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.
IHE Cardiology Profiles for Year 1 Tom Dolan, Philips Co-editor, IHE Cardiology Technical Committee
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.
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.
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.
Image Archive – A system that provides long term storage of evidence objects such as images, presentation states, Key Image Notes and Evidence Documents.
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.
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.
Order Placer – A hospital or enterprise-wide system that generates orders for various departments and distributes those orders to the correct department.
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.
Time Client – A system unit that synchronizes its time of day clock to the correct time provided by a time server
Patient Registration – The ADT system registers and/or admits a patient and forwards the information to other information systems. [RAD-1]
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]
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]
Procedure Scheduled – Schedule information is sent from the Department System Scheduler/Order Filler to the Image Manager. [RAD-4]
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].
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]
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]
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]
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]
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]
Procedure Update – The Department System Scheduler/Order Filler sends the Image Manager updated order or procedure information. [RAD-13]
Query Images – An Image Display queries the Image Archive for a list of entries representing images by patient, study, series, or instance. [RAD-14]
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]
Maintain Time – Synchronize the local time with the time maintained by the Time Server. [ITI-1]
Case 1 : Patient Registered at ADT and Ordered at the Order Placer
Corresponds to traditional Radiology workflow
Order placed in central system
Also deals with case where emergency identifier has been created
Common identifiers known ahead of time
MPPS in Progress from first modality used to update worklists for others
Case 2 : Patient Registered at ADT and Ordered at DSS/OF
Slight difference to Case 1
Order placed NOT in central system but in department
Department system provides info to Central ordering system
Typical of many institutes, relieves need for HIS terminal in lab
Filler Order Management (New Order) transaction [RAD-3] is sent from Department System Scheduler/Order Filler to the Order Placer.
Case 3 : Patient Registered at ADT and Procedure Not Ordered – Schedule on MPPS
Procedure not ordered at hospital/dept. e.g. due to time-constraints.
A modality initiates creation of common identifiers on Departmental system
Allows multiple modalities participating in the case to be synchronized
DSS/OF creates a Requested Procedure/Scheduled Procedure Steps in response to the first MPPS- In-Progress
Requested Procedure created without waiting for response from Order Placer. This improves speed of cross-modality synchronization
TO BE CONTINUED……
Case 4 : Patient Registered at Department System Scheduler/OF and Procedure Ordered
Variation on Case 2 (procedure ordered in Department)
Patient registered NOT in central system but in department
Covers emergency case or when HIS is unavailable
Temporary Patient identifier used,
Manual reconciliation with official HIS ID later is used to update department records and ordering system
Temp ID is used to schedule procedure steps to modalities as normal.
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
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]