IHE / RSNA Image Sharing Project - IHE Colombia Workshop (12/2014) Module 5b

1. IHE: INTEROPERABILITY AT WORK
THE USA PILOT RADIOLOGY
NATIONAL IMAGE-SHARING PROGRAM
Based on presentation at the Radiological Society of North America
Annual meeting in Chicago, December 2013
Written by: David S. Mendelson, M.D.
Professor of Radiology
The Icahn School of Medicine at
Mount Sinai
Senior Associate - Clinical Informatics
The Mount Sinai Medical Center
Co-chair IHE International Board
Adapted and presented for the
IHE Colombia IHEWorkshop by:
Elliot B. Sloane, PhD, CCE,
FHIMSS
Co-chair IHE International Board
President, Center for Healthcare
Information Research and Policy
(CHIRP)

2. Image sharing- Why?
 Benefit of historical exam during interpretation
 Rapidly growing cost of healthcare especially
growing utilization of imaging
 Overutilization- Inappropriate Utilization
 Prevent duplicate exam because a recent exam is
inaccessible
 Radiation exposure- reduction
 Quality
 Expedites clinical care through easy availability of
imaging examination

3. Sharing Healthcare Information in the Cloud
Hospital
Imaging
Center
Primary
Doctor
Consultant
Patient
Patient
Surrogate
2nd
Radiologist
2nd
Hospital
Clinical
Trial

4. Challenges to exchange
 Who pays for an exchange infrastructure
 What is the persistence of the information in the
exchange
 Are images different from other forms of healthcare
data
 Easy secure access is good for the patient
 Does it endanger the provider?- is this an impediment?
 Economic adjustments and evolution are likely to occur
 Balance of cost control vs. Quality
 Reduction in Radiation exposure
 Not all patients agree

6. Development - IHE Domains
• Anatomic Pathology
• Cardiology
• Dental
• Eye Care
• IT Infrastructure (ITI)
• Laboratory
• Patient Care Coordination
• Patient Care Devices
• Pharmacy
• Quality, Research and Public Health
• Radiation Oncology
• Radiology
• Mammography
www.ihe.net
Ihe.wiki.net

7. ITI Profiles
 XDS,XDS- I Cross Enterprise Document Sharing
 XCA, XCA-I Cross Community Access
 XDR, XDR-I Cross-Enterprise Document Reliable Interchange
 Document sharing in the absence of a registry and repository
 XDM Cross-enterprise Document Media Interchange
 XUA Cross Enterprise User Assertion Integration Profile
 XDS-SD Cross-Enterprise Sharing of Scanned Documents
 BPPC Basic Patient Privacy Consents
 ATNA AuditTrail and Node Authentication

8. ITI- Trial implementation
 Cross-Community Fetch (XCF) - Published
2011-08-19
 Cross-Community Patient Discovery (XCPD) -
Revised 2012-08-31
 Cross-Enterprise DocumentWorkflow (XDW)
- Revised 2013-09-20

9. Interoperability Profiles-
Radiology specific
 PDI Portable Documents for Imaging
 IRWF Import ReconciliationWorkflow
 TCE Teaching File and ClinicalTrial Export
Trial Implementation
 IOCM Imaging Object Change Management
 MIMA Multiple Image Manager/Archive
 IID Invoke Image Display
Development
 Mobile Access to Health Documents - Imaging

10. IHE-XDS
(Cross-Enterprise Document Sharing)

11. XDS-I.b

12. XCA-I

13. Importing an Exam
 Establish a standard viewing environment for clinicians for
outside exams.
 Allow them to designate exams for import from this
environment
 Import into local PACS
 IHE solutions
 [PDI] Portable Data for Imaging provides reliable interchange of
image data and diagnostic reports on CDs for importing, printing,
or optionally, displaying in a browser.
 [IRWF] Import ReconciliationWorkflow manages importing
images from CDs, hardcopy, etc. and reconciling identifiers to
match local values.

14. A Standards Based Solution
NIBIB/RSNA Image Sharing Project
2009-2012
2012-2016

15. Image Share: Rationale
 Medical imaging is a high-value, high-cost,
rapidly expanding medical service
 Current method of sharing via CDs is beset
with inefficiencies and frustration
 Studies show significant rates of redundant
imaging procedures due to inaccessible priors
 Patient empowerment is a key goal of current
federal initiatives
16

16. NIBIB/RSNA Image Sharing Project
 Consumer controls the flow of
information –Patient
Engagement
 Diminishes the need for BAAs
between enterprises
 Imaging Site to Clearinghouse
 Clearinghouse to PHR
 Bootstrap an IHE based network
 IHE generally has not focused on
consumer driven solutions but
rather on institutional and
enterprise workflow
 Primary emphasis is Consumer
Control through PHRs
 Can be extended to other forms of
sharing
 HIE
 Security and Confidentiality are
drivers
 Replacement / Alternative toCD
 5 Academic Institutions
 Develop a solution for all
Radiology Sites
 Establish a clearinghouse
 Engage PHRs
A Standards Based Solution

17. Participants
18

18. Industry Participants
 Clearinghouse
 EdgeServer- in progress
 lifeIMAGE
 Dell
 DICOMGRID
 eHealthTechnologies
19
• PHRs
itMD

20. Image Sharing/Elements of Solution
 Edge Server
 Register a patient
 Listens to a Radiology Information System (RIS)- looking for a complete
exam
 Retrieves Image set from PACS and Report from RIS
 Send both to clearinghouse
 PHI hidden; an RSNA ID and 2nd factor security token are used to identify
the patient
 Clearinghouse (XDS-I) – functions as a secure router
 Transiently hold encrypted patient data
 PHR
 Consumer controls upload and future access
 Must have RSNA ID available and know answer to 2nd factor question
 Develop web based viewers
 Download full DICOM data set
 Misc Consumers

21. Image Sharing Systems Overview
22

22. Radiology Dept

28. Image Enabled PHR- DELL

32. Report

33. Patient PHR view

34. Patient and Dr. PHR view

35. Patient account permits sharing

36. Advantages of Approach
 Push model
 No Query of PACS from outside the firewall
 Full DICOM data set is available
 Web viewers
 Download and Import to PACS
 Report is available
 Historical exams can be sent simultaneously
 Consumer controls flow of information
 Affords the patient the ability to select what
information to share
 Is this good?

37. RSNA Image Share- Current
State
 4 Academic sites are live
 Mount Sinai, UCSF, University of Maryland, Mayo
Clinic
 Last sites are navigating local issues and
hope to be live within a few months
 3 Community practices are live- Oct 2013
 Active discussions with approximately 15
additional sites
 An additional 15-20 under preliminary discussion
 Version 2.1; version 3.0 just released

38. RSNA Image Share- Initial
Patient experience
 Patients enrolled in production environment-
6400
 Nov 23, 2013
 Approximately 30% have closed the loop and
used the PHR

39. Patient Responses
 Love it!
 Its about time
 This is great
 My doctor was really
pleased to have access
to my images
 Problems
 Couldn’t access my
images
 Got my images- but
difficult
 My doctor couldn’t see
my images

40. Edge Server Release 3.0
 New Features in Edge Server 3.0 (compared to prior version
2.1)
 Site-to-siteTransfer of Images for Clinical Use - Previous versions
of the Edge Server support transfer of image studies only from
the originating site to the Clearinghouse for retrieval into a
patient’s PHR. Edge Server 3.0 adds support for retrieval of the
Clearinghouse, enabling site-to-site transfer of images for clinical
care.
 ClinicalTrials Support - Edge Server 3.0 enables anonymization of
research imaging data set at field centers, which are then sent to
the Clearinghouse for retrieval by a primary investigation site.
 Edge Server 3.0 incorporates a unified GUI appearance for all
three functional modules: system administration, clinical
administration, and research administration.

41. Edge Server Release 3.1
 More flexible sending function to address a broader range of clinical use
cases
 Release 3.1 adds options for sending patient information- flexible send time:
 Normally, after the radiologist report is final, with a delay for communication with the patient
that is configurable and set to 72 hours by default
 Urgently, as soon as the report is final
 Immediately, without waiting for the radiologist's report
 Improved user convenience for patients
 Enables the use of patient email in place of system-generated security token
 Enables the reuse of a submission set ID for subsequent records of the same patient
 Sets password requirements at a minimum of eight characters, allowing any combination of
letters and symbols
 Improved user convenience and system reliability for site personnel and
administrators
 Provides automated resending of failed submissions
 Provides the option to include canceled exams in patient search results for troubleshooting
and exception resolution


42. Next steps - New NIBIB (NIH)
contract
 New Funding awarded by NIH for 2 years + 2 option
years
 Expansion of network
 Vendor Adoption of Edge Server (Open Source)
 Vendor migration to XDS for all services
 New use cases
 LeverageXDS infrastructure/ network
 PHR
 HIE
 XDR
 Edge Server as a platform
 QA, Comparative Effectiveness, CDS…..

43. Office of Civil Rights (OCR)
HIPAA discussion about
Privacy and Security -
8/21/13
 General Flow of Information is correctly
implemented
 OCR uggested the Clearinghouse vendor
disclose dual role to patients
 Validated use of email as a logon ID

44. Next steps and Future
Direction - New NIBIB (NIH) contract
 DICOM evolution
 Restful services
 Separation of Metadata from pixel data
 Enables discovery
 Viewer
 RefineWorkflow
 Initial workflow is to replace a CD
 Exam updates
 Download DICOM data and archive in a local PACS
 EHR Integration
 Edge server as a platform
 Radiation Monitoring
 Peer Review
 Quality Metrics