Formation IHE Octobre 2007 Cadre Technique de Radiologie

Radiology Technical Framework Il est décrit en quatre volumes: –V1 : Description des cas d’utilisation, des différents acteurs et des transactions, des différents profils –V2: Détail des transactions et des messages –V3: Détail des transactions et des messages –V4: Extensions nationales

Vue d’ensemble Développé depuis sept ans, Développé depuis sept ans, Plus de 15 profils définis ou en cours de définition. Plus de 15 profils définis ou en cours de définition. Qui couvrent: Qui couvrent: – Processus de base: Demande et réalisation d’une acquisition, Post-processing, Suivi de l’activité, Transmission de cas pour formation et essais cliniquesDemande et réalisation d’une acquisition, Post-processing, Suivi de l’activité, Transmission de cas pour formation et essais cliniques –Transmission des images après interprétation: Mesures, présentations de l’image, images clés, rapport …Mesures, présentations de l’image, images clés, rapport … - Diffusion des informations d’imagerie: Sur CD, au système d’information médical, tout en assurant la traçabilitéSur CD, au système d’information médical, tout en assurant la traçabilité

The IHE Initiative Worldwide November 28th, 2006 IHE Success: Integration Profiles Solutions to Real-World Problems in Radiology Patient Information Reconciliati on Reconcile worklists, status, and data objects for unknown patients and demographics changes Access to Radiology Information - Consistent access to images and reports Consistent Presentation of Images Manage, retrieve & use objects for hardcopy and softcopy grayscale presentation states Key Image Notes Create, store, manage, retrieve & use objects to flag significant images Simple Image and Numeric Reports Manage simple diagnostic reports with optional images, measurements Scheduled Workflow Presentation of Grouped Procs Manage individual procedure image subsets from a multi-procedure acquisition for viewing & reporting Charge Posting Collect and post timely billable procedure details ITI ATNA – Radiology Option (Replaces Basic Security) Reporting Workflow Manage worklists, track status, perform & notify diagnostic reporting steps Evidence Documents Manage, retrieve & use objects to record study evidence Manage worklists, track status, perform & notify image processing & CAD steps Post- Processing Workflow Manage worklists, track status, perform & notify acquisition related step, create, store, manage, retrieve & use images NM Image Create, store, manage, retrieve & use NM image objects Portable Data for Imaging - Consistent access to images and reports on CD Media Admit, Order, Schedule Teaching Files & Clinical Trials Export Standardize Clinical Trial Data and Anonymization XDS for Imaging - Sharing of Imaging Information across health enterprises WorkflowsBilling Teaching/ Research Contents & DisplayCommon Infrastructure

–Scheduled Workflow (SWF) –Patient Information Reconciliation (PIR) –Access to Radiology Information (ARI) –Key Image Notes (KIN) –Consistent Presentation of Images (CPI) –Post-Processing Workflow (PPW) –Reporting Workflow (RWF) –Portable data Imaging (PDI) –Access Radiology Information (ARI) Les Profils

Scheduled Workflow Présentation et points importants Squelette d’IHE Radiologie Intègre: Admission patient, Prescription, Acquisition des images, Interprétation des images Utilise HL7 et DICOM Utilise HL7 et DICOM Préserve la continuité de la prescription –“Close the Loop” –Maintient la cohérence (accession number), évite la confusion entre Filler number, Placer number, etc. Augmente l’intégrité des données –Saisie unique, transmission de système à système –Diminue le risque d’erreurs

Scheduled Workflow Les points importants Augmente l’efficacité du processus –Utilisation de Worklist moins de temps en saisie de données moins de temps en saisie de données initialisation des systèmes semi-automatique initialisation des systèmes semi-automatique Sûreté du Stockage –Storage Commitment Moins d’études perdues Moins d’études perdues Plus de confiance dans les résultats Plus de confiance dans les résultats Améliore le suivi de la prescription –MPPS (management performed procédure step) de la Modalité au RIS & PACS Un retour mieux synchronisé Un retour mieux synchronisé Un retour plus précis Un retour plus précis

Order Placer Performed Procedure Step Manager ADT Patient Registration Image Archive Image Manager Image Display Image Creator Acquisition Modality Department System Scheduler – Order Filler – Modality Worklist Patient Registration Procedure Scheduled Images Availability Query Images Stored Storage Commit Storage Commit Images Stored PPS In-Progress / Completed Filler Order Management Placer Order Management Q /R Images PPS In-Progress / Completed PPS In-Progress / Completed Scheduled Workflow RIS HIS IMAGING: PACS Workstations Modalities

IHE Workflow Concepts PROCEDURE STEP : Plus petite entité du workflow Scheduled Procedure Step: ‘Unité de travail à réaliser’ Performed Procedure Step: ‘Unité de travail réalisé’ PROCEDURE STEP : Plus petite entité du workflow Scheduled Procedure Step: ‘Unité de travail à réaliser’ Performed Procedure Step: ‘Unité de travail réalisé’ IHE a sélectionné trois termes Hl7/DICOM : ORDER : Demande d’examen de radiologie ORDER : Demande d’examen de radiologie REQUESTED PROCEDURE : Une unité de travail dont le résultat REQUESTED PROCEDURE : Une unité de travail dont le résultat est présenté sous la forme d’un seul rapport (associés à des actes codifiées et facturables)

Workflow Concept Mapping Ces 3 niveaux sont en relation avec des niveaux métiers: ORDER: A request for imaging service (Accession Number) REQUESTED PROCEDURE : Units of work resulting in one Report with associated codified, billable acts (Requested Procedure ID) PROCEDURE STEP : The smallest unit of work in the workflow (modality worklist entry) CLINICIEN ou Médecin demandeur: “le client du département d’imagerie RADIOLOGUE : C’est lui qui produit Le compte rendu TECHNICIEN (et RADIOLOGUE) En charge de l’acquisition des images…

Acquisition Modality Normal Workflow ORDER A request for Radiologic Service Radiology Department Set of Codifiable, Billable, Acts One or more series of images Performed Procedure Step Requested Procedure Scheduled Procedure Step Report DICOM Modality Worklist Typical workflow: One Order – One Procedure – One Report

Acquisition Modality Multiple Modality Steps ORDER A request for Radiologic Service Radiology Department Set of Codifiable, Billable, Acts One or more series of images Performed Procedure Step P1 Scheduled Procedure Step B Requested Procedure 1 Scheduled Procedure Step A Report One or more series of images Performed Procedure Step P2 DICOM Modality Worklist

–Scheduled Workflow (SWF) –Patient Information Reconciliation (PIR) –Access to Radiology Information (ARI) –Key Image Notes (KIN) –Consistent Presentation of Images (CPI) –Post-Processing Workflow (PPW) –Reporting Workflow (RWF) –Portable data Imaging (PDI) –Access Radiology Information (ARI) Les Profils

Patient Information Reconciliation Les points importants Extension du Scheduled Workflow Coordonne les modifications des données démographiques dans le workflow et les objets manipulés Permet de gérer les cas exceptionnels –Cas d’urgence ou trauma: Patient inconnu ou pas encore enregistré –Erreurs de saisie –Autre changement démographique (noms jeune/fille vs nom marital)

Formation IHE Octobre 2007 Order Placer Performed Procedure Step Manager ADT Patient Registration Image Archive Image Manager Image Display Image Creator Acquisition Modality Department System Scheduler – Order Filler – Modality Worklist Patient Registration Procedure Scheduled Images Availability Query Images Stored Storage Commit Storage Commit Images Stored PPS In-Progress / Completed Filler Order Management Placer Order Management Q /R Images PPS In-Progress / Completed PPS In-Progress / Completed Patient Information Reconciliation Patient Update Procedure Update RIS HIS IMAGING: PACS Workstations Modalities

“Emergency” - Case 3 ADT Order Placer Image Manager Modality Department System Database/Scheduler/ Order Filler Filler Order Mgmt New Order [3] Procedure Scheduled [4] Patient Reconciliation J.Doe ->J.Smith Patient Update [12] Schedule Procedure Images Acquired ModalityProcedure Step Completed [7] Modality Procedure Step Completed [7] RegisterJ.Doe Patient Update [12] Patient Registration [1]

–Scheduled Workflow (SWF) –Patient Information Reconciliation (PIR) –Access to Radiology Information (ARI) –Key Image Notes (KIN) –Consistent Presentation of Images (CPI) –Post-Processing Workflow (PPW) –Reporting Workflow (RWF) –Portable data Imaging (PDI) –Access Radiology Information (ARI) Les Profils

Access to Radiology Information Les points importants Fourni l’accès aux informations radiologiques dans l’ensemble de l’établissement (cardiologie, oncologie….) –Images, evidence documents, presentation states, key image notes, structured radiology reports Modèle basique de Query and retrieve Permet aux utilisateur d’accéder à de l’information radiologique distribuée –Décrit comment les utilisateurs peuvent interroger des sources d’information multiples.

Access to Radiology Information Transaction Diagram

–Scheduled Workflow (SWF) –Patient Information Reconciliation (PIR) –Access to Radiology Information (ARI) –Key Image Notes (KIN) –Consistent Presentation of Images (CPI) –Simple Image and Numeric Report (SINR) –Presentation of Grouped Procedures (PGP) –Portable data Imaging (PDI) Les Profils

for referring physician Here you can see the osteopathy. For teaching Fibroosteoclasia

Different notes on different images Same note on different images for referring physician Here you can see the renal rupture. Note1 for referring physician This is the hematoma. Note2 for refering physician Here you can see the renal rupture. Note1 for refering physician This is the hematoma. Note2 for refering physician Hematoma everywhere Note3 for refering physician Hematoma everywhere Note3 for refering physician Hematoma everywhere Note3 for refering physician Hematoma everywhere Note3 for referring physician Hematoma everywhere Note3

Key Image Notes Titles are Coded Defined by DICOM. May be extended The note title defines the semantics of the reason of significance. Key Image Notes can be queried by code. The user comments are meant to be informal. Codes Of Interest Rejected for Quality Reasons For Referring Provider For Surgery For Teaching For Conference For Therapy For Patient For Peer Review For Research Quality Issue For Reporting

–Scheduled Workflow (SWF) –Patient Information Reconciliation (PIR) –Access to Radiology Information (ARI) –Key Image Notes (KIN) –Consistent Presentation of Images (CPI) –Simple Image and Numeric Report (SINR) –Presentation of Grouped Procedures (PGP) –Portable data Imaging (PDI) Les Profils

Problème de la cohérence d’affichage tumeur visibletumeur invisible VOI chosen on one display device Rendered on another with different display Mass expected to be seen is no longer seen Slide Provided by David Clunie

Problème de l’incohérence de rendu Tous les niveaux de gris ne sont pas perceptibles sur les différents écrans ! Slide Provided by David Clunie

DISPLAY Image Archive Image Manager Image Display Image Creator Present. State Stored Q /R Presentation Sates Images Stored Acquisition Modality PRINTING Print Server Print Request with Presentation LUT Print Composer Consistent Appearance of Images: –Display Devices –Printed Output Consistent Presentation of Images Transaction Diagram Present. State Stored

Consistent Presentation of Images DICOM Standard Used: Calibration of the Softcopy Display and the Hardcopy Output Devices using DICOM Grayscale Standard Display Function (GSDF) Creating Hardcopy Output Using DICOM Basic Print with Presentation LUT (P-LUT) Support Preserving/Using the Softcopy Display Viewing Parameters in the DICOM Grayscale Softcopy Presentation State (GSPS) container Cal Hard Soft

Acquire DisplayPrint Consistent Presentation of Images Slide Provided by David Clunie

–Scheduled Workflow (SWF) –Patient Information Reconciliation (PIR) –Access to Radiology Information (ARI) –Key Image Notes (KIN) –Consistent Presentation of Images (CPI) –Simple Image and Numeric Report (SINR) –Portable data Imaging (PDI) Les Profils

Simple Image and Numeric Reports

Simple Image & Numeric Reports Les points importants Le contenu d’un rapport est plus que des mots… Basé sur DICOM SR Permets d’inclure sans retranscription: –mesures –Liens vers les images –Contenus structurés Intégré dans le workflow d’imagerie Compatible avec des implémentations XML Facilement exportable vers HL7

Pattern – Simple Image Report Minimal Structure : Coded Title and HeadingsMinimal Structure : Coded Title and Headings Full image links from specific sections of reportFull image links from specific sections of report Observation Context (who, what, when) may be section specificObservation Context (who, what, when) may be section specific

Pattern – Simple Image & Numeric Report Simply adds Measurements to Simple Image Reports

Un example

–Scheduled Workflow (SWF) –Patient Information Reconciliation (PIR) –Access to Radiology Information (ARI) –Key Image Notes (KIN) –Consistent Presentation of Images (CPI) –Simple Image and Numeric Report (SINR) –Presentation of Grouped Procedures (PGP) –Portable data Imaging (PDI) Les Profils

IHE Workflow is User Driven Information Unit has its Prime User ORDER: A request for imaging service (Accession Number) REQUESTED PROCEDURE : Units of work resulting in one Report with associated codified, billable acts (Requested Procedure ID) PROCEDURE STEP : The smallest unit of work in the workflow (modality worklist entry) CLINICIAN OR REFERING DOC: The Imaging Dept Customer RADIOLOGIST : In Charge of producing the Report the Report TECHNOLOGIST (and RADIOLOGIST) In charge of acquiring images, etc.

Normal Workflow Typical workflow: One Order – One Procedure – One Report ORDER A request for Radiologic Service Requested Procedure Radiology Department One or more series of images Report Set of Codifiable, Billable, Acts Acquisition Modality

Multiple Modality Steps ORDER A request for Radiologic Service Radiology Department Set of Codifiable, Billable, Acts One or more series of images Performed Procedure Step P1 Scheduled Procedure Step B Requested Procedure 1 Scheduled Procedure Step A Report One or more series of images Performed Procedure Step P2 DICOM Modality Worklist

The Group Case Approach ORDER A request for Radiologic Service CT Chest & Abdomen Radiology Department Acquisition Modality Requested Procedure CT Chest Requested Procedure CT Abdomen Report CT Chest Set of Codifiable, Billable, Acts Report CT Abdo Set of Codifiable, Billable, Acts One or more series of images One Order – Two Procedures – One Acquisition - Two Reports

Group Case ORDER A request for Radiologic Service Radiology Department Report Set of Codifiable, Billable, Acts Acquisition Modality Report Set of Codifiable, Billable, Acts Requested Procedure 2 Scheduled Procedure Step B Requested Procedure 1 Scheduled Procedure Step A One or more series of images Performed Procedure Step P1 DICOM Modality Worklist

Cas d'utilisation du PGP CT Thorax/Abdomen/Pelvis Neuroradiologie: CT Cou & CT Thorax IRM de différentes section du rachis IRM et MRA acquisent simultanément IRM du crane et de la nuque à l'aide d'une antenne spécialisée...

Pourquoi a-t-on besoin de PGP ? Maintenir un lien avec chacune des procédures groupées S'assurer que chacun des ensembles d'images correspondants aux procédures demandées soit bien identifié et présenté. De trier correctement les images : sur le film, s'est naturel, dans un environement “filmless” c'est moins évident ! Optimise le confort du patientOptimise le confort du patient Optimise le temps d'acquisition.Optimise le temps d'acquisition. Mais il est nécessaire de :

Grouping of Procedures in IHE Group Case support is required by the IHE Scheduled Workflow Integration Profile: On Image Managers (PACS) On Order Fillers (RIS). Group Case support is optional on Modalities. PGP requires support of the “Group Case Option” on Modalities.

PGP Integration Profile builds upon SWF and CPI Consistent Presentation of Images Softcopy grayscale and presentation state Scheduled Workflow Admit, order, schedule, acquire images, notify of completed steps + Presentation of Grouped Procedures Presentation of Subsets of a Single Acquisition Required for

MODALITY IHE – Presentation of Grouped Procedures Requested Procedure: CHEST Report: CHEST Requested Procedure: ABDOMEN Report: ABDOMEN Performs a single acquisition Operator groups 2 procedures Chest View Abdome n View RIS / PACS Chest View Abdome n View Scheduled Procedure Step Chest Scheduled Procedure Step Abdo

IHE PGP - Implementation Example Image Display Constraints MODALITY Requested Procedure: CHEST Report: CHEST Requested Procedure: ABDOMEN Report: ABDOMEN Performs a single acquisition Operator groups 2 procedures Chest View Abdomen View Order Filler Chest View Abdomen View Scheduled Procedure Step Chest Scheduled Procedure Step Abdo Image Mgr (Incl. Display) PGP Actors Chest View Abdomen View Image Display CPI only Actor Image Display has no access to full Requested Procedure Information

–Scheduled Workflow (SWF) –Patient Information Reconciliation (PIR) –Access to Radiology Information (ARI) –Key Image Notes (KIN) –Consistent Presentation of Images (CPI) –Simple Image and Numeric Report (SINR) –Presentation of Grouped Procedures (PGP) –Portable data Imaging (PDI) Les Profils

PDI – Value Proposition Media amovible contenant des données Dicom et éventuellement des données multimédia (browsable) –Pour le patient –Pour le médecin demandeur –Pour échanger des données au sein de l’établissement –Pour échanger des données entre établissement Valider l’interopérabilité de ce type de media Compatibilité avec les navigateurs Avoir des CD que l’on puisse graver et lire sur n’importe quel système !

PDI –Value Proposition La validation de l’interopérabilité est essentielle ! –Problèmes d’interopérabilité réseau : Immédiats, sans ambiguïtéImmédiats, sans ambiguïté Solution rapideSolution rapide –Problèmes d’ interopérabilité Media Long délai avant la détection (et la reconnaissance)Long délai avant la détection (et la reconnaissance) Long délai avant de résolutionLong délai avant de résolution Large volume de media non inter-opérable créé suite aux long délais !Large volume de media non inter-opérable créé suite aux long délais !

PDI – Actors and Transactions Portable Media Creator Print Composer Report Reader Image Display Display Distribute Imaging Information on Media Media Importer

PDI – Media Creator Create DICOM Compliant CDROM media Create web content (optional)

CDROM Structure DICOMDIR INDEX.HTM README.TXT Directory of DICOM files IHE_PDI Directory of web files Other optional content Web content (optional)

CDROM Rules DICOM Part 10 compliance will be verified. This is done by both MESA tools and the project managers. IHE_PDI web content corresponds exclusively to the DICOM content, although it need not represent the entire DICOM content. Other content will not be placed in DICOM or IHE_PDI directories, but may be placed in other locations on the CDROM. Do not assume that an application on the media will automatically be launched. IHE recommends that media readers not automatically run software on the media. Web content use of XHTML and JPEG formats is restricted to ensure interoperability.

All PDI reading actors Shall indicate to the user when they find DICOM instances that are not supported by the reader. It is recommended that readers not automatically run software found on the media (for security reasons).

PDI Importer (Reader) Rules Portable Media Importer is required to have facilities to accommodate updating patient information to use values for the receiving enterprise, e.g. update patient ID. Portable Media Importer shall be grouped with at least one of the following actors: Evidence CreatorEvidence Creator Acquisition ModalityAcquisition Modality Image Manager/Image ArchiveImage Manager/Image Archive Report CreatorReport Creator Report ManagerReport Manager Report RepositoryReport Repository

CDROM Creator Rules All DICOM file names are limited to 8 characters (no extensions). This is the Part 10 requirement. All other file names are restricted to the ISO file name. E.g. “support_for_my_app.dll” would need to be “SUPPORT.DLL” or some other 8.3 name.

–Scheduled Workflow (SWF) –Patient Information Reconciliation (PIR) –Access to Radiology Information (ARI) –Key Image Notes (KIN) –Consistent Presentation of Images (CPI) –Simple Image and Numeric Report (SINR) –Presentation of Grouped Procedures (PGP) –Portable data Imaging (PDI) –Reporting Workflow (RWF) Les Profils