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, Plus de 15 profils définis ou en cours de définition. Qui couvrent: Processus de base: Demande 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 … - Diffusion des informations d’imagerie: Sur CD, au système d’information médical, tout en assurant la traçabilité Se placer aux tableaux, faire répondre les participants et les noter aux tableaux. Question complémentaire avez-vous déjà informatisés ces flux si oui comment ?

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

Les Profils 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)

Scheduled Workflow Présentation et points importants Squelette d’IHE Radiologie Intègre: Admission patient, Prescription, Acquisition des images, Interprétation des images 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 initialisation des systèmes semi-automatique Sûreté du Stockage Storage Commitment Moins d’études perdues 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 plus précis

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

IHE Workflow Concepts IHE a sélectionné trois termes Hl7/DICOM : ORDER : Demande d’examen de radiologie 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) PROCEDURE STEP : Plus petite entité du workflow Scheduled Procedure Step: ‘Unité de travail à réaliser’ Performed Procedure Step: ‘Unité de travail réalisé’

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

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

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

Les Profils 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)

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)

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

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

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

Les Profils 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)

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 Detailed specs for DICOM Q/R: Defines Matching keys for response filtering by Image Archive Defines Return keys to be requested by Image Display Defines Returned attributes by Image Archive in query responses Defines Returned attributes required to be displayed on Image Display

Les Profils 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)

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

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

Key Image Notes Titles are Coded Defined by DICOM. May be extended 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 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.

Les Profils 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)

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

Problème de l’incohérence de rendu 0.5 1.0 Tous les niveaux de gris ne sont pas perceptibles sur les différents écrans ! 1.5 3.0 Slide Provided by David Clunie

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

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

Consistent Presentation of Images Acquire Print Display Slide Provided by David Clunie

Les Profils 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) Reporting Workflow (RWF)

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 Headings Full image links from specific sections of report Observation Context (who, what, when) may be section specific

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

Un example

Les Profils 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)

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

One or more series of images Normal Workflow Typical workflow: One Order – One Procedure – One Report Radiology Department ORDER A request for Radiologic Service Set of Codifiable, Billable, Acts Requested Procedure Report Acquisition Modality Representation includes: healthcare providers, information systems vendors, imaging systems vendors, and standards groups participating One or more series of images

Multiple Modality Steps DICOM Modality Worklist Radiology Department ORDER A request for Radiologic Service Scheduled Procedure Step A Acquisition Modality Report One or more series of images Performed Procedure Step P1 Set of Codifiable, Billable, Acts Requested Procedure 1 DICOM Modality Worklist Scheduled Procedure Step B One or more series of images Performed Procedure Step P2 Acquisition Modality Representation includes: healthcare providers, information systems vendors, imaging systems vendors, and standards groups participating

The Group Case Approach One Order – Two Procedures – One Acquisition - Two Reports Radiology Department ORDER A request for Radiologic Service CT Chest & Abdomen Set of Codifiable, Billable, Acts Requested Procedure CT Chest CT Abdomen Report CT Chest One or more series of images Acquisition Modality Report CT Abdo Set of Codifiable, Billable, Acts Representation includes: healthcare providers, information systems vendors, imaging systems vendors, and standards groups participating

DICOM Modality Worklist One or more series of images Group Case DICOM Modality Worklist Radiology Department ORDER A request for Radiologic Service Set of Codifiable, Billable, Acts Report Requested Procedure 1 Scheduled Procedure Step A One or more series of images Performed Procedure Step P1 Set of Codifiable, Billable, Acts Report Requested Procedure 2 Scheduled Procedure Step B Representation includes: healthcare providers, information systems vendors, imaging systems vendors, and standards groups participating Acquisition Modality

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 ? Optimise le confort du patient Optimise le temps d'acquisition. Mais il est nécessaire de : 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 !

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

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

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

Les Profils 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)

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 ambiguïté Solution rapide Problèmes d’ interopérabilité Media Long délai avant la détection (et la reconnaissance) Long délai avant de résolution Large volume de media non inter-opérable créé suite aux long délais !

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

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

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

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 Creator Acquisition Modality Image Manager/Image Archive Report Creator Report Manager Report 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 9660 8.3 file name. E.g. “support_for_my_app.dll” would need to be “SUPPORT.DLL” or some other 8.3 name.

Les Profils 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)

Reporting Workflow Les points importants Plannifie, distribue et trace le statut de tache de Reporting comme Interpretation Transcription Verification. Worklists sont générées et font l’objet de query

Reporting Workflow Transaction Diagram Procedure Scheduled Procedure Update Report Manager Creator/ Reader IM/IA PPS DSS/OF Reporting Worklist Provided P. Work Status Update MPPS Completed Image Availability Workitem Claimed Workitem PPS in Progress Workitem PPS Completed Workitem Completed

Reporting Workflow Grouping Report Manager not grouped with neither IM nor DSS Performed Work Status Update DSS/OF Report Manager RWF Profile Performed Work Status Update, if needed SWF Profile IM/IA SWF Profile

Reporting Workflow Grouping Report Manager grouped with Image Manager Performed Work Status Update (optional) DSS/OF Report Manager RWF Profile IM/IA SWF Profile

Reporting Workflow Grouping Report Manager grouped with DSS/OF Performed Work Status Update, if needed Report Manager RWF Profile DSS/OF IM/IA SWF Profile

Diagnostic Reporting Use Cases Predefined report Workitem deferred Direct report creation Interpretation and dictation Transcription Partial completion Verification

The user chooses a report from a list of pre- configured draft reports Predefined report The user chooses a report from a list of pre- configured draft reports The results are normal I will also verify the report

The user selects the task and decides not to perform it Task deferred The user selects the task and decides not to perform it Put this task back on the worklist.

Partial Completion The user begins the task and then decides that this task cannot be completed at this moment Bad data quality! New acquisition is required

The user may need to correct the report's content by dictation Verification The user may need to correct the report's content by dictation Send report back to the transcriptionist for correction