IHE CardiologyImage Enabled Office

Harry Solomon

Based on IEO draft 12

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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 PDI, 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 EHR-S workstationReport Creator actor should operate with no changes from Displayable Reports

• Destination of Encapsulated Report is EHR-S

Image Manager/Archive shall support a web-based viewer interface

• Usable from EHR-S workstation• Upon arrival of study images, the IM/IA shall send a link to the study to

the EHR-S

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

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

Dynamic Model – Explicitly Ordered Exam: Acquisition

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EHR-S / DSS/OF /PPS Manager /Report Manager

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

Procedure Scheduled [RAD-4]

Images/Evidence Stored- [RAD-8, RAD-43, CARD-2]

Notify Study Access- [CARD-y]

Dynamic Model – Imaging Study Analysis / Reporting

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EHR-S / PPS Manager / DSS/OF / Report Manager

Image Manager/Image Archive/ Report Repository

Image Display /Evidence Creator

Create Report

Modaility Procedure Step In Progress- [RAD-6]

Modaility Procedure Step Completed- [RAD-7]

Storage Commitment- [CARD-3]

Image Display /Report Creator

Notify Study Access- [CARD-y]

Encapsulated Report Submission [CARD-7]

Encapsulated Report Storage[CARD-9]

Retrieve Images/Evidence[RAD-16, RAD-45,CARD-4]

Query Images/Evidence[RAD-14, RAD-44]

Modaility Procedure Step In Progress- [RAD-6]

Modaility Procedure Step Completed- [RAD-7]

Images/Evidence Stored- [RAD-8, RAD-43, CARD-2]

Query Images/Evidence[RAD-14, RAD-44]

Retrieve Images/Evidence[RAD-16, RAD-45,CARD-4]

Retrieve Encapsulated Reports [CARD-11]

Query Encapsulated Reports [CARD-10]

Transactions from DRPT Profile

Encapsulated Report Submission [CARD-7]• Report Creator to Report Manager (EHR-S)

• HL7 MDM

• OBX with encapsulated PDF or CDA

Encapsulated Report Storage [CARD-9]• Optional – allows EHR-S to store copy of report in DICOM study

data set

• Report Manager (EHR-S) to Image Manager/Archive

• DICOM Encapsulated PDF or CDA

Encapsulated Report Query/Retrieve [CARD-10/11]• Image Display to Image Manager/Archive

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New Transactions

Notify Study Access [CARD-y]• Image Manager/Archive to EHR-S (Report Manager)

• HL7 ORU^R01

• Trigger Event – availability of study images at Image Manager

• OBX segment with Study Unique ID– Or should it be a full URL?

Access DICOM Study for Display [CARD-z]• EHR-S (Display) to Image Manager/Archive

• Web service over HTTP

• Invokes navigation / viewing study in standard web browser– What else needs to be standardized for execution environment?

Notify Study Access [CARD-y]: 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 [CARD-z]

Access based on Study UID or Patient ID

Follows model of IHE ITI Retrieve Info for Display web services

• http://<location>/IHERetrieveDICOMInfo?requestType=STUDY&studyUID=<studyUID>&userID=<userID>

• http://<location>/IHERetrieveDICOMInfo?requestType=SUMMARY&patientID=<patientID_HL7v2CX>&lowerDateTime=<LDT>&upperDateTime=<UDT>&mostRecentResults=<num>&userID=<userID>

Web service URL must be constructed at run-time• Display actor (in EHR-S) must be configured with web access port of

Image Manager (<location>)

• Uses Study UID from Notify Study Access transaction, or Patient ID from patient context

• Includes UserID from user context for informative annotation, not for access control on Image Manager/Archive

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IEO Issues

1. Security – no requirement for ATNA2. User ID on web service invocation – for annotation only3. How to specify display client in IHE Profile4. Web integration (RID) EHR-S to imaging workstation for

access to clinical record5. SWF RAD-12 Patient Update (vs. PAM ITI-30)6. Grouping of defined transaction end-point actors7. DICOM workflow responsibility of EHR-S product8. Dual study notification to EHR-S: MPPS and ORU9. Study notification ORU UID (vs. URL)10. Import reconciliation workflow explicitly included11. Discrete data elements only through CDA (vs. ORU)12. Where to specify transcoding DICOM SR

measurements?

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