1

Integrating the HealthcareEnterprise

- Radiat ion Oncology -

Bruce Curran, M.S., M.E.Bruce Curra n, M.S., M.E.Department of Radiation OncologyUniversity of MichiganAnn Arbor, MI

Acknowledge ments

• IHE-RO Symposi um @ ASTRO 2006– Mike Vannie r– Jay Cooper– Keith LaPlain

• IHE-RO Technical Commi ttee– ihero tech@aa pm.org

• IHE 2007 Worksh op– http: //www.i he.net

Disclo sure s

• Co-chair, IHE-RO Technical Commi ttee– Funding from ASTRO for participation

• Vice-Chair, DICOM Working Group 7– Funding from AAPM for parti cipation

Outline

• DICOM in Radiation Therapy– Brief History– Scope– Why it doesn ’t work

• IHE– Brief History– Structure and Current Activi ties

• IHE-RO

2

• Orig inal ly Developed as AAPM Report #10• “ A Standard Format for Digital Image Exchange ”

• Modified by NCI Particle Intercompar isonContra ct• Used by NCI High Energy Photon External Beam

Contract

• Modified further by NCI Electr on Exte rnalBeam Cont ract

• Ado pted and Significant Exte nded by RTOGQA Center

AAPM / RTOG

• Started as ACR-NEMA– Committee formed in 1983– 1985 - ACR-NEMA V1.0– 1988 - ACR-NEMA V2.0– V1.0 & v2.0 image transfer based on point -to-point

medium.– Version 3, renamed DICOM 3. Used network for image

transfer.

DICOM 3 Histor y

• 1990 - The name was change d to separ atethe standard from the or iginating body

• 1991 - Release of Parts 1 and 8 of DICOM• 1992 - RSNA demonstra tion, Part 8• 1993 - DICOM Parts 1-9 approved, RSNA

demon stration of ALL parts• 1994 - Part 10: Media Storage and File

Format• 1995 - Parts 11,12, and 13 plus Supplements

DICOM 3 History

Part 2 Conformance

Par

t1O

verv

iew

Part 4 Service Class Specifications

Part 3 Information Object Definitions

Part 6 Data Dictionary

Part 5 Data Structure & Encoding

Part 7 MessageExchange

Part 10 Storage Media& File Format

Part 8Network

Part 9Point-to-Point

Part 12 PhysicalMedia Formats

Par

t11

Med

iaS

tora

geA

ppl.

Pro

files

DICOM 3 Struc ture

3

HISHISHIS

ORSurgery

ORORSurgerySurgeryWardsWards

InsuranceInsuranceInsurance

PharmacyPharmacyPharmacyTreatment

(RT)TreatmentTreatment

(RT)(RT)

GeneralPractitioners

GeneralGeneralPractitionersPractitioners

CardiologyCardiologyCardiology ICUICUICU

LaboratoryLaboratoryLaboratory

RadiologyRadiologyRadiology

DICOMDICOM

HL7HL7

e.g.e.g. EDIfactEDIfacte.g.e.g. EDIfactEDIfact

HospitalHospital

TeleradiologyTeleradiologyto clinicsto clinics

PathologyPathologyPathology

Healthcare Standard s

MAGN

ETOM

Inform ation Managemen t System

Stora ge, Query/Ret rieve,Stora ge, Query/Ret rieve,Study Comp onentStudy Comp onent

Query/Retrieve, Patient &Query/Retrieve, Patient &Study Managem entStudy Managem ent

Query/RetrieveQuery/Retriev eResults ManagementResu lts Management

Print ManagementPrint Management

Media ExchangeMedia Exch ange

Li teBox

DICOM App lication Domai n

Radiati on Therapy: Imaging +

• Need for mor e that just Images– Field descr ip tions– Prescription / Fractionation

• Infor mation objec ts “ evolv e”– At simulation , only basic setup

inform ation– Af ter plannin g, fields, doses, …– Verific ation data

Depar tmental Data Flows

MAGNETOM

MAGNETOM

LiteBoxLi teBox

CT MR

DB

R&V / Arch ive

CT Sim RTP LinacSimulator

Image

SS, Plan,Dose

Image,Setup

Image All Image

PlanImage, SS,Plan

SS, Plan,Image

Image

Li teBox

Porta l Imaging

4

DICOM RT

• Proposed at RSNA, 1994– Working Group star ted in 1995 as NEMA RT Section

TG– First obj ects approved in 1998

• Ad ded several objects for Radiation Therapy– RT Dose– RT Structur e Set– RT Image– RT Plan– RT Treatment Record(s )

• Since DICOM 3.1, jus t another part of DICOM

• DICOM Part 2 specifies the stru cture of aconformance statemen t

• DICOM does not speci fy a test suite or acompl iance verification mechanism

• All DICOM implementations must besupported by a properly constructedconformance statement

DICOM “ Testing ”

• Implementati on Model which describes theApplic atio n Entities in the implem entatio n

• Detailed specifica tion of each App lication Entity– SOP Classes suppor ted– policies for initiat ion and acceptance of associations

• Presentation Contexts• SOP options• Suppo rted communications protocols• Specializations• Configuration

DICOM Confor mance Statemen t Hmmmmmm

DICOM

The New Yorke r, 7/2007

5

DICOM Conform ance Statement

• Allow a user to dete rmine which optionalcompo nents of the DICOM Stand ard aresuppo rted by a particular impleme ntation, andwhat extensio ns or specia lizati ons animplementation adds.

• By comp aring the Conforma nce Statementsfrom two impl ementat ions, a knowl edgeableuser should be able to determine whether or notinterop erability is possible.

The Problems

• DICOM-RT Objects Evolve– Numerous ‘Optio nal ’ Fields– Diffe rent Interpretations– ‘Stale’ Data

• Securit y– HIPPA has heightened awareness of the

need to protect data– Netw ork Protection / Isolat ion

DICOM

• No for mal testing struct ure– Left to the user to examine

manufacturer Conformance Statementsto verify compatib ili ty

– Know ledge necessary to truly verif ycomp atibility is arcane , not easy toacquire or keep current

– Much more difficult for DICOM RTExten sions compar ed to images

What is IHE?

• Standards -based,• Globa l Initiativ e

generating

• Real-wor ld Impl ementa tionsin patient care

“ Defining, testing , and imp lemen tingstandar ds -based in teroperability forEHR’s”

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Why IHE?

• 1970’s—Mainframe Era--$100,000 perinterfac e

• 1990’s—HL7 2.x--$10,000 per interface• 2000’s—IHE Implementation Profiles —

Cheaper than a new pho ne line!

How? IHE Elimi nates Optio nsfound in Publish ed Standards

IHE bri ngs reality to workflo w

Who is IHE?

• IHE is a joint ini tiative among:– American College of Cardiology (ACC)– Radiologica l Society of North America (RSNA)– Healthc are Information Managemen t Systems Society (HIMSS)– GMSIH, HPRIM, JAHIS (laborato ry)– American Soc iety of Opht halm olo gy– American College of Physicians (ACP)– American College of Clinical Engineerin g (ACCE)– And many more ….

• Began in 1997 in Radiology (RSNA) and IT (HIMSS)• Internation al effor t: IHE- Europe and IHE-Asia• Addition al sponsors for Cardiology includi ng ASE, ESC,

ASNC, SCA&I, HRS and more

IHE Organizational StructureMulti -Domain & Multi -National

IHE Organizational StructureIHE Organizational Stru ctureMultiMulti --Domain & MultiDomain & Multi --NationalNational

Participants

contribute

Global Development:Radiology,IT Infra structure,Cardiolo gy,Lab, etc .

Delegates

IHE Europ e

IHE NorthAmerica

IHE Asia/O ceania

Regional &NationalDeploym ent

supervises reports

IHE (Inter national) Strategi c Developm ent Committee

Spons orCo-Chairs

Global

Inter oper abili ty

IHE Domain-relat edPlanning and

Technical Committees

7

Electronic Health Record

Cardiology

Laboratory

Radiology

Oncology

FutureDomains

I HEIT Infrastru cture

14 Integra tion Profil es

5 Integration Profi les

4 Integrati on Profiles

1133 IInntteeggrraatt iioonn PPrrooff ii lleess

Patient CareCoordination

1 Integrati on Profile

Patient CareDevices

PathologyEye Care

IHE 2006IHE 2006 –– Nine Active DomainsNine Active DomainsOver 100 vendors involved worl dOver 100 vendors involv ed world --wide,wide, 5 Technic al Frameworks5 Technical Frameworks

37 Integra tion Profil es, Testing at Connectath ons37 Integrati on Profiles, Testing at Connectathon sDemons trat ions at major confe rences worldDemon strati ons at major conferences world --widewide

15 Ac tive national chap ters on 4 co ntinents15 Active nati onal chapters on 4 con tin ents

IHE Standards -Based Integra tion SolutionsIHE StandardsIHE Standards --Based Integration Soluti onsBased Integration Solu tion s

Professional Societies SponsorshipHealthcare Providers & Software Developers

Healthcare IT StandardsHL7, DICOM, etc.

General IT StandardsIntern et, ISO, etc.

Interoperable Healthcare ITSolution Specifications

IHE Integr ation ProfileInteroperable Healthcare IT

Solution SpecificationsIHE Integration Profile

Interoperable Healthcare ITSolution Specifications

IHE Integration Profi leInteroperable Healthcare IT

Solution SpecificationsIHE Integra tio n Profile

IHEProcess

IHE Integration Profil es

Access to Radiology Inform ation

ConsistentPresentati on

of Images

Sched uled Workflow

Basic Security

-

EvidenceDocumen ts

Key ImageNotes

SimpleImage andNumericReports

Presentationof GroupedProcedures

Post -ProcessingWorkflow

ReportingWorkflow

ChargePostingP

atient

Information

Reconciliation

Proven Standa rds Adop tion Process

IHEIntegrationProfiles B

IHEIntegratio n

Profile A

Easy toIntegrateProd uct s

IHEIHEDemonstrati onDemonstrati on

User Site

RFPRFP

StandardsStandards

IHETechnical

Framewor k

Product IHE Integrati onStatement

IHE Integrat ion Pro files at the heart of IHE :– Detailed selection of standards and optio ns each solving a speci fic

in tegration problem– A growing set of effective prov ider/ softwar e-develo per agreed soluti ons– Vendors can imple ment wit h ROI

IHEIHEConnectConnect --aa--thonthon

ProductWith IHE

IHE Connect -a-thonResul ts

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IHE Technical Frameworks

↑↑

↓ Pt. Registrat ion[RAD-1]↓ Patient Update[RAD-12]

Pt. Registration [RAD-1 ] ↓PatientUpdate[RAD-12] ↓

←PlacerOrderManagement [RAD-2]→Filler Order Management [RAD-3]

ADT

↓ Query Images[RAD-14]↓ RetrieveImages/Evidence[CARD-4]

ImageDisplay

Modality Image/EvidenceStored[CARD-2]

StorageCommitment

[CARD-3]

↓ ProcedureScheduled[RAD-4]

↓ ProcedureUpdated[RAD-13]

←QueryModality Worklist [RAD-5]

PerformedProcedure

StepManager

↑ M odali ty PSin Progress [CARD-1]↑ Modali ty PSCompleted[RAD-7]

→ M odali ty PSin Progress[CARD-1]→ M odali ty PSCompleted[RAD-7]

←Modality PSin Progress[CARD-1]←Modality PSCompleted[RAD-7]

OrderPlacer

AcquisitionModality

ImageManager

ImageArchive

DSS/OrderFiller

↓ PatientUpdate[RAD-12]

Modality Image/EvidenceStored[CARD-2]

StorageCommitment

[CARD-3]

↓↓

EvidenceCreator← Modal ity PSin Progress[CARD-1]

← Modal ity PSCompleted[RAD-7]

InstanceAvai lab ility Not ification [RAD-49]↑

↑↑

↓ Pt. Registrat ion[RAD-1]↓ Patient Update[RAD-12]

Pt. Registration [RAD-1 ] ↓PatientUpdate[RAD-12] ↓

←PlacerOrderManagement [RAD-2]→Filler Order Management [RAD-3]

ADT

↓ Query Images[RAD-14]↓ RetrieveImages/Evidence[CARD-4]

ImageDisplay

Modality Image/EvidenceStored[CARD-2]

StorageCommitment

[CARD-3]

↓ ProcedureScheduled[RAD-4]

↓ ProcedureUpdated[RAD-13]

←QueryModality Worklist [RAD-5]

PerformedProcedure

StepManager

↑ M odali ty PSin Progress [CARD-1]↑ Modali ty PSCompleted[RAD-7]

→ M odali ty PSin Progress[CARD-1]→ M odali ty PSCompleted[RAD-7]

←Modality PSin Progress[CARD-1]←Modality PSCompleted[RAD-7]

OrderPlacer

AcquisitionModality

ImageManager

ImageArchive

DSS/OrderFiller

↓ PatientUpdate[RAD-12]

Modality Image/EvidenceStored[CARD-2]

StorageCommitment

[CARD-3]

↓↓

EvidenceCreator← Modal ity PSin Progress[CARD-1]

← Modal ity PSCompleted[RAD-7]

InstanceAvai lab ility Not ification [RAD-49]↑

Query Modality Worklist [RAD-5]

ADT OrderPlacer

Regist erJ.Doe

AcquisitionModality

PlacerOrderManagement–New [RAD -2]

PatientReconcili ation

DepartmentSystemScheduler/

OrderFi ller

ScheduleProcedure

ProcedureScheduled[RAD-4]

Modalit yProcedureStepCompleted[ RAD-7]J.Doe->

J.Smith

Pat ientUpdate/Merge [RAD-12]

Modality ProcedureStep Completed[RAD-7]

PatientRegistration[RAD-1]

Patient Update/

Merge[RAD -12]

Modalit y ProcedureStep In Progress[CARD-1]

Modality ProcedureStepIn Progress[ CARD-1]

PerformAcquisition

Fill erOrderMgmt - StatusUpdate [RAD -3]

Fill erOrderMgmt - StatusUpdate [RAD -3]

I mageManager/

PPSManager

Filler OrderManagement-New[RAD-3]

Oneor theothermethodsof creatinganorder is used

Query Modality Worklist [RAD-5]

ADT OrderPlacer

Regist erJ.Doe

AcquisitionModality

PlacerOrderManagement–New [RAD -2]

PatientReconcili ation

DepartmentSystemScheduler/

OrderFi ller

ScheduleProcedure

ProcedureScheduled[RAD-4]

Modalit yProcedureStepCompleted[ RAD-7]J.Doe->

J.Smith

Pat ientUpdate/Merge [RAD-12]

Modality ProcedureStep Completed[RAD-7]

PatientRegistration[RAD-1]

Patient Update/

Merge[RAD -12]

Modalit y ProcedureStep In Progress[CARD-1]

Modality ProcedureStepIn Progress[ CARD-1]

PerformAcquisition

Fill erOrderMgmt - StatusUpdate [RAD -3]

Fill erOrderMgmt - StatusUpdate [RAD -3]

I mageManager/

PPSManager

Filler OrderManagement-New[RAD-3]

Oneor theothermethodsof creatinganorder is used

Detailed standards implementationguides

IHE Connectathon

• Open invitation to the SoftwareDeveloper Communi ty

• Advance testing tools (MESA) applie d• Compliance Testi ng organized and

supervi sed by the sponsors of IHE• Thous ands of cross -system tests

perform ed• Produ ct Integratio n Statemen ts

validate d

IH E Connectathon, January 2006••300+ parti cip ants, 120+ systems300+ parti cipan ts, 120+ systems••60+ systems devel opers60+ systems developers••Four Domain s: Cardiology, IT Infrastructure,Four Domains: Cardi ology, IT Infrastructure,

Patient Care Coordinati on, RadiologyPatient Care Coordinati on, Radiology••2800+ monitored test cases2800+ monito red test cases

Request for Proposals (RFPs)• Much easier to speci fy and agree to an IHE

Integration Profil e than detailed technical specs:

– “ Devic e must support IHE Scheduled WorkflowIntegration Profile, and vendor must suppl y anIHE Integrati on Statement. ”

• Software Developer response:

9

• Results– Over 3000 attendees visited the HIMSS RHIO Showcase– 37 vendors demonstrated 48 systems– 700 attendees created and tracked their own health record– 63 educational sessions were presented– 5 International delegations– 3 VIP tours– 16 clinical scenarios were demonstrated

IHE-RO

• DICOM WG-7 (Apr il, 2004)– Intr oduc tion to IHE– Discussion on how Radiation Oncol ogy coul d

participat e• NEMA Radiation Therapy Section

– At AAPM 2004, dis cuss ed need to impro veinteroperabili ty in RT

• ASTRO– Board of Directors Proposal, June 2004– Kick -off, ASTRO Annual Meetin g, 2004– First Meeting of IHE-RO PC & TC @ RSNA, 2004– Joint Effort led by ASTRO with AAPM, NEMA, and others

• IHE-RO Technical Committee– First Meeting, January, 2005 w/ DICOM WG-7

IHE-RO

INTEGRATING THE HEALT HCARE ENTERPRISE (IHE) –

RADI ATIO N ONCOLOGY (RO)

Participants in IHE-RO International Atomic Energy

Agency (IAEA)

Impac

Japanese Society for

Therapeutic Radiology and

Oncology (JASTRO)

Miranda Solutions

National Cancer Institute

(NCI)

National Electrical

Manufacturers Association

(NEMA)

Nucletron

Philips

Tomotherapy

Radiological Society of North

America (RSNA)

Siemens

Varian

Advanced Technology Consortium

(ATC)

American Association of Physicists

in Medicine (AAPM)

American College of Radiology

(ACR)

American Society for Therapeutic

Radiology and Oncology (ASTRO)

Association of Radiation

Oncologists of India (AROI)

Canadian Association of Radiation

Oncologists (CARO)

Chinese Society of Radiation

Oncologists (CSRO)

CMS

Egyptian Cancer Society –Radiation

Oncology

Elekta

European Society for Therapeutic

Radiology and Oncology (ESTRO)

10

IHE-RO

INTEGRATING THE HEALTHCARE ENTERPRISE (IHE) –

RADIATI ON ONCOLOGY (RO)

Participants in IHE-RO International Atomic Energy

Agency (IAEA)

Impac

Japanese Society for

Therapeutic Radiology and

Oncology (JASTRO)

Miranda Solutions

National Cancer Institute

(NCI)

National Electrical

Manufacturers Association

(NEMA)

Nucletron

Philips

Tomotherapy

Radiological Society of North

America (RSNA)

Siemens

Varian

Advanced Technology Consortium

(ATC)

American Association of Physicists

in Medicine (AAPM)

American College of Radiology

(ACR)

American Society for Therapeutic

Radiology and Oncology (ASTRO)

Association of Radiation

Oncologists of India (AROI)

Canadian Association of Radiation

Oncologists (CARO)

Chinese Society of Radiation

Oncologists (CSRO)

CMS

Egyptian Cancer Society –Radiation

Oncology

Elekta

European Society for Therapeutic

Radiology and Oncology (ESTRO)

Exactly How Does IHE-RO Function?

• Planni ng Commit tee– Identifies information

systems or compone ntsof infor mati on systemsthat produce, manage,or act on informationassociated wi th clinicaland operationalactivities that requir eintegration .

• Techn ical Committee– Identifies and

impl ements standardsfor interactio ns betweenactors that communi catethe requi red informati onthrough stand ards -basedmessages.

ThePCandTC work togethertoPrioritize Efforts,ProposeSolutions,and Eventually Demonstrate Connectivity

- whatdid he justsay?

IHE-RO Basic Inter operabili ty2005-2007 Integr ation Profi le

ImagingStudyContouring

System

SimulationSystem

PlanningWorkstation

RadOncIMS

TreatmentDelivery

TreatmentVerification

IHE-RO Actors

• Proposals circul ating betweenPlanni ng Comm ittee and Techni calComm ittee– Many applica tions combin e actor s

ImageArchive

RTArchive

PatientRegistrarMulti-Media Registration

ContouringReference Point Generation

Prescription EntryBeamPlacer/ Shaper

DoseCalculatorPlan Evaluator

FractionatorReferenceImage Creator

Planning Application

RT SSet

RT Plan G

RT SSet RT Plan

RT Dose ReferenceImages

RT Dose

DICOM

11

IHE-RO CT Simulatio n Applic ation

RTArchive

ImageArchive

Multi-Media RegistrationContouring

Reference Point GeneratorBeam Shaper / Placer

Prescription EntryReference Image Creator

Contouring &Beam Editor Application

RT SSet

RT Plan G

DICOM

Reference Images

IHE-RO Treatment Plannin g App licatio n

ImageArchive

RTArchive

Patient RegistrarMulti-Media Registration

ContouringReference Point Generation

Prescription EntryBeam Placer / Shaper

Dose CalculatorPlan Evaluator

FractionatorReference Image Creator

Planning Application

RT SSetRT Plan G

RT SSet RT Plan

RT Dose Reference Images

RT Dose

DICOM

IHE-RO Treatme nt Delivery IHE-RO Techn ical Frameworks

12

Actors

• Archive• Contourer• Geometric Planner• Dosi metric Planner• Dose Displa yer

IHE-RO Connectath on 2006

Supporters• Keith La Plain (Varian)• Stuart Swerdl off (IMPAC)• Robyn Watson (ASTRO)• Jamie Gale (ASTRO)• Mike Sul livan (ASTRO)• Amy Kapinus (ASTRO)• Stephen Vastagh (NEMA)

Evaluators• Bruce Curran (U Mich)• Walter Bosch (Wash U ATC)• Chuck Pelizzari (U Chicago)• Philip Devlin (Harvard)

Participan ts• Phillips• Siemens• Nuclet ron• Varian• Elekta• Brainlab• Tomotherapy• CMS• IMPAC

Informa l Connect athon 2006

••25+ particip ants, 9 Vendors, 10+ systems25+ parti cipan ts, 9 Vendors, 10+ systems••95+ monitored test cases95+ monit ored test cases

Infor mal Conne ctatho n 2006

13

What’s Next?

• Compositing Dose• Residual Dose Optimization• Multimodality Image Registra tion• On-line Image Review (referen ce image vs.

deli very image)• Off -line Image Review (reference image vs.

deli very image)• Scheduling Treatment Delivery and

Veri fy/Record• Query/Retrieve• Configuration Management

Selected for 2008

Profi le Roadmap

• Initial Implementati on (2005-2007)– RO General Integrati on Profil e

• CT Image Retri eval / Storage• Image Set Contouring• Geometric Plan Definition• Dosimetric Plan Definition• 3D Dose Matrix Viewer

– Reduce Multipli city of Implement ation Paths– Test Tools Contract in place– Connect athon Scheduled (8/25/2007)

• 2008 Profil es– RO Multimodalit y Regis trati on– Treatment Deliver y Workflow

IHE-RO 2006 Connectath on