IHE & YOU—How Does it Work IHE & YOU—How Does it Work in the Clinic?in the Clinic?

Linda Wedemeyer, MD, MS--OphthalmologistLinda Wedemeyer, MD, MS--Ophthalmologist

Veterans Health AdministrationVeterans Health Administration

Los Angeles, CALos Angeles, CA

Mrs. Smith Arrives for Mrs. Smith Arrives for AppointmentAppointment

• The clerk checks her in, providing demographic The clerk checks her in, providing demographic information to the ADT actorinformation to the ADT actor

• ADT actor: possibly practice management system ADT actor: possibly practice management system or hospital information systemor hospital information system

• ADT actor sends demographic information to the ADT actor sends demographic information to the order filler or order placerorder filler or order placer

• Order filler: possibly EMROrder filler: possibly EMR• Order placer: possibly practice management Order placer: possibly practice management

systemsystem

Generic Eye Care Orders Generic Eye Care Orders CreatedCreated

• Order Filler (possibly EMR) creates Order Filler (possibly EMR) creates automatic orders for lensometry and automatic orders for lensometry and autorefraction.autorefraction.

Why do we need Generic Eye Why do we need Generic Eye Care Orders?Care Orders?

• Have you ever heard of a physician writing an Have you ever heard of a physician writing an order every time a pair of glasses gets measured?order every time a pair of glasses gets measured?

• Can you guess what he would say if you asked Can you guess what he would say if you asked him to?him to?

So Why Do We Need Orders at So Why Do We Need Orders at All?All?

• For Data IntegrityFor Data Integrity

• Right patient, right image, right dataRight patient, right image, right data

How do we solve the How do we solve the dilemma?dilemma?

• Generic eye care ordersGeneric eye care orders

• Automatic creation of orders when a Automatic creation of orders when a patient is registeredpatient is registered

• Some of the orders will be Some of the orders will be performed, and some won’tperformed, and some won’t

• The tech decides which ones, as he The tech decides which ones, as he would normallywould normally

What is different about a What is different about a generic order?generic order?

• It may or may not be executed, as It may or may not be executed, as decided by the technician or by some decided by the technician or by some other informal processother informal process

• Generic orders that are not executed Generic orders that are not executed will probably expire in a shorter time will probably expire in a shorter time frame than more specific ordersframe than more specific orders

Generic Eye Care Orders—Mrs. Generic Eye Care Orders—Mrs. SmithSmith

• Again, recall that automatic orders Again, recall that automatic orders were created for lensometry and were created for lensometry and auto-refraction for Mrs. Smithauto-refraction for Mrs. Smith

• Triggered when Mrs. Smith was Triggered when Mrs. Smith was registered in the clinicregistered in the clinic

Information Flows to Modality Information Flows to Modality WorklistWorklist• Generic eye care orders cause Mrs. Smith’s Generic eye care orders cause Mrs. Smith’s

demographic information to be listed on the demographic information to be listed on the lensometer and auto-refractor lensometer and auto-refractor

• Both instruments are acqusition modalitiesBoth instruments are acqusition modalities• This list is the Modality WorklistThis list is the Modality Worklist

The eye tech calls for Mrs. The eye tech calls for Mrs. SmithSmith• He brings her to an exam room, takes a history, He brings her to an exam room, takes a history,

then measures her glasses.then measures her glasses.• The tech arrives at the lensometer with Mrs. The tech arrives at the lensometer with Mrs.

Smith’s glasses.Smith’s glasses.• On the lensometer, he selects Mrs. Smith’s name On the lensometer, he selects Mrs. Smith’s name

on the Modality Workliston the Modality Worklist• This confirms what procedure was actually doneThis confirms what procedure was actually done• He measures the glassesHe measures the glasses• Measurements are uploaded by the image Measurements are uploaded by the image

manager to the storage servermanager to the storage server

Tech decides not to perform Tech decides not to perform auto-refractionauto-refraction

• Mrs. Smith’s vision is 20/20 and she is Mrs. Smith’s vision is 20/20 and she is happy with her glasseshappy with her glasses

What happens to the order for What happens to the order for auto-refraction? auto-refraction?

• It expiresIt expires

• At whatever time the clinic determinesAt whatever time the clinic determines

• Time for expiration is set in the Order Filler (possibly EMR)Time for expiration is set in the Order Filler (possibly EMR)

• Expiration could be triggered by time of day, or perhaps by Expiration could be triggered by time of day, or perhaps by an event such as completion of physician documentation an event such as completion of physician documentation

Tech completes appropriate Tech completes appropriate workupworkup

• Mrs. Smith is ready for the physicianMrs. Smith is ready for the physician

Physician Sees Mrs. SmithPhysician Sees Mrs. Smith

• Takes a historyTakes a history

• Performs an exam using multiple Performs an exam using multiple instruments--slit lamp, indirect instruments--slit lamp, indirect ophthalmoscope, tonometer…ophthalmoscope, tonometer…

• Some of these instruments may Some of these instruments may produce digital images—generic produce digital images—generic orders might be used as described orders might be used as described aboveabove

Physician Elects Further Physician Elects Further WorkupWorkup

• Decides that a fundus photo and Decides that a fundus photo and visual field are indicatedvisual field are indicated

• Orders these proceduresOrders these procedures

• Uses either the order placer (possibly Uses either the order placer (possibly practice management system or practice management system or hospital information system) hospital information system)

• Or the order filler (possibly eye clinic Or the order filler (possibly eye clinic EMR)EMR)

Specific Orders This TimeSpecific Orders This Time

• This is a physician generated order, This is a physician generated order, where a specific procedure is ordered where a specific procedure is ordered for a patientfor a patient

• The expectation is that these orders The expectation is that these orders will be executedwill be executed

• They may or may not be set to expire They may or may not be set to expire automaticallyautomatically

Orders Created by Orders Created by physicianphysician

Orders Transmitted to Orders Transmitted to InstrumentsInstruments

• The visual field machine and the camera query The visual field machine and the camera query the order filler (probably EMR) for the patient’s the order filler (probably EMR) for the patient’s demographic informationdemographic information

• This creates the Modality Worklists on those This creates the Modality Worklists on those devices (acquisition modalities)devices (acquisition modalities)

Technician NotifiedTechnician Notified

• Yelling down the hallYelling down the hall

• Or tech looks at orders in EMROr tech looks at orders in EMR

Mrs. Smith is sent to camera--Mrs. Smith is sent to camera--Imager Selects Imager Selects name/demographicsname/demographics

Photos Taken—any IHE Photos Taken—any IHE Compliant CameraCompliant Camera

Images uploaded to Images uploaded to storage serverstorage server

With a couple mouse With a couple mouse clicks…clicks…

Charge Posting—Procedure Charge Posting—Procedure CodesCodes

• The instrument passes procedure codes to the order filler The instrument passes procedure codes to the order filler (optional feature)(optional feature)

• The order filler maps to CPT codesThe order filler maps to CPT codes

• The order filler notifies the billing system (charger processor The order filler notifies the billing system (charger processor or charge poster) that a billable procedure has been or charge poster) that a billable procedure has been completedcompleted

Charge Posting—Diagnosis Charge Posting—Diagnosis CodesCodes

• Diagnosis codes added manually Diagnosis codes added manually using charge processorusing charge processor

• By physician or billing personnelBy physician or billing personnel

• Some day we’ll automate this too!Some day we’ll automate this too!

What happens to studies to be What happens to studies to be read?read?

• After the modality performed procedure stepAfter the modality performed procedure step

• The order filler can be configured to notify the The order filler can be configured to notify the physician that there are results to be readphysician that there are results to be read

Physician notifiedPhysician notified

Images now viewableImages now viewableImages now viewableImages now viewable

Image Display ActorImage Display Actor

• Desktop computerDesktop computer

• Retrieves images from a storage Retrieves images from a storage serverserver

Physician reviews the photosPhysician reviews the photos

And writes a reportAnd writes a report

• In the future, report creation will be In the future, report creation will be standardized in IHEstandardized in IHE

• Once report creation is addressed in Once report creation is addressed in IHE eye care, automatic charge IHE eye care, automatic charge posting for the physician’s report can posting for the physician’s report can occuroccur

Tech Calls Mrs. SmithTech Calls Mrs. Smith

• And brings her in to the visual field And brings her in to the visual field machinemachine

• Selects Mrs. Smith’s name on the Selects Mrs. Smith’s name on the visual field machine and then visual field machine and then performs the procedureperforms the procedure

• Data is uploaded to the storage Data is uploaded to the storage serverserver

Charge Posting—Procedure Charge Posting—Procedure CodesCodes

• The instrument passes procedure codes to the order filler The instrument passes procedure codes to the order filler (optional feature)(optional feature)

• The order filler maps to CPT codesThe order filler maps to CPT codes

• The order filler Notifies the billing system (charger processor The order filler Notifies the billing system (charger processor or charge poster) that a billable procedure has been or charge poster) that a billable procedure has been completedcompleted

Charge Posting—Diagnosis Charge Posting—Diagnosis CodesCodes

• Diagnosis codes added manually Diagnosis codes added manually using charge processorusing charge processor

• By physician or billing personnelBy physician or billing personnel

• Some day we’ll automate this too!Some day we’ll automate this too!

The physician is notifiedThe physician is notified

• He retrieves the visual field from the He retrieves the visual field from the storage server (image archive)storage server (image archive)

• While sitting at his desktop computer While sitting at his desktop computer (image display actor)(image display actor)

• Reviews the studyReviews the study

And writes a reportAnd writes a report

• Some day this will generate a chargeSome day this will generate a charge

Diabetic Teleretinal Diabetic Teleretinal ScreeningScreening

• Perfect example for generic ordersPerfect example for generic orders

• Every patient gets the same thingEvery patient gets the same thing

• Every scheduled patient is Every scheduled patient is automatically on the Modality automatically on the Modality Worklist of the cameraWorklist of the camera

Integrating the Healthcare Integrating the Healthcare Environment (IHE) Eye CareEnvironment (IHE) Eye Care

• Patient Data Anytime, Anywhere…Patient Data Anytime, Anywhere…

• Standards make it happen!Standards make it happen!

More information….More information….• IHE Web siteIHE Web site: : www.ihe.netwww.ihe.net

• Technical FrameworksTechnical Frameworks– ihe_eyecare_tf_TI_vol1_2006_06_01 (Trial Implementation ihe_eyecare_tf_TI_vol1_2006_06_01 (Trial Implementation

version)version)– ihe_eyecare_tf_TI_vol2_2006_06_01 (Trial Implementation ihe_eyecare_tf_TI_vol2_2006_06_01 (Trial Implementation

version)version)– ihe_tf_rev6.0ft_vol1_2005-05-18-FINAL (Radiology)ihe_tf_rev6.0ft_vol1_2005-05-18-FINAL (Radiology)– ihe_tf_rev6.0ft_vol2_2005-05-18-FINAL (Radiology)ihe_tf_rev6.0ft_vol2_2005-05-18-FINAL (Radiology)– ihe_CARD_tf_vol2_2.1_FT (Cardiology)ihe_CARD_tf_vol2_2.1_FT (Cardiology)

• Standards used by IHE Eye CareStandards used by IHE Eye Care– DICOM StandardDICOM Standard www.nema.medical.orgwww.nema.medical.org– HL7 StandardHL7 Standard www.hl7.orgwww.hl7.org

• IHEIHE Connectathon Oct. 2006 at RSNA HQConnectathon Oct. 2006 at RSNA HQ

• IHEIHE Showcase at Nov. 2006 AAO ConferenceShowcase at Nov. 2006 AAO Conference

• Vendor Products Integration StatementsVendor Products Integration Statements