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IHE 2008 Cardiology
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IHE 2008 Cardiology

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  • To play in the EHR, data must be managed and properly identified There is a saying in the computer industry…..garbage in = garbage out So, this is where we started beginning in Year 1 of IHE-Cardiology (back in 2003) – lay the foundation
  • Anybody recognize this? Unfortunately it’s frighteningly familiar ! It is a typical cath lab control room. I count at least 11 monitors (there are some more in the lab room). These represent a half dozen different systems. On each one you need to enter the patient name and ID – the same each time (yeah, right …) The non-integration issues are not just within the lab, but between the lab and the hospital information systems Takeaway – we tackled this mess and defined the interfaces necessary to manage the cath workflow. This one profile doesn’t solve all the cath lab data integration problems, but it is a huge step forward to get it under control.
  • Echo presents a different type of workflow problem. What’s wrong with this picture? It’s the wheels! Echo machines go to the point of care, and they get disconnected from the network. This creates the common “drive-by echo” scenario – Even if there were a new order for a stat exam, the machine may not get it. Stress echo – A second issue is in stress echo, where a non-productive step is required to blend images into a quad view. Takeaway – IHE addresses both these issues with the Echo Workflow Profile, with a complete scenario for managing post-hoc updates, and accurate stress image labeling by the modality.
  • All these workflows use the same standards-based architecture – which means that we can start moving away from the silos of non-integrated information But in going to a common architecture we do not abandon the very real requirements of the separate modalities. We do specify how echo and nuc images are labeled and displayed – to improve workflow and to improve the consistency of clinically appropriate user interfaces. In fact, by combining these specialized requirements into a common framework, we push the availability of those clinically appropriate user interfaces into the general workstation space.
  • Measurements have historically been printed to paper and inserted into a patient’s folder. To use the measurements, a cardiologists or technologist typically has to retype the information into a separate reporting system. There have been several kludges, none of which work well. Takeaway - IHE Evidence Documents provides for the accurate electronic exchange of cath and echo measurements, including standard measurement definitions and structure. Thus, e.g., preliminary measurements can be made on the echo machine by the sonographer, and transferred to the reporting application for final cardiologist review. Ask an echocardiographer how important this is – especially since the standard measurement set implements the ASE recommendations for reporting data. Profile can also be used for cath procedure logs, hemo measurements, QCA/QVA measurements, IVUS, etc.
  • ECGs have been digital for, what?, 20 years? Why are they not ubiquitously available to all clinical workstations, throughout the institution? Takeaway – IHE Cardiology has specialized the RID Profile use of Web technology so that any ECG management system will respond to a standard IHE query to access a high quality displayable ECG. That standard query can be built into any clinical workstation application.
  • Remember - our 1 st reason for “Why IHE Cardiology” is because the practice inherently extends across institutional boundaries. IHE is tackling the problem of effectively, and securely, sharing data. This IHE Profile is called Cross Enterprise Document Sharing, or commonly “XDS”, and has huge implications for cardiology. distribution beyond the boundaries of the healthcare institution. But here, IHE Cardiology is simply leveraging the excellent work being done in 4 other IHE domains
  • The document content profiles for cardiology are all the same as those need for the rest of medical care – since cardiology spans all care settings.
  • Transcript

    • 1. Presenter Maria Rudolph, American College of Cardiology Staff IHE Cardiology
    • 2. Why IHE Cardiology?
      • Multiple locations
        • Office, in-patient, ED
        • Individual patient is seen in multiple locations – distributed patient record
        • Individual clinician practices in multiple locations – across organizational boundaries
      • Multiple devices and modalities
        • Need to integrate data for comprehensive view of patient
        • Multiple specialists cooperating on single patient
      • Chronic Disease
        • Long term patient care – persistent and evolving patient record
      Lots of hard data integration problems
    • 3. IHE Cardiology Organization
      • Principal Sponsor : American College of Cardiology
      • European Sponsor : European Society of Cardiology
      • Specialty Society Sponsors : American Society of Echocardiography American Society of Nuclear Cardiology Heart Rhythm Society
    • 4. The Workflow Foundation
      • Managing cardiology procedure workflow to ensure consistently identified and integrated data
        • Cardiac Catheterization Workflow Profile
        • Echocardiography Workflow Profile
        • Stress Testing Workflow Profile
        • Nuclear Medicine Image Profile (Cardiology option)
    • 5. Cath Lab Workflow 1 2 3 4 5 6 7 Multiple re-entry of Patient ID Error prone data entry Results fragmented across systems Results inconsistently time-tagged Custom solutions needed for data sharing Difficult to manage Uncoordinated with Hospital Information System Unidentified patients (emergency) Un-ordered cath exams Diagnostic and interventional procedures Ad hoc scheduling of cath labs Change of rooms during procedure 8 9 10 11 note: Cath Profile includes Electrophysiology lab
    • 6. Echo Workflow
      • The “drive-by echo” – Cardiologist to sonographer in CCU: “While you’re here, do a TTE on bed 3”
        • Unordered, unscheduled exam
        • Machine disconnected from network
      • Stress echo – After exam, sonographer creates new quad displays of stages and views
        • No intrinsic value add
        • Data is redundantly copied to storage
    • 7. Stress Workflow
      • ~85% of stress tests are multi-modality (ECG + imaging)
      • ~0% of current architectures manage ECG and imaging workflow and results in an integrated manner
      • Poor adherence to ACC/ASNC nuclear image display requirements
      IHE Stress Testing Profile and IHE Nuclear Medicine Image Profile Trial Implementation
    • 8. Workflow Architecture Summary
      • Cath, echo and stress workflows (and cardiac CT and MR) managed with a common architecture
        • HL7 Patient Demographics
        • HL7 Orders
        • DICOM Worklist Management
        • DICOM Object Management and Display
          • Images, waveforms, measurements, procedure logs
      • Modality specific requirements to improve workflow and clinical utility
    • 9. Getting results
      • Consistent electronic methods for reporting on cardiology findings
        • Evidence Documents Profile (quantitative measurements)
          • Cath and Echo options
        • Implantable Cardiac Device Observations Profile
        • Retrieve Information for Display Profile
          • Retrieve ECG for Display Profile
    • 10. Cath and Echo Evidence Documents Echocardiography Measurement Patient: Doe, John Technologist: der Payd, N Measurements: Mitral valve diameter 3.1cm - shown in image at [ ] Ventricular length, diastolic 5.97 cm - shown in image at [ ] Ventricular volume, diastolic 14.1 ml - inferred from [ ] - inferred from VLZ algorithm
      • Current kludges:
      • Measurements made on modality or workstation, and written onto a paper worksheet, then transcribed into a report
      • Measurements output to a printer port, intercepted by an application that scrapes the values
      • Screen capture of measurements sent to a reporting system, which uses OCR (optical character recognition) to reconstruct the original measurement names and numbers
    • 11. Implanted Device Observations
      • Explosion in number of implantable cardioverter defibrillators
      • Clinicians need to manage patients with a wide variety of devices in many contexts
        • ICDs, CRTDs, pacemakers, etc.
        • Implant, office follow up, home monitoring
      • Need standard set of observations, communicated in standard messages
        • Therapy settings, events, device self-monitoring
        • Enables consistent presentation of data from all devices
      Trial Implementation
    • 12. Retrieve Information for Display
      • How does the clinical workstation on the ward get the report from the cardiology department?
      • How does the workstation in the cardiology department get a report from radiology, or a history and physical report from the outpatient department?
      IHE Retrieve Information for Display Profile using Web technology (HTTP, PDF, XML)
    • 13. Retrieve ECGs for Display
      • Specialized use of RID Profile Web technology (HTTP, PDF, XML)
        • Integrated into client medical applications (clinical workstations – not free-standing Web browsers)
        • Vector PDF, XML list
    • 14. Beyond the Enterprise
      • Sharing data between the office and in - patient environments, or on the regional or national level
        • Cross-Enterprise Document Sharing (XDS)
        • Cross-Enterprise Document Content
      from IHE IT Infrastructure, Patient Care Coordination, Laboratory and Radiology Domains
    • 15. Cardiology Document Sharing Use Cases
      • Initial referral to cardiologist – family and social history, medications, test results
      • ACS presentation at emergency dept – last ECG, meds, history of care
      • Interventional report to referring physician – procedures performed, discharge summary
      • many, many more …
      IHE XDS / XDR / XDM Profiles
    • 16. Document Content Profiles for Cardiology
      • Medical Summary – encounter notes, discharge summary
      • Imaging – exchange of image links
      • Emergency Department Referral
      • Pre-procedure History and Physical
      • Scanned Documents
      • Personal Health Records
      • Basic Patient Privacy Consents
      • Laboratory Reports
    • 17. What’s coming up!
      • Evidence Content – structured measurement data for stress testing, electrophysiology lab, and CTA / MRA
      • Displayable Reports Profile – workflow for graphics-rich reports in PDF
      • New IHE Quality Domain – secondary use of clinical data for quality measures, outcomes research, pay for performance
    • 18. 2007-2008 IHE Cardiology Events
      • March – Year 3 demonstration at American College of Cardiology (New Orleans)
      • April – release Year 4 profiles for public comment
      • June – release Year 4 profiles for Trial Implementation
      • September – Year 3 demonstration at European Society of Cardiology (Vienna)
      • January 2008 – IHE Connectathon for Year 4
    • 19.
      • Providers and Vendors
      • Working Together to Deliver
      • Interoperable Health Information Systems
      • in the Enterprise
      • and Across Care Settings
      http://www.ihe.net
    • 20.