Integrating the Healthcare Enterprise RSNA/NIBIB Image Sharing:
An IHE profile tailored to Consumer Control David S. Mendelson,
M.D. Chief of Clinical Informatics The Mount Sinai Medical Center
Co-chair IHE Board
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Meaningful Use Objectives Improving Quality, Safety, Efficiency
& Reducing Health Disparities Engage Patients and Families in
Their Care Improve Care Coordination Ensure Adequate Privacy and
Security Protections for Personal Health Information 2
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IHE XDS profile was built around the concept of an affinity
domain Legal relationships at the enterprise level How can the
consumer fit into this model Use the same actors and transactions
3
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Image sharing- Why? Benefit of historical exam during
interpretation Rapidly growing cost of healthcare especially
growing utilization of imaging Overutilization Prevent duplicate
exam because a recent exam is inaccessible Radiation exposure
Quality Expedites clinical care through easy availability of
imaging examination
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Issues that govern sharing Imaging Exams What is our product?
Who are our customers? What are the mechanisms of sharing? What are
the impediments? Technology Policy
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Issues that govern sharing Imaging Exams What is our product?
Who are our customers? What are the mechanisms of sharing? What are
the impediments? Technology Policy
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Our Product Information! Imaging Exam Order Direct patient
history Prior exams Report Demographics Referring Clinician
Reporting Team Indication Narrative Procedure Impression Structured
report
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Issues that govern sharing Imaging Exams What is our product?
Who are our customers? What are the mechanisms of sharing? What are
the impediments? Technology Policy
Who? Primary Clinician Often has existing access Not always
Consulting Physician Ambulatory Imaging Center Hospital Either
direction Second Hospital or enterprise Patient or relative
Research De-identified
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Issues that govern sharing Imaging Exams What is our product?
Who are our customers? What are the mechanisms of sharing? What are
the impediments? Technology Policy
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Film Are you old enough to remember film? Still exists Clinical
offices
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Film Today generally regarded as the least desirable media
Expensive Medium Limited latitude Expensive to handle Sharing
Copying expensive, time consuming, bulky Accessibility Import -
scanning
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The CD- better than sliced bread or be careful what you ask for
you may get it Portable Compact Can hold thousands of images
Inexpensive ($0.50 or less) Whats wrong here?
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CDs- Problems Different data formats Non-Dicom Different
viewers End-user confusion Defective Discs Disc must be in your
possession Patient Identity Wrong Patient on Disc Time consuming
Clinicians are confused They share their confusion with their
Radiologist
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Difficult Discs-Wrong Patient/Information Mayo Clinic
Unreadable Disc 0.6% Wrong- 0.2% Mount Sinai- estimates 5% cannot
be imported Rare wrong patient
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Patient Identity Patient has a MRN at importing institution
Patient does not have a MRN at importing institution MRN is in the
DICOM header
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Help!
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Importing an Exam- the process Identify the patient locally
Confirm the images belong to the patient Determine the name the
imported exam Convert into DICOM format Scan film Read disc ? Dicom
Read from buffer Import and perform reconciliation Into PACS? Into
RIS? Into a parallel system? EMR Is it for interpretation? Is it to
be billed?
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Importing an Exam a variant Establish a standard viewing
environment for clinicians for outside exams. Allow them to
designate exams for import from this environment Import into local
PACS
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Issues for exam import Accuracy of the foreign information
Compatibility Legal? Responsibility ??? Changes to the exam or
report after import How does one become aware?
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CD- Opportunities to improve Importing a disc provides the
opportunity to correct Robust import solutions -commercial Standard
import interface Reconciliation process Trained personnel Standards
DICOM PDI extensions (IHE- Portable Documents for Imaging) BIR-
(IHE- Basic Image Review) Minimum requirement for review
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Mechanisms of Sharing- Reports Mail RIS FAX E-Mail PACS VPN
Internet EMR-Patient Portal PHR
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When to release a Report vs. Image? o The patient is entitled
Legal Practical Is the patient prepared for the information in the
report? o Immediate use to clinician o May be meaningless to most
patients other than a curiosity
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Network/Internet base sharing Replace the CD (SneakerNet) with
the Internet Convenience vs. Security New opportunities Shared
Image processing Efficiencies
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Network/Internet base sharing Proprietary applications Usually
used within an enterprise or a limited domain with legal agreements
Health Information Exchange (HIE) Multiple enterprises with a set
of legal agreements Often have selected their own standards- not
truly open standards based Sustainability
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Network/Internet Security/Privacy-Confidentiality HIPAA
Security/ Privacy-Confidentiality HIPAA This is the networked
version of the CD More convenient Same issues need to be
addressed
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Network/Internet VPN/Enterprise Portal Clinical Staff Patient
Temporary credentials Enterprise- multi-sites; proprietary solution
Multiple PACS and RIS feed one central archive All credentialed can
view that archive Point to Point networks HIE Standards based or
proprietary sharing network IHE model Patient Centric model /
PHR
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Challenges to exchange Who pays for an exchange infrastructure
What is the persistence of the information in the exchange Are
images different from other forms of healthcare data Easy secure
access is good for the patient Does it endanger the provider?- is
this an impediment? Economic adjustments and evolution are likely
to occur Balance of cost control vs. Quality Reduction in Radiation
exposure Not all patients agree
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Methods Point to Point E-mail Cloud Computing HIE (Health
Information Exchange) These are not mutually exclusive- there is
overlap
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Point to Point A limited number of entities establish direct
connections Usually requires a direct formal relationship (legal)
Can be successful to address very specific interoperability
problems Doesnt scale
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HIE Requires legal relationships between participants Requires
patient identity management Enables a greater number of entities to
participate May be scalable HIE to HIE Consent issues Commonly all
or nothing rather than episode or event based Patients may wish to
only expose limited pieces of data
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Sharing Healthcare Information in the Cloud Hospital Imaging
Center Primary Doctor Specialist Hospital Patient Patient
Surrogate
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Cloud Computing o WHO o Enterprise o HIE o Consumer o WHAT o
Services o Transactions o Archive
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IHE-XDS (Cross-Enterprise Document Sharing) XDS.a XDS- I.a
XDS.b ?? XDS-I.b a vs. b Related to web standards and
transactions
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XDS
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XDS-I
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Canada Health Infoway
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NIBIB/RSNA Image Sharing Project A Standards Based
Solution
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Goals of Contract NIBIB contract Bootstrap an IHE based network
Primary emphasis is Consumer Control through PHRs Can be extended
to other forms of sharing HIE Security and Confidentiality are
drivers Replacement / Alternative to CD
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NIBIB contract summary o Consumer Control o Employ IHE
solutions whenever possible IHE generally has not focused on
consumer driven solutions but rather on institutional and
enterprise workflow o 5 Academic Institutions Mayo Clinic Mount
Sinai Medical Center University of California San Francisco
University of Chicago University of Maryland o Establish a
clearinghouse o Engage PHRs o 300,000 patients over 2 years
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Image Sharing/Elements of Solution Edge Server Register a
patient Listens to a Radiology Information System (RIS)- looking
for a complete exam Retrieves Image set from PACS and Report from
RIS Send both to clearinghouse PHI hidden; an RSNA ID and 2 nd
factor security token are used to identify the patient
Clearinghouse (XDS-I) functions as a secure router Transiently hold
encrypted patient data PHR Consumer controls upload and future
access Must have RSNA ID available and know answer to 2 nd factor
question Develop web based viewers Download full DICOM data set
Misc Consumers
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Software architecture Prepare contentPoll database, get report,
get exam,prepare big fat file Background java srvlet25 days
Transfer contentPoll database for transfer out, package content
into xds.b Background java srvlet35 days HL7 receiverReceive HL7
A04 messages, extract reports and store them in database Mirth HL7
Channel. Let Mirth create its default database, all script work-but
may have to customize per site 65 days for 5 sites Token AppCreate
new tokens based on two parts, associate token with accession
numbers, update database, user interface with login, get patient
info,create job Ajax based web front-end,JavaServlet for CFIND
using dcm4che, creating job in the RSNA database, creating tokens
using kerberos tokens generated locally 30 days DatabaseStore
reports, logs, audit trails, user accounts, etc. Mirth instance for
HL7 & DICOM, RSNA instance for everything else 50 days 2
databases Management AppCreate users, monitor logs, check health
Ajax gui front end, backend servlet, dicom targets etc. 45
days
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Project design assumptions Security is paramount Restrictive
policy PHI is never unsecured Consumer controls the flow of
information by placing it in the PHR Diminishes the need for BAAs
between enterprises Imaging Site to Clearinghouse Clearinghouse to
PHR
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Advantages of Approach Push model No Query of PACS from outside
the firewall Full DICOM data set is available Web viewers Download
and Import to PACS Report is available Historical exams can be sent
simultaneously Consumer controls flow of information Affords the
patient the ability to select what information to share Is this
good?
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Future Directions Refine Workflow Initial workflow is to
replace a CD Exam updates Download DICOM data and archive in a
local PACS Edge server as a platform Radiation Monitoring Peer
Review Quality Metrics
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Research CTP- The RSNA Clinical Trial Processor CTP is a
stand-alone program that provides all the processing features of a
MIRC site for clinical trials in a highly configurable and
extensible application. It connects to FieldCenter applications and
can also connect to MIRC sites when necessary. CTP has the
following key features: Single-click installation. Support for
multiple pipelines. Processing pipelines supporting multiple
configurable stages. Support for multiple quarantines for data
objects which are rejected during processing. Pre-defined
implementations for key components: HTTP Import DICOM Import DICOM
Anonymizer XML Anonymizer File Storage Database Export HTTP Export
DICOM Export FTP Export Web-based monitoring of the application's
status, including: configuration logs quarantines status
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Issues that govern sharing Imaging Exams What is our product?
Who are our customers? What are the mechanisms of sharing? What are
the impediments? Technology Policy
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Conclusions We live in a heterogeneous world needing multiple
solutions CDs and portable media have both advantages and drawbacks
Compliance with standards helps We are transitioning to
network/internet solutions Security and confidentiality are even
more difficult ONC and State policies will foster these solutions
Solutions are evolving Proprietary solutions are often easier to
implement Solutions based on open standards will provide the
patient with greater flexibility Interoperability will require an
adjustment to the way we all think of healthcare data
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Future Directions Refine Workflow Initial workflow is to
replace a CD Exam updates Download DICOM data and archive in a
local PACS Edge server as a platform Radiation Monitoring Peer
Review Quality Metrics
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Radiation Exposure Monitoring Profile - REM Supplement to
Technical Framework for Trail Implementation Acquisition modalities
inlcudes information regarding dose exposure Estimates Permits
communication of that information to other systems Useful for
Individual lifetime estimates as well as Population analysis
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Radiation Exposure Monitoring (REM) Includes CT Plain X-Ray
Mammography Current Exclusions Nuclear Medicine RT Brachytherapy
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DICOM Dose SR objects DICOM 2008 PS 3.3: A.35.8 X-Ray Radiation
Dose SR IOD