IHE Cardiology  Profiles for Year 1 Tom Dolan, Philips Co-editor, IHE Cardiology Technical Committee
Presentation structure <ul><li>IHE Cardiology profile context </li></ul><ul><ul><li>What we are covering and why </li></ul...
Three profiles selected for year 1 <ul><li>Cardiac Catheterization Workflow </li></ul><ul><ul><li>Based on IHE Radiology  ...
Why  these  profiles? <ul><li>High return on investment -  important integration problems </li></ul><ul><li>Standards in p...
Cath Lab (A) room for improvement !
Cath Workflow Management  Multi-Modality,  Intra -Lab issues <ul><li>Multiple re-entry of Patient ID </li></ul><ul><li>Err...
Cath Workflow  Management  Extra -lab issues  <ul><li>Un-ordered cath exams (emergency) </li></ul><ul><li>Unidentified pat...
Cardiac Catheterization Workflow - What’s in? <ul><li>Management of cath exams (in-lab portion) </li></ul><ul><ul><li>Simi...
<ul><li>Pre-cath and post-cath activity </li></ul><ul><li>Hemo waveforms and reports* </li></ul><ul><li>Procedure logs </l...
Cath actors and transactions    Pt. Registration [Rad-1]  Patient Update [Rad-12] Pt. Registration [Rad-1]   Patient ...
Actors/Transactions take-away <ul><li>NO new actors </li></ul><ul><ul><li>Same actors as Radiology scheduled workflow </li...
Cardiac Cath – 8 use cases <ul><li>All use cases must be supported </li></ul><ul><li>Case C1: Patient Registered at ADT an...
Cath Workflow Management <ul><li>Technical Framework  requirements : </li></ul><ul><ul><li>Diagnostic/Interventional may b...
Benefits <ul><li>Simplify Management of Cath exams (In Lab) </li></ul><ul><ul><li>High-value, high-complexity workflow add...
ACTORS <ul><li>Acquisition Modality –  A system that acquires and creates medical images or waveforms while a patient is p...
ACTORS <ul><li>Image Display –  A system that offers browsing of patients’ studies. In addition, it may support the retrie...
TRANSACTIONS <ul><li>Patient Registration –  The ADT system registers and/or admits a patient and forwards the information...
TRANSACTIONS <ul><li>Modality Procedure Step Completed –  An Acquisition Modality notifies the Performed Procedure Step Ma...
Case 1 : Patient Registered at ADT and Ordered at the Order Placer  <ul><li>Clinical Context </li></ul><ul><ul><li>Corresp...
Case 2 : Patient Registered at ADT and Ordered at DSS/OF  <ul><li>Clinical Context </li></ul><ul><ul><li>Slight difference...
Case 3 : Patient Registered at ADT and Procedure   Not Ordered  – Schedule on MPPS <ul><li>Clinical Context </li></ul><ul>...
Case 4 : Patient Registered at Department System Scheduler/OF and Procedure Ordered <ul><li>Clinical Context </li></ul><ul...
Case 5 : Patient NOT Registered <ul><li>Clinical Context </li></ul><ul><ul><li>Combination of  Case 3 and Case 4 </li></ul...
Case 6 : Patient Update During Procedure  <ul><li>Clinical Context </li></ul><ul><ul><li>unidentified patient registered a...
Case 7 : Change Rooms   During Procedure  <ul><li>Clinical Context </li></ul><ul><ul><li>Not uncommon – diagnostic   inte...
Case 8 : Cancel Procedure  <ul><li>Clinical Context </li></ul><ul><ul><li>When cases are cancelled it’s important that inf...
Case 3: Patient Registered at ADT and  Procedure Not Ordered  – Schedule on MPPS Case 3A: Unidentified Patient Registered ...
Case 3 :  Significant Transactions   <ul><ul><li>MWLM query (not shown) will not return a response for current patient (fr...
Case 3 :  Highlights   <ul><li>Contributions </li></ul><ul><ul><li>Multi-modality synchronization supported </li></ul></ul...
For more info: <ul><li>IHE Cardiology Technical Framework version 1.0 for Trial Implementation at: </li></ul><ul><ul><li>w...
IHE Workflow <ul><li>Three levels of IHE workflow control: </li></ul><ul><ul><li>Order  /  Requested Procedure  /  Procedu...
Integration Profile: A Solution to an Integration Problem Actors   cooperating through   Transactions   to solve a specifi...
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Cardiac Catheterization Workflow: Tom Dolan

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  • Go into ALL detailled transactions – or pick out highlights (clinically relevant, way diferent from rad) e.g. case 3 and 5
  • Cath - is complex procedure and benefits from attention to workflow and data integrity, high visibility within customer community. ECG - Getting access to ECG is “huge” in clinicians world, recognized by the ACC Echo – very common procedure, significant customer benefits from efficiencies here.
  • Anybody recognize this? Unfortunately it’s frighteningly familiar ! It is a typical cath lab control room. I count at least 7 monitors (there are some more in the lab rrom). Each is a different system. On each one you need to enter the patient name and ID …
  • … which is the multi-modality problem in the cath lab. … Each system stores it own results – so they are fragmented. If you can manage to bring the results together, you find that the system clock in each one is different, so you don’t know what happened first … This is the internal lab problem – but it is not the only problem …
  • … because there is the broader external problem of the cath lab in the context of the hospital and department workflow
  • Important differences with Radiology highlighted in yellow
  • yellow indicates new IHE-cardiology transactions
  • Case 3 explored later in more detail for illustration
  • hide – back-up material @ end
  • Highlight what is specific for cardiology – just list here – leave defs and only read what is used !! CARD-1 – allows DSS/OF to creat scheduled procedure step updates for multiple modalities in response to an MPPS-In-progress from one modality. This reflects the multi-modality nature of the cath lab where a procedure selected on one modality – usually hemo – may be used to trigger the appropriate procedure for other modalities in the lab.
  • CARD –2 Similar to RAD-8 (images) and RAD-43 (evidence) with three options to deal with common cath/echo image format SOP-classes CARD-3 Similar to RAD-10 with an additional option to cover Image manager communication with intermittently connected modalities, common in echo. It allows the IM to report on successful storage as soon as mobile reconnects and therefore ensures device’s local storage is optimized. Card-4 Similar to RAD-16 with an additional option to support stress echo SOP-classes and attributes.
  • From Radiology TF Figure 3.2-1. The Cath DSS/OF has an optional function to start the Cath Procedure, typically to allow the collection of patient data specifically tied to the procedure, and to facilitate shared procedure identifiers across the multiple cath lab modalities. Note that the MWL query may be broad (get a list of scheduled procedures from which one will be selected), or narrow (provided with sufficient query keys to get back the scheduled procedure for a single patient). The latter case may be facilitated by entering the Patient ID from a barcoded wristband into the MWL query (as a standard cath lab operating procedure). If the Cath DSS/OF has started the Cath Procedure, or in the case of the patient-specific MWL query, it is possible that the DSS/OF will return in the MWL response only a single SPS for the patient assigned to the cath lab (room) in which the modality resides. From Radiology TF Figure 3.2-2. Adaptations for cardiology in green. Initial Procedure scheduling may be vague (I.e., not exactly specify a time or cath lab). If the DSS/OF has not started the procedure, upon receipt of first MPPS In Progress for the Cath Lab, which includes the patient ID/name and the modality station name (which allows it to be linked to a specific cath lab), the DSS/OF updates the Scheduled Procedure Steps for all the modalities in that same cath lab to reflect the current active case (that MPPS serves as “current patient / lab selection”). Subsequent MWL queries from modalities in that cath lab may specify their station name and a Scheduled Procedure Step Start Time of the current time +/- a fudge factor. The response should be an SPS for the querying modality with the current patient of that lab. Need new Cath-specific Modality Images/Evidence Stored to includes XA, IVUS images (with whatever attributes raised to required status), hemo waveforms, hemo reports, QCA/QVA and IVUS reports. This transaction in IHE-CARD-TF can reference details in IHE-Rad transaction 8 and transaction 43. Note that MPPS Complete also supports MPPS Discontinued, which is a bit redundant with full explanation of any procedure discontinuation in a Procedure Log.
  • From Radiology TF Figure 4.3-3. Unordered/unscheduled procedure. From the first acquisition modality’s perspective, the difference between this and cases 1 and 2 is that the MWL query (not shown) will not return a response for this patient. An option to improve workflow and reduce errors is for the first acquisition modality to scan the patient’s barcoded wristband (provided by the ADT system) as the input for local entry of the patient ID for the MPPS (which is required in this use case). As in case 1, upon receipt of first MPPS In Progress for the Cath Lab, which includes the patient ID and the modality station name, the DSS/OF creates Scheduled Procedure Steps for all the modalities in that same cath lab to reflect the current active case. Note that since the patient is registered, the DSS/OF will have received the demographics associated with the patient ID. A difference from the Radiology TF is that the DSS/OF creation of a Requested Procedure occurs upon the MPPS In Progress (N-CREATE) message, not the MPPS Completed message. This allows multi-modality synchronization to the same RP. The DSS/OF is required to use the Study Instance UID from the first MPPS as the Study Instance UID for other modalities MWL data.
  • From Radiology TF Figure 4.4-4. An institution may allow a department system to register a patient with a temporary ID (e.g., in an emergency case), and simultaneously create the Requested Procedure. From the modality perspective this is the same as cases 1 and 2 (but very different for DSS/OF!).
  • From Radiology TF Figure 4.4-5. When all else fails, a temporary patient ID is entered at the first modality. For the modalities, this is similar to case 3. However, unlike case 3, the DSS/OF receives an MPPS N-CREATE for a patient of whom it has no knowledge (and presumably of whom the Order Placer system also has no knowledge). So the DSS/OF must hold off sending order messages to the Order Placer until the patient is registered by the ADT system and reconciled with the local temporary patient ID.
  • From Radiology TF Figure 4.4-6. The Modality may continue to send information using the original patient information even after the patient update has occurred. The Image Manager must continue reconciling Patient Information even after the Patient Update transaction has been completed.
  • Each modality in Room 1 issues an MPPS Discontinued The Cath DSS/OF has an optional function to reassign the Cath Procedure to a new room, which will create SPSs for the new room modalities. If this option is not used, the DSS/OF will create SPSs for the new room modalities when it receives the MPPS In Progress (N-CREATE) from a modality in the new room. Note: There is a part of the clinical workflow where a patient is moved from the procedure room to a “holding area”, but information (typically vital signs and cardiac rhythms) is still being monitored and recorded. This is outside the scope of the current IHE Cardiology Technical Framework.
  • From Radiology TF Figure 4.3-3.
  • Unordered/unscheduled procedure. From the first acquisition modality’s perspective, the difference between this and cases 1 and 2 is that the MWL query (not shown) will not return a response for this patient. An option to improve workflow and reduce errors is for the first acquisition modality to scan the patient’s barcoded wristband (provided by the ADT system) as the input for local entry of the patient ID for the MPPS (which is required in this use case). Need to resolve with ITI Tech Cttee whether barcoded wristband is a “transaction” they want to formally identify. As in case 1, upon receipt of first MPPS In Progress for the Cath Lab, which includes the patient ID and the modality station name, the DSS/OF creates Scheduled Procedure Steps for all the modalities in that same cath lab to reflect the current active case. Note that since the patient is registered, the DSS/OF will have received the demographics associated with the patient ID.
  • A difference from the Radiology TF is that the DSS/OF creation of a Requested Procedure occurs upon the MPPS In Progress (N-CREATE) message, not the MPPS Completed message. This allows multi-modality synchronization to the same RP. The DSS/OF is required to use the Study Instance UID from the first MPPS as the Study Instance UID for other modalities MWL data.
  • Cardiac Catheterization Workflow: Tom Dolan

    1. 1. IHE Cardiology Profiles for Year 1 Tom Dolan, Philips Co-editor, IHE Cardiology Technical Committee
    2. 2. Presentation structure <ul><li>IHE Cardiology profile context </li></ul><ul><ul><li>What we are covering and why </li></ul></ul><ul><li>Cardiology Catheterization Workflow </li></ul><ul><ul><li>Overview, benefits, actors/transactions, highlights </li></ul></ul><ul><li>ASSUMPTIONS </li></ul><ul><ul><li>Basic understanding of IHE concepts from earlier sessions </li></ul></ul>
    3. 3. Three profiles selected for year 1 <ul><li>Cardiac Catheterization Workflow </li></ul><ul><ul><li>Based on IHE Radiology Scheduled Workflow and Patient Information Reconciliation Profiles </li></ul></ul><ul><li>Echocardiography Workflow </li></ul><ul><ul><li>Based on IHE Radiology Scheduled Workflow and Patient Information Reconciliation Profiles </li></ul></ul><ul><li>Retrieve ECG for Display </li></ul><ul><ul><li>Based on IHE IT Infrastructure Retrieve Information for Display Profile </li></ul></ul>
    4. 4. Why these profiles? <ul><li>High return on investment - important integration problems </li></ul><ul><li>Standards in place (DICOM, HL7) </li></ul><ul><li>Leverage IHE Radiology and IT Infrastructure </li></ul><ul><li>No “political” challenges – just technical </li></ul><ul><li>Restricted scope for “quick win” </li></ul>
    5. 5. Cath Lab (A) room for improvement !
    6. 6. Cath Workflow Management Multi-Modality, Intra -Lab issues <ul><li>Multiple re-entry of Patient ID </li></ul><ul><li>Error prone </li></ul><ul><li>Results fragmented across systems </li></ul><ul><li>Custom solutions needed for data sharing </li></ul><ul><li>Difficult to manage </li></ul>
    7. 7. Cath Workflow Management Extra -lab issues <ul><li>Un-ordered cath exams (emergency) </li></ul><ul><li>Unidentified patients </li></ul><ul><li>Uncoordinated with Hospital Information System </li></ul><ul><li>Diagnostic and interventional procedures </li></ul><ul><li>Ad hoc scheduling of cath labs </li></ul><ul><li>Change of rooms during procedure </li></ul><ul><li>… and interactions among these issues! </li></ul>
    8. 8. Cardiac Catheterization Workflow - What’s in? <ul><li>Management of cath exams (in-lab portion) </li></ul><ul><ul><li>Similar to IHE-Radiology SWF </li></ul></ul><ul><ul><li>Multi-modality, multiple procedure steps </li></ul></ul><ul><li>Reconciliation of patient information </li></ul><ul><ul><li>Similar to IHE-Radiology PIR </li></ul></ul><ul><ul><li>Unscheduled cath is the norm, not the exception </li></ul></ul><ul><li>Time synchronization </li></ul><ul><ul><li>Modalities must support IHE-ITI Consistent Time </li></ul></ul>
    9. 9. <ul><li>Pre-cath and post-cath activity </li></ul><ul><li>Hemo waveforms and reports* </li></ul><ul><li>Procedure logs </li></ul><ul><li>QCA/QVA* </li></ul><ul><li>Final cath reports* </li></ul><ul><li>Supply chain </li></ul><ul><li>*Archives must support storage, but no actors specified for display </li></ul>Cardiac Catheterization Workflow - What’s OUT?…for year 1 But on the 5-year roadmap!
    10. 10. Cath actors and transactions    Pt. Registration [Rad-1]  Patient Update [Rad-12] Pt. Registration [Rad-1]  Patient Update [Rad-12]   Placer Order Management [Rad-2]  Filler Order Management [Rad-3] ADT  Query Images [Rad-14]  Retrieve Images [ Card-4 ] Image Display Modality Image/Evidence Stored [ Card-2 ] Storage Commitment [ Card-3 ]  Procedure Scheduled [Rad-4]  Procedure Updated [Rad-13]  Query Modality Worklist [Rad-5] Performed Procedure Step Manager  Modality PS in Progress [ Card-1 ]  Modality PS Completed [Rad-7]  Modality PS in Progress [ Card-1 ]  Modality PS Completed [Rad-7]  Modality PS in Progress [ Card-1 ]  Modality PS Completed [Rad-7] Order Placer Acquisition Modality Image Manager Image Archive DSS/ Order Filler  Patient Update [Rad-12] <ul><li>Many actors cooperating in a complete end-to-end workflow </li></ul><ul><li>Documented in the Technical Framework </li></ul>
    11. 11. Actors/Transactions take-away <ul><li>NO new actors </li></ul><ul><ul><li>Same actors as Radiology scheduled workflow </li></ul></ul><ul><li>4 “modified” transactions </li></ul><ul><ul><li>Existing Radiology-based transactions have been modified to accommodate cardiology specifics </li></ul></ul>
    12. 12. Cardiac Cath – 8 use cases <ul><li>All use cases must be supported </li></ul><ul><li>Case C1: Patient Registered at ADT and Procedure Ordered at the Order Placer </li></ul><ul><li>Case C2: Patient Registered at ADT and Procedure Ordered at DSS/OF </li></ul><ul><li>Case C3: Patient Registered at ADT and Procedure Not Ordered </li></ul><ul><li>Case C4: Patient Registered at DSS/OF and Procedure Ordered </li></ul><ul><li>Case C5: Patient Not Registered </li></ul><ul><li>Case C6: Patient Updated During Procedure </li></ul><ul><li>Case C7: Change Rooms During Procedure </li></ul><ul><li>Case C8: Cancel Procedure </li></ul>
    13. 13. Cath Workflow Management <ul><li>Technical Framework requirements : </li></ul><ul><ul><li>Diagnostic/Interventional may be managed at the Procedure Step level, or may simply be reported at end of case </li></ul></ul><ul><ul><li>Support for ad hoc scheduling, room reassignment, and multi-modality coordinated identifiers </li></ul></ul><ul><ul><li>Backfilling of orders to Order Entry system </li></ul></ul><ul><ul><li>Complete patient demographics update capability </li></ul></ul><ul><li>Technical Framework recommendation : </li></ul><ul><ul><li>Single Requested Procedure for cath procedure (not split into Diagnostic and Interventional) </li></ul></ul>
    14. 14. Benefits <ul><li>Simplify Management of Cath exams (In Lab) </li></ul><ul><ul><li>High-value, high-complexity workflow addressed </li></ul></ul><ul><ul><ul><li>Basic lab-centric workflow addressed </li></ul></ul></ul><ul><ul><ul><li>Worklist-driven for speed and accuracy </li></ul></ul></ul><ul><ul><ul><li>Solid basis for extension in future </li></ul></ul></ul><ul><li>Reuse of existing standards </li></ul><ul><ul><li>Similar to IHE-Radiology SWF means savings in training, development and reduced risk </li></ul></ul><ul><ul><li>But cath-specific issues addressed </li></ul></ul><ul><li>Aim to remove the integration-barriers compromising efficiency and safety between cath-modalities/vendors </li></ul>
    15. 15. ACTORS <ul><li>Acquisition Modality – A system that acquires and creates medical images or waveforms while a patient is present, e.g., an X-ray angiography or hemodynamic measurement system. A modality may also create other evidence objects such as Structured Report Documents containing measurements. </li></ul><ul><li>ADT – A system responsible for adding and/or updating patient demographic and encounter information (Admission/Discharge/Transfer). In particular, it registers a new patient with the Order Placer and Department System. </li></ul><ul><li>Department System Scheduler/Order Filler – A department-based (for instance, Cardiology or Radiology) information system that provides functions related to the management of orders received from external systems or through the department system’s user interface. </li></ul><ul><li>Image Archive – A system that provides long term storage of evidence objects such as images, presentation states, Key Image Notes and Evidence Documents. </li></ul>
    16. 16. ACTORS <ul><li>Image Display – A system that offers browsing of patients’ studies. In addition, it may support the retrieval and display of selected evidence objects including sets of images, presentation states, Key Image Notes, and/or Evidence Documents. </li></ul><ul><li>Image Manager – A system that provides functions related to safe storage and management of evidence objects. It supplies availability information for those objects to the Department System Scheduler. </li></ul><ul><li>Order Placer – A hospital or enterprise-wide system that generates orders for various departments and distributes those orders to the correct department. </li></ul><ul><li>Performed Procedure Step Manager – A system that re-distributes the Modality Performed Procedure Step information from the Acquisition Modality to the Department System Scheduler/Order Filler and Image Manager. </li></ul><ul><li>Time Client – A system unit that synchronizes its time of day clock to the correct time provided by a time server </li></ul>
    17. 17. TRANSACTIONS <ul><li>Patient Registration – The ADT system registers and/or admits a patient and forwards the information to other information systems. [RAD-1] </li></ul><ul><li>Placer Order Management – The Order Placer informs the Order Filler of the initiation or cancellation of an order. The Placer/Filler Order Management transaction will sometimes be referred to as “-New” when a new order is being initiated, or as “-Cancel” when an existing order is canceled. [RAD-2] </li></ul><ul><li>Filler Order Management – The Order Filler informs the Order Placer of the initiation, cancellation, or change in the status of an order. The Placer/Filler Order Management transaction will sometimes be referred to as “-New” when a new order is being initiated, or as “-Cancel” when an existing order is canceled. [RAD-3] </li></ul><ul><li>Procedure Scheduled – Schedule information is sent from the Department System Scheduler/Order Filler to the Image Manager. [RAD-4] </li></ul><ul><li>Query Modality Worklist – Based on a query entered at the Acquisition Modality, a modality worklist is generated listing all the items that satisfy the query. This list of Scheduled Procedure Steps with selected demographic information is returned to the Acquisition Modality [RAD-5]. </li></ul><ul><li>Modality Procedure Step In Progress – An Acquisition Modality notifies the Performed Procedure Step Manager of the start of a new Procedure Step and the PPS Manager informs the Department System Scheduler/Order Filler and Image Manager. [ CARD-1 , derived from RAD-6] </li></ul>
    18. 18. TRANSACTIONS <ul><li>Modality Procedure Step Completed – An Acquisition Modality notifies the Performed Procedure Step Manager of the completion of a Procedure Step and the PPS Manager informs the Department System Scheduler/Order Filler and Image Manager. [RAD-7] </li></ul><ul><li>Modality Images/Evidence Stored – An Acquisition Modality sends acquired or generated images, waveforms, or other evidence documents to the Image Archive. [ CARD-2 , derived from RAD-8 and RAD-43] </li></ul><ul><li>Storage Commitment – A requestor (Acquisition Modality) requests that the Image Manager confirm ownership for the specified DICOM objects (images, waveforms, evidence documents, or any combination thereof) that the requestor stored in the Image Archive, thus allowing the sender to delete those objects now owned by the Image Manager. [ CARD-3 , derived from RAD-10] </li></ul><ul><li>Patient Update – The ADT Patient Registration System informs the Order Placer and the Department System Scheduler/Order Filler of new information for a particular patient. The Department System Scheduler may then further inform the Image Manager. [RAD-12] </li></ul><ul><li>Procedure Update – The Department System Scheduler/Order Filler sends the Image Manager updated order or procedure information. [RAD-13] </li></ul><ul><li>Query Images – An Image Display queries the Image Archive for a list of entries representing images by patient, study, series, or instance. [RAD-14] </li></ul><ul><li>Retrieve Images – An Image Display requests and retrieves a particular image or set of images from the Image Archive. [ CARD-4 , derived from RAD-16] </li></ul><ul><li>Maintain Time – Synchronize the local time with the time maintained by the Time Server. [ITI-1] </li></ul>
    19. 19. Case 1 : Patient Registered at ADT and Ordered at the Order Placer <ul><li>Clinical Context </li></ul><ul><ul><li>Corresponds to traditional Radiology workflow </li></ul></ul><ul><ul><li>Order placed in central system </li></ul></ul><ul><ul><li>Also deals with case where emergency identifier has been created </li></ul></ul><ul><ul><li>Common identifiers known ahead of time </li></ul></ul><ul><li>IHE Context </li></ul><ul><ul><li>MPPS in Progress from first modality used to update worklists for others </li></ul></ul>
    20. 20. Case 2 : Patient Registered at ADT and Ordered at DSS/OF <ul><li>Clinical Context </li></ul><ul><ul><li>Slight difference to Case 1 </li></ul></ul><ul><ul><li>Order placed NOT in central system but in department </li></ul></ul><ul><ul><li>Department system provides info to Central ordering system </li></ul></ul><ul><ul><li>Typical of many institutes, relieves need for HIS terminal in lab </li></ul></ul><ul><li>IHE Context </li></ul><ul><ul><li>Filler Order Management (New Order) transaction [RAD-3] is sent from Department System Scheduler/Order Filler to the Order Placer. </li></ul></ul>
    21. 21. Case 3 : Patient Registered at ADT and Procedure Not Ordered – Schedule on MPPS <ul><li>Clinical Context </li></ul><ul><ul><li>Procedure not ordered at hospital/dept. e.g. due to time-constraints. </li></ul></ul><ul><ul><li>A modality initiates creation of common identifiers on Departmental system </li></ul></ul><ul><ul><li>Allows multiple modalities participating in the case to be synchronized </li></ul></ul><ul><li>IHE Context </li></ul><ul><ul><li>DSS/OF creates a Requested Procedure/Scheduled Procedure Steps in response to the first MPPS- In-Progress </li></ul></ul><ul><ul><li>Requested Procedure created without waiting for response from Order Placer. This improves speed of cross-modality synchronization </li></ul></ul><ul><li>TO BE CONTINUED…… </li></ul>
    22. 22. Case 4 : Patient Registered at Department System Scheduler/OF and Procedure Ordered <ul><li>Clinical Context </li></ul><ul><ul><li>Variation on Case 2 (procedure ordered in Department) </li></ul></ul><ul><ul><li>Patient registered NOT in central system but in department </li></ul></ul><ul><ul><li>Covers emergency case or when HIS is unavailable </li></ul></ul><ul><ul><li>Temporary Patient identifier used, </li></ul></ul><ul><ul><li>Manual reconciliation with official HIS ID later is used to update department records and ordering system </li></ul></ul><ul><li>IHE Context </li></ul><ul><ul><li>Temp ID is used to schedule procedure steps to modalities as normal. </li></ul></ul><ul><ul><li>Filler Order management is not invoked until after the reconciliation with official ID occurs. This is trigger to update DSS/OF, Image Manager and Order Placer with official patient, and order numbers </li></ul></ul>
    23. 23. Case 5 : Patient NOT Registered <ul><li>Clinical Context </li></ul><ul><ul><li>Combination of Case 3 and Case 4 </li></ul></ul><ul><ul><li>No information/time to create patient/order identifiers at HIS or Department system </li></ul></ul><ul><ul><li>Patient ID entered at first modality is adopted for other modalities (as in Case 4) </li></ul></ul><ul><ul><li>procedure triggered by first modality shared across other modalities (as in Case 3) </li></ul></ul><ul><li>IHE Context </li></ul><ul><ul><li>DSS/OF creates a Requested Procedure/Scheduled Procedure Steps in response to the first MPPS- In-Progress </li></ul></ul><ul><ul><li>Filler Order management is not invoked until after the reconciliation with official ID occurs. This is trigger to update DSS/OF, Image Manager and Order Placer with official patient, and order numbers </li></ul></ul>
    24. 24. Case 6 : Patient Update During Procedure <ul><li>Clinical Context </li></ul><ul><ul><li>unidentified patient registered at the ADT system and brought into the cath lab with temporary patient demographics </li></ul></ul><ul><ul><li>Patient is identified and official ID/demographics sent by HIS while procedure is in progress. </li></ul></ul><ul><ul><li>Some data in the procedure is produced with temporary info and some with official. </li></ul></ul><ul><ul><li>This must be reconciled across the procedure </li></ul></ul><ul><li>IHE Context </li></ul><ul><ul><li>Modality may continue to transmit data with temporary identifiers </li></ul></ul><ul><ul><li>DSS/OF and Image Manager must continue to automatically reconcile such incoming data with the official data throughout procedure. </li></ul></ul>
    25. 25. Case 7 : Change Rooms During Procedure <ul><li>Clinical Context </li></ul><ul><ul><li>Not uncommon – diagnostic  interventional, equipment failure,… </li></ul></ul><ul><ul><li>procedure is halted in one room, with one set of modality equipment, and resumed in another room with different equipment </li></ul></ul><ul><ul><li>For continuity of clinical data, it is critical that this be treated as a single Procedure </li></ul></ul><ul><li>IHE Context (no comparable case in Radiology TF) </li></ul><ul><ul><li>Each modality in the first room will issue a Modality Procedure Step Completed or Discontinued </li></ul></ul><ul><ul><ul><li>Note – not required prior to moving, can be done later, but needed to complete the step at end of procvedure. </li></ul></ul></ul><ul><ul><li>DSS/OF used to can reassign the Requested Procedure to a new room and create Scheduled Procedure Steps for those modalities who use WLM to restart procedure </li></ul></ul><ul><ul><li>IF no re-assignment - new modalities can issue broad (not own AE Title) query to get original SPS and then append an MPPS to that </li></ul></ul>
    26. 26. Case 8 : Cancel Procedure <ul><li>Clinical Context </li></ul><ul><ul><li>When cases are cancelled it’s important that information systems reflect same so that staff are informed and can respond appropriately. </li></ul></ul><ul><ul><li>Case covers procedure cancelled prior to start </li></ul></ul><ul><li>IHE Context </li></ul><ul><ul><li>DSS/OF notifies the Order Placer system and Image Manger. </li></ul></ul><ul><ul><li>All three systems may maintain information about the cancelled Order and Requested Procedure for a pre-determined length of time . </li></ul></ul>
    27. 27. Case 3: Patient Registered at ADT and Procedure Not Ordered – Schedule on MPPS Case 3A: Unidentified Patient Registered at ADT and Procedure Not Ordered Case 3 : again….. Patient Registration [RAD-1] Register J.Doe ADT Order Placer Acquisition Modality Filler Order Management - New [RAD-3] Department System Scheduler/ Order Filler Auto-create Procedure Procedure Scheduled [RAD-4] Modality Procedure Step Completed [RAD-7] Modality Procedure Step Completed [RAD-7] Modality Procedure Step In Progress [CARD-1] Modality Procedure Step In Progress [CARD-1] Acquisition Modality n Query Modality Worklist [RAD-5] Patient Reconciliation J.Doe -> J.Smith Patient Update / Merge [RAD-12 ] Patient Update / Merge [RAD-12] Perform Acquisition Perform Acquisition Filler Order Mgmt - Status Update [RAD-3] Image Manager/ PPS Manager Filler Order Mgmt - Status Update [RAD-3]
    28. 28. Case 3 : Significant Transactions <ul><ul><li>MWLM query (not shown) will not return a response for current patient (from card/wristband) </li></ul></ul><ul><ul><li>Unscheduled Performed Procedure Step created </li></ul></ul><ul><ul><li>DSS/OF recognizes patient and room from data in MPPS-In-Progress [CARD-1] (i.e. Patient ID and AE Title) </li></ul></ul><ul><ul><li>DSS/OF creates a (generic/specific) Requested Procedure/Scheduled Procedure Steps for other modalities in room using info above. Different than Radiology ! </li></ul></ul><ul><ul><li>Order Placer and Image Manager informed of new, active procedure. </li></ul></ul><ul><ul><li>Requested Procedure created without waiting for response from Order Placer. This improves speed of cross-modality synchronization. </li></ul></ul><ul><ul><li>Subsequent MWLM queries [RAD-5] from equipment in this cath lab will receive the appropriate scheduled procedure steps including the necessary patient/study identifiers </li></ul></ul>
    29. 29. Case 3 : Highlights <ul><li>Contributions </li></ul><ul><ul><li>Multi-modality synchronization supported </li></ul></ul><ul><ul><li>Modality-initiated, ad-hoc , cases become “managed” </li></ul></ul><ul><ul><ul><li>Time delays between first MPPS and shared SPS are seconds/minutes </li></ul></ul></ul><ul><ul><ul><li>Avoids trying to synch multiple studyUID’s later (not addressed) </li></ul></ul></ul><ul><li>Different…. not Deviant  </li></ul><ul><ul><li>Auto create of Requested Procedure contradicts “ letter ” of IHE-R – but not “ spirit ” </li></ul></ul><ul><ul><ul><li>Goal is to reconcile and unscheduled PPS with a Requested Procedure </li></ul></ul></ul>
    30. 30. For more info: <ul><li>IHE Cardiology Technical Framework version 1.0 for Trial Implementation at: </li></ul><ul><ul><li>www.rsna.org/ihe </li></ul></ul><ul><ul><li>www.acc.org/quality/ihe.htm </li></ul></ul><ul><li>Submit questions and comments to: </li></ul><ul><ul><li>http://forums.rsna.org </li></ul></ul>
    31. 31. IHE Workflow <ul><li>Three levels of IHE workflow control: </li></ul><ul><ul><li>Order / Requested Procedure / Procedure Step </li></ul></ul><ul><li>Workflow management issues for cath </li></ul><ul><ul><li>Un-ordered cath exams (emergency) </li></ul></ul><ul><ul><li>Unidentified patients </li></ul></ul><ul><ul><li>Multi-modality coordination </li></ul></ul><ul><ul><li>Diagnostic and interventional procedures </li></ul></ul><ul><ul><li>Change of rooms during procedure </li></ul></ul><ul><ul><li>… and interactions among these issues! </li></ul></ul>
    32. 32. Integration Profile: A Solution to an Integration Problem Actors cooperating through Transactions to solve a specific problem  Pt. Registration [Rad-1]  Patient Update [Rad-12] Pt. Registration [Rad-1]  Patient Update [Rad-12]   Placer Order Management [Rad-2]  Filler Order Management [Rad-3] ADT  Procedure Scheduled [Rad-4]  Procedure Updated [Rad-13]  Modality PS in Progress [Card-1]  Modality PS Completed [Rad-7] Order Placer DSS/ Order Filler  Patient Update [Rad-12]
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