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IHE CardiologyImage Enabled Office
Harry Solomon
IHE Cardiology Page 2
Image Enabled Office Problem Statement
An increasing number of clinicians have both imaging equipment and electronic medical records in their offices. The prevalence of imaging equipment is increasing as lower cost systems are being brought to market, and the universal deployment of EMRs is an explicit goal of the U.S. government. Note: The draft U.S. “meaningful use criteria” for 2015 would require EMRs to handle medical imaging objects, although the extent and nature of such support is undetermined.
This equipment needs to be integrated into the office environment workflow, and the imaging results need to be seamlessly integrated into the EMR.
Note that the systems in an office environment must in may ways be more technically sophisticated than in an in-patient environment, as they must operate with less IT-savvy human supervision, and combine features that would otherwise be distributed across multiple systems.
Profile Scope
The Image-Enabled Office (IEO) Profile specifies the integration of an imaging suite (modalities, storage server, and workstations) with an electronic health record system in an ambulatory office setting.
This is a fully bi-directional integration, including ordering/scheduling of an imaging exam, status reporting for that exam, report creation, and web-based imaging exam review integration.
It also addresses import of referral image exams from exchange media into the integrated office environment.
Out of Scope:
Exchange with other entities (supported by XDS and XDS-I functionality), except for image import from media
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Use Case 1
Andy Carditis, a patient, is referred to Belle Plummer, a cardiologist, for consultation regarding a fever and associated heart murmur (potential infective endocarditis). Dr. Plummer orders blood labs and an echo study, which the patient elects to have performed in Dr. Plummer’s cardiology office. The patient and the cardiology office manager schedule the echo for later that day.
At the scheduled time, Sue Skann, the sonographer in the office, preps Mr. Carditis. She uses the ultrasound machine to query for the scheduled exams, and selects Mr. Carditis from the list. She performs the echo study, and makes preliminary measurements on the ultrasound machine. The images and measurements are sent to a local mini-PACS image server.
On an imaging workstation, Dr. Plummer reviews the images and measurements, and notes the vegetation on the mitral valve. She selects a representative image, and saves a reference to it in a note that is stored on the mini-PACS. She defers creating a report until the lab results will have been returned.
The next morning, the lab results are returned electronically and recorded in the office EMR. On the EMR workstation, Dr. Plummer reviews both the lab results and the echo measurements, and creates a report with findings, selected measurements, and the representative image selected the previous day. She orders a two week regimen of intravenous antibiotics, which will be administered by her nurse practitioner. The report is stored in the EMR, and is also sent to the referring primary care physician.
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Approach
Reuse capabilities from existing IHE Profiles:• Radiology Scheduled Workflow
• Radiology Import Reconciliation Workflow
• Radiology/Cardiology Evidence Documents
• Cardiology Displayable Reports
• IT Infrastructure Patient Demographics Query
• IT Infrastructure Consistent Time
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In-patient Scheduled Workflow Diagram
Pt. Registration [RAD-1] Patient Update [RAD-12]
Pt. Registration [RAD-1] Patient Update [RAD-12]
Placer Order Management [RAD-2] Filler Order Management [RAD-3]
ADT
Query Images [RAD-14] Retrieve Images [CARD-4]
Image Display
Modality Image/Evidence Stored [CARD-2]
Storage Commitment
[CARD-3]
Procedure Scheduled [RAD-4]
Procedure Updated [RAD-13]
Query Modality Worklist [RAD-5]
Performed Procedure
Step Manager
Modality PS in Progress [CARD-1] Modality PS Completed [RAD-7]
Modality PS in Progress [CARD-1] Modality PS Completed [RAD-7]
Modality PS in Progress [CARD-1] Modality PS Completed [RAD-7]
Order Placer
Acquisition Modality
ImageManager
Image Archive
DSS/ Order Filler
Patient Update [RAD-12]
Evidence Creator
Modality Image/Evidence Stored [CARD-2]
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IEO Functional Features
Equivalent to in-patient “top half” systems should be a single actor incorporating both practice management and EMRImage Manager/Archive should be an actor separate from PM/EMRModality, Image Display, and Evidence Creator actors should operate with no changes from Scheduled Workflow / ED
• Modality worklist, MPPS, image/evidence storage
Reports should be creatable on either an imaging workstation, or at an EMR workstationReport Creator actor should operate with no changes from Displayable Reports
• Destination of Encapsulated Report is EHRS
Image Manager/Archive shall support a web-based viewer interface
• Usable from EMR workstation• Upon MPPS complete (Storage Commitment?), the IM/IA shall send a
link to the web viewer for the study to the EHRS
System Actors (top level)
Acquisition Modality
Importer
Image Manager /Image Archive
Retrieve Images/Evidence
Image Display
Images /Evidence Stored
Modality Worklist
Procedure Step in Progress/Completed
Report Submission
Procedure Scheduled / UpdatePatient Update
Patient Demographics
Access DICOM Study for Display
Storage Commitment
Report Storage
EHR-S
IEO Issues
Should EHRS DICOM interface be broken out to a separate actor (as not typically included in EHRS)?
• No – it is responsibility of EHRS vendor to integrate with an interface engine if needed.
Existing IHE transactions specified with a variety of end point actor definitions
• Modality Worklist transaction to Department System Scheduler / Order Filler actor; Patient Demographics Query transaction to Patient Demographics Consumer actor
• Need to group these formal actor definitions with our desired actors
Transcoding of DICOM Structured Report measurements into CDA observations is non-trivial
• No transcoding functional requirements included in Profile – left to implementation
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Refined Actor / Transaction Diagram
Report Manager
Display
Patient Demographics Supplier
DSS / OF
Acquisition Modality
Importer
Performed Procedure
Step Manager
Image Manager /Image Archive Query Images/Evidence […]
Retrieve Images/Evidence […]
Image Display
Image /Evidence Stored […]
Query Modality Worklist [RAD-5]
Procedure Step in Progress […] Procedure Step Completed […]
Report Creator
Encapsulated Report Submission [CARD-7]
Procedure Scheduled [RAD-4]
Procedure Updated [RAD-13] Patient Update [RAD-12]
Notify Study Access [CARD-y]
Patient Demographics Query [ITI-21]
Evidence Creator
Access DICOM Study for Display [CARD-z]
Storage Commitment [RAD-10]
Encapsulated Report Storage [CARD-9]
Report DisplayReport Repository
Encapsulated Report Retrieve [CARD-11]
Encapsulated Report Query [CARD-10]
EHR-S
Patient Demographics Consumer
Patient Demographics Consumer
Dynamic Model – Process Flow 1
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Practice Manager/EMR- DSS/OF
Image Manager/Image Archive/ PPS Manager
Acquisition Modality
Query Modality Worklist [RAD-5]Select Patient
Modaility Procedure Step In Progress- [RAD-6]
Perform Acquisition
Modaility Procedure Step In Progress- [RAD-6]
Modaility Procedure Step Completed- [RAD-7]Modaility Procedure Step Completed- [RAD-7]
Storage Commitment- [RAD-10]
Register Patient/Create Order
Schedule Procedure
Start Procedure
Procedure Scheduled [RAD-4]
Notify Study Access- [CARD-y]
Images/Evidence Stored- [RAD-8, RAD-43, CARD-2]
Dynamic Model – Process Flow 2
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New Transactions
Notify Study Access• HL7 ORU^R01
• Trigger Event – availability of study images at Image Manager
• OBX segment with Study Unique ID
• Alternate under consideration – ORI^O24
Access DICOM Study for Display• Web service over HTTP
• Uses Study UID from Notify Study Access transaction
• Returns top level web page for navigation / viewing study in standard web browser
Notify Study Access - OBX
• OBX-2 Value Type : “HD” (Hierarchical Designator)
• OBX-3 Observation Identifier : “113014^DICOM Study^DCM”
• OBX-5 Observation Value : DICOM Study Instance UID as an ISO OID
• OBX-11 Observation Result Status : “R” (Results entered -- not verified)
• OBX-14 Date/Time of the Observation : date and time of the most recent update made to the study content (e.g., most recent addition, deletion or modification of images or objects within the study).
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SEQ LEN DT Usage Card. TBL# ITEM# ELEMENT NAME
1 4 SI R 00569 Set ID – OBX
2 3 ID R 0125 00570 Value Type = HD
3 705 CWE R 00571 Observation Identifier
5 70 HD R 00573 Observation Value
11 1 ID R 0085 00579 Observation Result Status = R
14 24 DTM R2 00582 Date/Time of the Observation
Access DICOM Study for Display
Follows model of IHE ITI Retrieve Info for Display web services
• http://<location>/IHERetrieveDICOMInfo?requestType=DICOM-STUDY&studyUID=<studyUID>
Display actor (in EHRS) must be configured with web access port of Image Manager (<location>)
Alternatively (not part of IEO profile), EHRS can be configured with (thick) client app from Image Manager vendor, and invoke it with the Study UID
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