Clinical Operations Workgroup: Image Sharing Recommendations

Clinical Operations Workgroup:Image Sharing Recommendations

Jamie FergusonJohn Halamka

December 6, 2013

Clinical Operations Members

12/6/2013 Office of the National Coordinator for Health Information Technology 2

WG Members • Jaime Ferguson, Kaiser Permanente• John Halamka, Beth Israel Deaconess

Medical Center• Don Bechtel, Siemens• Martin Harris, Cleveland Clinic• Stanley Huff, Intermountain Healthcare• Kevin Hutchinson, My-Villages Inc • Elizabeth Johnson, Tenet Health• John Kimek, NCPDP• Rebecca Kush, CDISC• Nancy Orvis, Department of Defense• Marjorie Rallins, American Medical

Association

• Wes Rishel, Gartner• Christopher Ross, Mayo Clinic• Joyce Sensmeier, HIMMS• Karen Trudel, HHS/CMS• Dan Vreeman, Regenstrief Institute

Ex Officio Members • Jay Crowley, FDA/HHS• Marjorie Greenburg, HHS/CDC• Clem McDonald, National Library of

Medicine• Terrie Reed, FDA/HHS

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Agenda

12/6/2013 Office of the National Coordinator for Health Information Technology

• Welcome• Charge• Discuss recommendations on Image Sharing

based on HITSC feedback• Clinical Operations Workgroup Update • Public Comment

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CHARGE

12/6/2013 Office of the National Coordinator for Health Information Technology

• How full image sets or designated key images are shared between different facilities and specialists: the high level architecture e.g. role PACS, Archives, and EMRs

• How this is deployed with central and distributed reading facilities

• What methods and technical standards are used to push, pull, or view images in one place that originated or were interpreted in another place

• Issues encountered sharing reports and interpretations, or auditing, with or alongside the images themselves

• Inclusion of time series data in scope in addition to radiological images

Office of the National Coordinator for Health Information Technology

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Recommendations for Image Sharing

Tier 1. Radiology Reports and low res/ Non-Diagnostic images: Specify a document syntax and vocab standard, likely HL7+, for radiology reports. Separately, for non-diagnostic images specify a few acceptable formats e.g. PDF/A or TIFF. Specify HIE methods for exchange of these artifacts - Direct Email and SOAP Exchange and RESTful paradigms.

Tier 2. Key Diagnostic Images as designated by a reader/interpreter: Implementation guide for DICOM image objects. Query and push modalities required but need to be very loose, perhaps silent, on allowable transport. Preference for RESTful approaches to sharing in the long term should not constrain current exchange implementation, architectures, and innovation.

Tier 3. Full image sets. Implementation guide for DICOM image objects. Query modality only. Same transport approach as #2.

HIT Standards Committee

Clinical Operations WG UpdateImage Sharing

September 18, 2013

Jamie FergusonJohn Halamka


Use Case Framework For Image Sharing

VIEW DOWNLOAD TRANSMITTO 3rd PARTY

Each Use Case Scenario Must Define:• Actors: Clinician, Care Team, Patient• Actions: Clinical Decision, Report, Audit• Content: Full Set, Key Images, Report• Initiation: Manual, Triggered, Automatic• Systems: EHR, PHR, PACS, Archives

Before Analyzing and Recommending:• Payload Packages• Protocols and Modalities• Image Quality• Etc. . .

Adapted from Clinical Operations discussions with thanks to David Clunie

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Image Sharing Use Cases

• Encompassed by View/Download/Transmit (VDT):– View – select, navigate, display, interact, measure, analyze– Download – to local machine or media – use, archive, share– Transmit – to 3rd party – provider, archive, analysis service

• For Each:– Who – imager, clinician (ordering, referral), “team”, patient– What – complete set, subset, key images, report, other ‘ologies– When – manual or automatic (triggered)– Where – EHR, PHR, PACS, VNA, HIE Archive, …– Why – reporting, diagnosis (clinical decision), review, audit, …

• Scenarios Inform Requirements For Protocols/Modalities– push/pull, payload, protocol, image quality, speed, identifiers


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Example of Protocol Considerations View (Pull)

What does “zero footprint” mean?

• Zero footprint– No helper apps, plugins, applets, Flash or SilverLight

• Absolute zero – HTML pre-5, frames, tables, images• Almost zero – JavaScript +/- HTML5 Canvas• Pretending to be zero – Flash (etc.) dependency• Not zero - thick client spawned by browser (or EHR “app”)


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Example of Protocol Considerations, ContinuedView (Pull)

• Separation of requestor from performer– EHR/PHR/etc. user requests viewing of study– PACS/VNA/etc. actually performs it

• Very common proprietary pattern– e.g., encrypted URLs – identify, authorize, time-limited– n:m permutations of requestor/performer to customize

• Storing fully qualified links (URLs) – go stale


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Architecture Considerations

• Push “architecture”– easy, tempting– duplication (stored many places)– change management (wrong patient, side marker, etc.)

• Pull “architecture”– federated/distributed queries v. centralized registries– centralized image storage v. expose locally at edges– links go stale, enterprises go out of business, etc.

• “Brokered” “hybrid” “clearing house”– intermediary holds images transiently (possible encrypted)– sender pushes, then recipient notified and pulls– analogous to DropBox file sharing service, Filelink email

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Other Considerations

• Learn from global experience– Canada (DI-r) … regional repositories– UK (IEP) … point-to-point push –> brokered –> centralized

• Report in scope or not?

• Agility to adapt to rapidly changing technology (mobile)

• Transition from local to remote experience

• How to leverage the installed base

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Next Steps

• COWG to better define a few use cases for image sharing

• Identify for each use case– Minimum recommended bundle of standards– Needed improvements to standards

• Further HITSC discussion


14Office of the National Coordinator for Health Information Technology

Documents

Clinical Operations Workgroup: Image Sharing Recommendations