The patient should be registered at ADT and procedure ordered at DSS/OF for Cardiology Workflow said by Dr. Mubashar A Choudry MD.

1. Patient Registered at DSS/OF
and Procedure Ordered for Cardiology
Workflow
MUBASHAR A CHOUDRY MD

2. Agenda
 Cardiology Workflows General
 Cath Workflow
 Echo Workflow
 Stress Workflow
 Content Display Requirements
 Stress Echo
 Stress
 Nuclear Cardiology
2

3. Cardiology Workflows
 Cardiology:
the study of the
heart
its action
and diseases
3

4. The Problem
4
This is an example
of a cardiology
workflow.
Any questions!
Workflow is the
linchpin to data
integrity

5. General Workflow


 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/Evidence [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]
Modality Image/Evidence
Stored [CARD-2]
Storage
Commitment
[CARD-3]

Evidence
CreatorModality PS in Progress [CARD-1]
Modality PS Completed [RAD-7]
Instance Availability Notification [RAD-49]
5

6. Agenda
 Cardiology Workflows General
 Cath Workflow
 Echo Workflow
 Stress Workflow
 Content Display Requirements
 Stress Echo
 Stress
 Nuclear Cardiology
6

7. Cath Lab
7
1
2
3 4
5
6 7
• Multiple re-entry of Patient ID
• Error prone
• 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

8. Administrative Process Flow
8
ADT
Order
Placer
Image
Manager
Acquisition
Modality
Placer Order Mgmt -
New [Rad-2]
Department System
Scheduler/ Order Filler
Procedure
Scheduled [Rad-4]
Register/
Admit
Patient
Create Order
Schedule
Procedure
Patient
Registration [Rad-1]
Select
Patient
Query Modality Worklist [Rad-5]
Start
Procedure

9. Procedure Performance Process Flow
9
Image
Manager/
Image Archive
Acquisition
Modality
Department System
Scheduler/ Order
Filler
Modality Procedure
Perform
Acquisition
Modality Images/
Evidence Stored
[Card-2]
Storage
Commitment
[Card-3]
Modality Procedure
Step In Progress
[Card-1]
Modality Procedure
Step Completed [Rad-7]
Modality Procedure
Step In Progress
[Card-1]
Order
Placer
Order Status
Update [Rad-3]
Update
Schedule
Acquisition
Modality n
Query Modality Worklist [Rad-5]
Modality Procedure
Step In Progress
[Card-1]
Modality Procedure
Step In Progress
[Card-1]
Perform
AcquisitionModality Images/Evidence Stored
[Card-2]
Step Completed
[Rad-7]

10. Use Cases
 Case C1: Patient Registered at ADT and Procedure Ordered at the
Order Placer
 Case C2: Patient Registered at ADT and Procedure Ordered at
DSS/OF
 Case C3: Patient Registered at ADT and Procedure Not Ordered
 Case C4: Patient Registered at DSS/OF and Procedure Ordered
 Case C5: Patient Not Registered
 Case C6: Patient Updated During Procedure
 Case C7: Change Rooms During Procedure
 Case C8: Cancel Procedure
 Case C9: Post-Procedure Evidence Creation
 Case C10: EP Ablation / Implantation Lab
10
ALL Use Cases Must be Supported
Exception of C10 only required for EP Lab

11. Case C1: Patient Registered at ADT and Procedure
Ordered at the Order Placer
 Clinical Context
 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
 IHE Context
 MPPS in Progress from first modality used to update worklists for others
11

12. Case C2: Patient Registered at ADT and
Procedure Ordered at DSS/OF
 Clinical Context
 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
 IHE Context
 Filler Order Management (New Order) transaction [RAD-3] is sent from
Department System Scheduler/Order Filler to the Order Placer.
12

13. Case C3: Patient Registered at ADT
and Procedure Not Ordered
 Clinical Context
 Slight difference to Case 2
 Procedural information is NOT entered at the departmental
system
 The first modality must initiate the process of creating common
procedure identifiers (usually hemo)
 The common procedure identifiers are created by the
departmental system based on the information available from the
first modality
 Can generate a “generic cath procedure” if no coded procedural
type is available
 IHE Context
 Upon receiving the first MPPS the DSS/OF will auto generate a
Requested Procedure and its associated Scheduled Procedure
Steps utilizing the Study UID provided in the first MPPS. All
other modalities use the Query Modality Worklist transaction.
13

14. Case C4: Patient Registered at DSS/OF
and Procedure Ordered 14
Clinical Context
 This case accommodates the emergency case where there is
not enough time to register the patient on ADT system
 A temporary patient identifier is created at the department level
 The order placer is notified only after the patient is registered
and manually reconciled on the department system
IHE Context
 The DSS/OF assigns a temporary Patient ID with a temporary
name and schedules the required procedures
 The DSS/OF does not send the Filler Order Management (New
Order) transaction to the Order Placer until the patient is
registered on the ADT system and reconciliation occurs on the
DSS/OF.

15. Case C5: Patient Not Registered
15
Clinical Context
 This is the Emergent Case where the patient information is not
known or there is not enough time to enter the information
 A temporary ID is assigned by the department and entered at the
first modality and forwards that information to the departmental
system to be shared with the other modalities
 Like in C4 information is sent to the Order Placer post patient
registration and reconciliation on the departmental system
IHE Context
 Patient ID and name are selected based upon locally (usually
department) base rules
 The first modality will send an MPPS with the appropriate
information to the DSS/OF which will in turn generate the
appropriate requested procedure(s) using the Study UID
assigned by the first modality

16. Case C6: Patient Updated During Procedure
16
Clinical Context
 An unidentified patient may have been registered at the ADT and
brought into the cath lab with the temporary ID
 During the procedure the patient information is updated on the
ADT which sends the patient update information
 This can results is some of the information been associated with
the temp ID and the rest with the permanent ID
 The case defines how the reconciliation occurs.
IHE Context
 The modality may have requested information from the DSS/OF
prior the patient update
 The Image Manager needs to update the items stored to Image
Archive as well as any subsequent items received.

17. Case C7: Change Rooms During Procedure
17
Clinical Context
This is the case when the patient is moved due to any of the
following reasons:
 The change from a diagnostic to interventional procedure
 The need to use the current room for another patient
 Equipment failure
NOTE: This case does not cover the scenario where a patient is
moved to the holding area from a procedure room.
IHE Context
 Each modality will issue a MPS (Completed or Discontinued)
 The DSS/OF will reassign the requested procedure to the new
room
 In the event the DSS/OF does not reassign, each modality in the
new room would use the broad Modality Worklist Query
 This insures consistency of the Study UID for all information

18. Case 7: Change Rooms During Procedure
18Image
Manager Acquisition
Modality
Room 1
Department System
Scheduler/
Order Filler
Modality Procedure
Step Discontinued [Rad-7]
Modality Procedure
Step Discontinued [Rad-7]
Modality Procedure
Step In Progress [Card-1]
Modality Procedure
Step In Progress [Card-1]
Acquisition
Modality n
Room 1
Query Modality Worklist [Rad-5]
Perform
Acquisition
Perform
Acquisition
Acquisition
Modality
Room 2
Acquisition
Modality n
Room 2
Query Modality Worklist [Rad-5]
Modality Procedure
Step In Progress [Card-1]
Modality Procedure
Step In Progress [Card-1]
Modality Procedure
Step In Progress [Card-1]
Modality Procedure
Step In Progress [Card-1]
Query Modality Worklist [Rad-5]
Perform
Acquisition
Perform
Acquisition
Query Modality Worklist [Rad-5]
Modality Procedure
Step In Progress [Card-1]
Modality Procedure
Step In Progress [Card-1]
Reassign
Procedure
Update
Schedule
Update
Schedule

19. Case C8: Cancel Procedure
19
Clinical Context
 This case allows for the information systems to keep track of
cancelled procedures allowing the cath lab staff to appropriately
respond to queries regarding that patient.
IHE Context
 When the procedure is cancelled within the department the
DSS/OF notifies the Order Placer system and Image Manager
 The length of time this procedural information is maintained is
determined by local policy.

20. Case C9: Post-Procedure Evidence Creation
20
Clinical Context
 Allows for imaging and other procedural data to be analyzed
post-procedure using specialized software (e.g., QCA, QLV,
derived images)
 This case does NOT apply to core lab analysis for clinical trials
or outcome analysis
IHE Context
 This analysis must be performed on a station that groups the
Image Display and Evidence Creator Actors
 The Evidence Creator notifies the IM/IA and DSS/OF of the
activity via the MPPS In Progress and Complete transactions
 The Evidence Creator stores its evidence to the IM/IA via the
Storage Commit Transaction.

21. Case C10: EP Ablation / Implantation Lab
21
Clinical Context
 Allows for the wide array of specialized equipment used in the
EP lab
 Provides demographic and time synchronization
IHE Context
 Initial implementation is an extension of the CATH profile
 Support for use cases C1 – C9
 Emergency use cases C3 and C5 are highly unusual in the EP
lab.
New CP

22. Agenda
 Cardiology Workflows General
 Cath Workflow
 Echo Workflow
 Stress Workflow
 Content Display Requirements
 Stress Echo
 Stress
 Nuclear Cardiology
22

23. Use Cases
 Case E1: Patient Registered at ADT and Procedure Ordered
 Case E2: Intermittently Connected Modality
 Case E3: Intermittently Connected Modality with Ad Hoc
Procedure, Patient Registered, Scheduled Procedure
 Case E4: Intermittently Connected Modality with Ad Hoc
Procedure, Patient Registered, Unscheduled Procedure
 Case E5: Intermittently Connected Modality with Ad Hoc
Procedure, Patient Unregistered, Unscheduled Procedure
 Case E6: Stress Echo Staged Protocol
 Case E7: Echo Measurements Evidence Creation
23

24. Case E1: Patient Registered at ADT and Procedure
Ordered
 Clinical Context
 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
 IHE Context
 The Scheduled Procedure Steps are obtained by the modality
through Query Modality Worklist, the acquisition is performed and
statused thought Modality Performed Procedure Step.
24

25. Case E2: Intermittently Connected Modality
 Clinical Context
 Allows for the mobile workflow typical of TTE and TEE
 Assumes the modality is only intermittently connected to the
network
 Also covers the case of the modality being turned off
 IHE Context
 Process flow identical to Case E1
 Must be paired with an Image Manager/Image Archive that
also supports Intermittent Connectivity
 MPPS are stored and sent when connection established
 Image Manage must queue N-Event Report messages for
storage commitment
25

26. Case E3: ICM with Ad Hoc Procedure, Patient
Registered, Scheduled Procedure
 Clinical Context
 This extends Case E2 to allow for a scheduled procedure
but the modality can’t query the worklist since it is not
connected to the network
 IHE Context
 The modality will treat this as unscheduled procedure
 The patient ID and demographics must be manually entered
 The modality must create the Study Instance UID
 Manual matching process at DSS/OF to reconcile the
scheduled and performed procedure information
 Post match the DSS/OF will reconcile with the Image
Manager to correct for the Study Instance UID
26

27. Case E4: ICM with Ad Hoc Procedure, Patient
Registered, Unscheduled Procedure
 Clinical Context
 This is the drive by echo or Stat echo performed without an
order placed in the system
 IHE Context
 This case is identical to other unscheduled procedure cases
 Modality creates the Study Instance UID
 When connected the modality will send a MPPS in Progress
 DSS/OF will generate an exception for reconciliation
 Patient demographic reconciliation should occur automatically
based on patient ID
 The Image Manager will use the Patient Update transaction to
update the demographics
27

28. Case E5: ICM with Ad Hoc Procedure, Patient
Unregistered, Unscheduled Procedure
 Clinical Context
 This case is similar to Case E4 except the patient
is not yet registered. (Emergency Admit)
 IHE Context
 Temporary Name and ID entered into the modality
 DSS/OF will generate an exception
 Manual match of the temporary ID with the Patient
Registration information
 Patient Update sent to the Image Manager
28

29. Case E6: Stress Echo Staged Protocol
 Clinical Context
 Allows for appropriate identification of Stages and Views
during a stress echo
 IHE Context
 Similar to Case E1
 Type of stress protocol is specified in the Scheduled Protocol
Code Sequence or Scheduled Step Description
 Within the “perform acquisition” activity there are several
stages but typically considered the same procedure step
 A status of “Discontinued” can indicate technical failure to
reach the end point of the exam.
29

30. Case E7: Echo Measurements Evidence
Creation
 Clinical Context
 Measurements are normally obtained during the acquisition on the
modality.
 This case supports the ability to obtain additional measurements on the
clinical workstation post acquisition and update the study data.
 IHE Context
 This case is similar to Cath C9
 The actor participates in both the ECHO and ED profiles
 Generation of a DICOM SR with reference to original
30

31. Amazing Facts
Your heart beats about
 70 beats per min
 4200 beats per hour
 100,800 beats per day
 35 million times in a year.
 Or more than 2.5 billion beats in your life time.
AND IT ONLY TAKES ONE
IRREGULAR BEAT TO KILL
YOU
31

32. Agenda
 Cardiology Workflows General
 Cath Workflow
 Echo Workflow
 Stress Workflow
 Content Display Requirements
 Stress Echo
 Stress
 Nuclear Cardiology
32

33. So what is Stress Testing?
 Uses exercise or medication
to increase the work of the
heart.
 Continuous 12 lead ECG
monitoring during study
 Looking for changes in ST
segments
 Used as a screening tool
 Or to test effectiveness of
therapy
 Done in Non-Invasive Lab,
and Cardiologist Office
33

34. Stress
 Image Intensive…multiple samples of 12 lead ECG during the
protocol
 Summary report usually one page in length
 Physician will do comparisons to previous studies
34

35. Stress Options
 Stress Echo
 Began in the early – mid 1990’s
 Observation of wall motion and ejection fractions with the heart
under stress
 High specificity for correlating ischemia to functional
abnormalities
 Can be done with exercise but mainly chemical
 Nuclear Stress
 Most often combined with exercise or chemical stress testing
 Use of radioisotope to detect presence and resolution of
ischemic regions of the heart
 Scan immediately post
 Scan 4 hours to 1 day later
 Resolution of ischemic area determines viability of muscle
35

36. Stress Workflow Diagram
36


 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/Evidence [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]
Modality Image/Evidence
Stored [CARD-2]
Storage
Commitment
[CARD-3]

Evidence
CreatorModality PS in Progress [CARD-1]
Modality PS Completed [RAD-7]
Instance Availability Notification [RAD-49]
Report Creator
Report Creator

37. Stress Workflow – Actors and Options
Actor Option Name Optionality Vol & Section
Acquisition Modality Patient Based Worklist Query O RAD-TF 2: 4.5
Broad Worklist Query R (see note 1) RAD-TF 2: 4.5
PPS Exception Management O RAD-TF 2: 4.7
Stress ECG R (see note 2) CARD-TF 2: 4.2
Stress Echo R (see note 2) CARD-TF 2: 4.2
Nuclear Medicine (see note 3) R (see note 2) RAD-TF 2: 4.8
Image Manager/ Image Archive PPS Exception Management O RAD-TF 2: 4.7
Intermittently Connected Modality R CARD-TF 2: 4.3
Stress ECG R CARD-TF 2: 4.2
Echocardiography R CARD-TF 2: 4.2
Nuclear Medicine (see note 3) R RAD-TF 2: 4.8
Availability of PPS-Referenced Instances O RAD-TF 3: 4.49
Image Display Stress ECG R CARD-TF 2: 4.4
Stress Echo R CARD-TF 2: 4.2
Cardiac NM (see notes 3, 4) R RAD-TF 2: 4.16
37

38. Use Cases
 Case S1: Cardiac Stress Test, ECG Only
 Limited use with lower sensitivities and specificities
 Screening tool only
 Case S2: Cardiac Stress Test with Imaging
 More common use case
 Echocardiography – requires Consistent Time to combine clinical
data from Stress Monitor and Echo Modality
38

39. Agenda
 Cardiology Workflows General
 Cath Workflow
 Echo Workflow
 Stress Workflow
 Content Display Requirements
 Stress Echo
 Stress
 Nuclear Cardiology
39

40. 40
Views
Apical two chamber
Apical four chamber
Apical long axis
Parasternal long axis
Parasternal short axis
Parasternal short axis at the aortic valve level
Parasternal short axis at the level of the mitral
chords
Parasternal short axis at the Mitral Valve level
Parasternal short axis at the Papillary Muscle
level
Right Ventricular Inflow Tract View
Right Ventricular Outflow Tract View
Subcostal long axis
Subcostal short axis
Suprasternal long axis
Suprasternal short axis
Stage and Views
Stress Echo Option
• Stage Number & View
Number
• Stage Code Sequence &
View Code Sequence
Coding
Scheme
Designator
(0008,0102)
Code Value
(0008,0100)
Code Meaning (0008,0104)
SRT P5-01201 Image acquisition at baseline
SRT P5-01202 Pre-stress image acquisition
SRT P5-01203 Mid-stress image acquisition
SRT P5-01204 Peak-stress image acquisition
SRT P5-01205 Image acquisition during
recovery

41. Benefit: Stress Echo
Viewing Consistency 41

42. Agenda
 Cardiology Workflows General
 Cath Workflow
 Echo Workflow
 Stress Workflow
 Content Display Requirements
 Stress Echo
 Stress
 Nuclear Cardiology
42

43. Stress: Protocol and Stage
Procedure
Protocol
Stages
43

44. Stress: Protocol and Stage
 Procedure : Exercise Stress
 Protocol: Bruce
 Stages:
 Standard Bruce has 7 stages
 Stage 1: 1.7 mph @ 10 % grade
 Stage 7: 6.0 mph @ 22 % grade
44
Important Note: A procedure can be
considered complete irrespective of the
protocol being complete!

45. Attribute Summary
Concept Modality Worklist Echo ECG NM
Requested
Procedure
Requested Procedure
Code Sequence
(0032,1064)
Procedure Code
Sequence
(0008,1032)
Procedure Code
Sequence
(0008,1032)
Procedure Code
Sequence
(0008,1032)
Protocol Scheduled Protocol
Code Sequence
(0040,0008)
Performed Protocol
Code Sequence
(0040,0260)
CID 12001*
Performed Protocol
Code Sequence
(0040,0260)
CID 3261
Performed Protocol Code
Sequence
(0040,0260)
CID 3261**
Protocol Stage
Number
Acquisition Context
Sequence
(0040,0555)
>(109055, DCM,
“Protocol Stage”)
Patient State Stage Number
(0008,2122)
Stage Code Sequence
(0040,000A)
CID 12002*
Acquisition Context
Sequence
(0040,0555)
>(109054, DCM,
“Patient State”)
CID 3262
Acquisition Context
Sequence
(0040,0555)
>(109054, DCM,
“Patient State”)
CID 3101
45

46. Agenda
 Cardiology Workflows General
 Cath Workflow
 Echo Workflow
 Stress Workflow
 Content Display Requirements
 Stress Echo
 Stress
 Nuclear Cardiology
46

47. Nuclear Cardiology
 Image formats
 Stress and Rest raw data review
 Stress and Rest processed data
 Gated SPECT data
 Quantitative data
 Screen captures, “snap shots”
 Color maps
 Gray scale is default
 Color overlays can be applied
47

48. Raw Data Images 48

49. Perfusion Display
 Standard perfusion
display
 Stress/Rest
 Short axis
 Horizontal long axis
 Vertical long axis
49

50. 50
Perfusion Display - Color
Standard perfusion
display
Stress/Rest
 Short axis
 Horizontal long axis
 Vertical long axis
Color map can be
overlaid on the image

51. Gated SPECT Display
 Apical, mid and basal
short axis slices
 Mid-ventricle vertical
and horizontal long axis
slices
51

52. Gated SPECT Display
 The whole
screen can be
gated as an
option
52

53. Quantitative Display
 Output from
3rd party
quantitative
perfusion
software can
be displayed
53

54. 54
Quantitative Display
Output from
3rd party
quantitative
gated
software
can be
displayed

55. Screen Captures
 Screen
captures
can be
displayed
to show
important
images
55