Distributing Images: Cross-enterprise Document Sharing for Imaging (XDS-I) Chris Lindop

Sharing of Imaging Information across health enterprises Imaging Information includes extensive sets of DICOM instances including images, evidence documents and presentation states diagnostic reports provided in a "for display" form selection of diagnostically significant images associated with the report content Abstract / Scope

Sharing of Imaging Information across health enterprises

Imaging Information includes

extensive sets of DICOM instances including images, evidence documents and presentation states

diagnostic reports provided in a "for display" form

selection of diagnostically significant images associated with the report content

Sharing Radiology Reports and Images in a Regional Health Information Network Radiology Enterprise A Radiology Enterprise B Physician Office Regional Health Information Network PACS B PACS A Radiology-to-radiology Radiology-to- Physicians

Sharing Radiology Reports and Images in a Regional Health Information Network Radiology Enterprise A Radiology Enterprise B Physician Office Regional Health Information Network Cross-Enterprise Registry Patient Id= 3547F45 Report 5/21/1998 : CT Head  B Study 5/21/1998 : CT Head  B Report 2/18/2005 : Chest Xray  A Study 2/18/2005 : Chest Xray  A PACS B PACS A

Patient Id= 3547F45

Report 5/21/1998 : CT Head  B

Study 5/21/1998 : CT Head  B

Report 2/18/2005 : Chest Xray  A

Study 2/18/2005 : Chest Xray  A

Physicians and Systems within a Regional Health Network - Routine Imaging Referral Radiology Enterprise A Radiology Enterprise B Physician Office Regional Health Information Network Cross-Enterprise Registry Patient Id= 3547F45 Report 5/21/1998 : CT Head  B Study 5/21/1998 : CT Head  B Query for Documents Register Imaging Information for sharing Prior imaging Reports & Studies Register Imaging Information for sharing

Patient Id= 3547F45

Report 5/21/1998 : CT Head  B

Study 5/21/1998 : CT Head  B

Physicians and Systems within a Regional Health Network - Routine Imaging Referral Radiology Enterprise A Radiology Enterprise B Physician Office Regional Health Information Network Cross-Enterprise Registry Register Imaging Information for sharing Notification of Doc Availability Register Imaging Information for sharing

Physicians and Systems within a Regional Health Network for a Routine Imaging Referral Radiology Enterprise A Radiology Enterprise B Physician Office Regional Health Information Network Cross-Enterprise Registry Patient Id= 3547F45 Report 5/21/1998 : CT Head  B Study 5/21/1998 : CT Head  B Report 2/18/2005 : Chest Xray  A Study 2/18/2005 : Chest Xray  A Prior Imaging Report & Study Query for documents Imaging Report & Study Notification of Doc Availability

Patient Id= 3547F45

Report 5/21/1998 : CT Head  B

Study 5/21/1998 : CT Head  B

Report 2/18/2005 : Chest Xray  A

Study 2/18/2005 : Chest Xray  A

Value proposition Imaging component of the Electronic Health Record: Shared imaging Record, in a community, region, etc. Effective means to contribute and access imaging documents across health enterprises. Without XDS-I, access to the radiology report across health enterprises is difficult Scalable sharing of imaging documents between radiology departments, private physicians, clinics, long term care, acute care with different clinical IT systems. Easy access: Care providers are offered means to query and retrieve imaging documents (images and reports) of interest with the same mechanisms used to query other documents

Imaging component of the Electronic Health Record: Shared imaging Record, in a community, region, etc.

Effective means to contribute and access imaging documents across health enterprises.

Without XDS-I, access to the radiology report across health enterprises is difficult

Scalable sharing of imaging documents between radiology departments, private physicians, clinics, long term care, acute care with different clinical IT systems.

Easy access: Care providers are offered means to query and retrieve imaging documents (images and reports) of interest

with the same mechanisms used to query other documents

Value proposition Distributed: Each Care delivery organization “publishes” imaging information for others. Actual images remain in the source/Image Manager. Cross-Enterprise: A Registry provides an index for published information to authorized care delivery organizations belonging to the same clinical affinity domain. Document Centric: Published clinical data is organized into “clinical documents”. using agreed standard document types (DICOM KOS, PDF and/or text report) Document Content Neutral: Document content is processed only by source and consumer IT systems. Standardized Registry Attributes: Queries based on meaningful attributes ensure deterministic document searches .

Distributed: Each Care delivery organization “publishes” imaging information for others. Actual images remain in the source/Image Manager.

Cross-Enterprise: A Registry provides an index for published information to authorized care delivery organizations belonging to the same clinical affinity domain.

Document Centric: Published clinical data is organized into “clinical documents”. using agreed standard document types (DICOM KOS, PDF and/or text report)

Document Content Neutral: Document content is processed only by source and consumer IT systems.

Standardized Registry Attributes: Queries based on meaningful attributes ensure deterministic document searches .

XDS-I Dependencies XDS-I depends on IT Infrastructure Cross-Enterprise Document Sharing (XDS) New Actors Imaging Document Source Imaging Document Consumer (should be grouped with Document Consumer) Same Actors as in XDS Document Consumer Document Registry Document Repository Added extension to support imaging data (images and reports)

XDS-I depends on IT Infrastructure Cross-Enterprise Document Sharing (XDS)

New Actors

Imaging Document Source

Imaging Document Consumer (should be grouped with Document Consumer)

Same Actors as in XDS

Document Consumer

Document Registry

Document Repository

Added extension to support imaging data (images and reports)

Document Consumer Retrieve Document Query Documents Patient Identity Source Patient Identity Feed Imaging Document Source Document Registry Document Repository Provide & Register Document Set Register Document Set Imaging Document Consumer Retrieve Images Retrieve Presentation States Retrieve Key Image Note Retrieve Evidence Documents WADO Retrieve XDS-I Actors and Transactions

XDS-I New Transaction requirements XDS-I Actors: Imaging Document Consumer at least one Retrieve ( [RAD-55], [RAD-16], [RAD-17], [RAD-27], [RAD-31] [RAD-35]) Imaging Document Source Provide and Register Document Set [RAD-54] WADO Retrieve [RAD-55] Retrieve Images [RAD-16], Retrieve Presentation States [RAD-17] Retrieve Reports [RAD-27], Retrieve Key Image Note [RAD-31], Retrieve Evidence Documents [RAD-45] XDS Actors Document Repository Provide and Register Document Set [RAD-54]

XDS-I Actors:

Imaging Document Consumer

at least one Retrieve ( [RAD-55], [RAD-16], [RAD-17], [RAD-27], [RAD-31] [RAD-35])

Imaging Document Source

Provide and Register Document Set [RAD-54]

WADO Retrieve [RAD-55]

Retrieve Images [RAD-16], Retrieve Presentation States [RAD-17] Retrieve Reports [RAD-27], Retrieve Key Image Note [RAD-31], Retrieve Evidence Documents [RAD-45]

XDS Actors

Document Repository

Provide and Register Document Set [RAD-54]

Options Imaging Document Source must support at least one of the following options: Extensive Set of DICOM Instances PDF Report NEW Text Report wrapped in a CDA Document NO Text option NO multipart Text / PDF option

Imaging Document Source must support at least one of the following options:

Extensive Set of DICOM Instances

PDF Report

NEW Text Report wrapped in a CDA Document

NO Text option

NO multipart Text / PDF option

Sharing of Extensive DICOM Instance Set

Document Registry Document Repository Manifest Reference to image 1 DICOM Manifest Reference to image 2 Reference to image 3 Manifest Manifest Clinical Encounter Clinical IT System Query Registry Manifest Retrieve Manifest Reference to image 1 DICOM Manifest Reference to image 2 Reference to image 3 Retrieve Images Register Manifest Manifest

Sharing of Extensive DICOM Instance Set The shared Document is a manifest a Key Object Selection DICOM Instance title : manifest Imaging Document Source is required to ensure that the referenced images from within a published manifest are available to be retrieved Imaging Document Source is responsible for replacing a previously submitted manifest Document when a change occurs to the manifest content (eg. Change of the DICOM SOP instances referenced within the manifest)

The shared Document is a manifest

a Key Object Selection DICOM Instance

title : manifest

Imaging Document Source is required

to ensure that the referenced images from within a published manifest are available to be retrieved

Imaging Document Source is responsible

for replacing a previously submitted manifest Document when a change occurs to the manifest content (eg. Change of the DICOM SOP instances referenced within the manifest)

Sharing of Imaging Report

Radiology system Report Source Text wrapped into CDA Report PDF Report … .. Findings: Header : Report Type: OB / Gyn BPD ... … .. Radiology Report Impressions : Gestational Age ...

Radiology system Report Source Document Registry Document Repository Report Report Clinical Encounter Clinical IT System Query Registry Retrieve Report Register Report Report … .. Findings : Header : Report Type: OB / Gyn BPD ... … .. Radiology Report Impressions : Gestational Age ...

Sharing of Reports The shared Report Document format is PDF, Text wrapped in a CDA A report can embed selected images in its PDF format include fully resolved hyperlinks (interactively clickable) that point to the selected images Imaging Document Source is responsible for formatting the hyperlink to reference relevant images as a DICOM WADO URI or as IHE RID Request for Document Imaging Document Source is required to ensure that image references are valid links

The shared Report Document format is

PDF, Text wrapped in a CDA

A report can

embed selected images in its PDF format

include fully resolved hyperlinks (interactively clickable) that point to the selected images

Imaging Document Source is responsible

for formatting the hyperlink to reference relevant images as a DICOM WADO URI or as IHE RID Request for Document

Imaging Document Source is required

to ensure that image references are valid links

XDS-I Actors / Grouping No specific grouping requirement on Imaging Document Source, however: Imaging Document Source is responsible of ensuring published images in a manifest are available to be retrieved Imaging Document Consumer shall be grouped with a Document Consumer

No specific grouping requirement on Imaging Document Source, however:

Imaging Document Source is responsible of ensuring published images in a manifest are available to be retrieved

Imaging Document Consumer shall be grouped with a Document Consumer

Linking Report to Complete Set of Images Document Repository Document Registry Study Manifest Report Document Entry Document Entry Submission Set

Linking Report to Complete Set of Images Document Repository Document Registry Document Entry Submission Set 1 Report Document Entry Submission Set 2 Study Manifest

Linking Report to Prior Images and Prior Report Document Repository Document Registry Document Entry Submission Set 3 Prior Study Manifest Document Entry Submission Set 1 Prior Report Document Entry Submission Set 2 Report Document Entry Submission Set 4 Study Manifest

Linking Report to Selected Images Radiology system Report Source … .. Findings : Header : Report Type: OB / Gyn Radiology Report Relevant Image Gestational Age ... WADO URI Link to image BPD ... … ..

XDS-I Metadata Radiology specific Acquisition Modality (e.g. CT, MR) Anatomic Region (e.g. Arm, Elbow, Hand) Requested procedure (e.g. MRI Knee with contrast) Query example find all “ CT of the Head ” of patient John Doe for the last 2 years

Radiology specific

Acquisition Modality (e.g. CT, MR)

Anatomic Region (e.g. Arm, Elbow, Hand)

Requested procedure (e.g. MRI Knee with contrast)

Query example

find all “ CT of the Head ” of patient John Doe for the last 2 years