step P 1 One or more series of images Performed Acquisition Procedure Step P 2 Modality One or more series of images Acquisition Modality Report Set of Codifiable, Billable, Acts

What is IHE ? Ø Ø Ø An Initiative Sponsored by Users: HIMSS plus clinical societies (e. g. RSNA) Active Industry Leadership, shaping direction Leverage existing standards (HL 7, IEFT, DICOM, etc. ) in an industry defined integration framework Proceed in pragmatic incremental steps to deliver easier to integrate product implementations Proven approach in IT & Radiology (over 100 vendors already participate).

Enterprise Archiving of Images and Waveforms

IHE Integration Profiles Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps Patient Information Reconciliation Unknown patients and unscheduled orders Post- Processing Workflow Schedule, perform, & notify image processing & CAD steps Charge Posting Collection of billable procedure details Consistent Presentation of Images Key Image Notes Simple Image and Numeric Reports Hardcopy and softcopy grayscale presentation state Flag significant images Simple reports with image links and, optionally, measurements Presentation of Grouped Procedures Subset a single acquisition Access to Radiology Information Consistent access to images and reports Basic Security Audit Trail Consolidation & Node Authentication

What is Unique about IHE ? Ø Ø A User/Vendor Team Effort : Ø Voluntary and Open to All Vendors. It is not a consortium. Ø Professional Associations Engaged (e. g. HIMSS leadership) Starts from concrete user integration needs, selects standards, sets a technical framework, provides a test-bed, and demonstrates/educates marketplace. Does not define product architectures or features, only the glue between products. Successful. Benefits both small and large vendors, worldwide : North America, Europe, Asia.

Industry is invited to shape and expand IHE Ø A kick-off meeting in order to : Ø Ø All vendors are invited : Ø Ø Review the current state of integration in the healthcare information technology industry Identify IT Infrastructure priorities necessary for building an EMR Establish the structure and timeline for implementation. Product marketing & technical leadership When & where : Ø Ø Ø November 4 -5, 2002 Malvern, (near Philadelphia, PA) Respond to invitation : ihe@rsna. org

IHE Scheduled Workflow Patient Registration/Update Order Management (HL 7) Worklist RIS Modality Worklist Procedure Scheduled (HL 7) Store Images Storage Commitment List of Images Storage Commitment Performed Step: Modality Performed Procedure Step PACS & Archive Status = Completed Performed CT Head Pat Name/ID, Dose, Accession #, Study UID Complete List of Images A Closed Loop • Update IS Scheduling • Match Procedure with Order • Support Billing Based on MPPS • Avoid Reading incomplete Procedures

Enterprise Archiving of Images and Waveforms

Enterprise Archiving for complex clinical data: images and waveforms • Large and "specialized" complex clinical data sets call for archiving outside of central EMR database • Images are being handled by PACS (radiology, cardiology, etc. ) and hospital wish to also share resource for waveforms • A consistent set of standards is required to achieve this integration of image and waveform enterprise archiving in an EMR driven environment.

Enterprise Archiving DICOM : 10 years of experience Media Interchange (Inst. + DIR) Store (Class/Instance UID) Enterprise Persistent Objects Repository Storage Commitment Retrieve (Instance UID) Store (Class/Instance UID) Departmental IS System RIS, PACS, CIS, etc. Transparent Persistent Object Payload (except for Class) Study/Patient Query (Study Root) Series Persistent Object Instance Web Access Native or presented forms

Web Access to Persistent DICOM Objects "Form of the reference" e. g. EPR "Form of the reference" Client Accessing Healthcare Documents io tat n e s re "p ve a rie Ret ea v e i etr ew" i v n Persistent Objects Repository et" S a at "D R Retrieve one "entire document" (either in a presentation view or as a data set) using its "Persistent Document Instance UID" Data Set "Retrieve": -Preferred transfer Syntax -Default transfer Syntax ? Presentation View "Retrieve": -Type of encoding for images (JPEG, GIF, etc. ) -Type of document presentation format (PDF, HTML, CDA-L 1) -Size of Images Intent is not to offer a "Query": - Need is only to get access to an object

Waveforms Standardization for Departemental Integration -Key Objectives-

Waveforms: why integrated & separated ? • Integrated with other persistent objects – Images • Supporting the waveforms (e. g. , for documentation of EP catheter location) • Supported by waveforms (e. g. , simultaneous ECG for IVUS post processing) – Various categories of Structured Reports with waveform references. • • Clinical reports Measurement reports (e. g. , hemodynamics, or ECG) Procedure Log documents (full procedural context for waveform acquisition) Key object selection (electronic “Post-It”) • Workflow integration: – worklists and status monitoring of scheduled tasks • including distribution of patient demographics – Object archiving and retrieval – Key for archiving of recorded vitals signs – Web accessible as persistent objects (presented or original data) • Focused on Full Fidelity Acquired Data: – – No Presentation: to be addressed independently. Compression: compact encoding, separate from the object definition Clearly distinguished from derived measurements and reports Patient/Visit/Order context driven by HL 7