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RCR Imaging Informatics Group www.pacsgroup.org.uk
07/11/11
Future Proof your PACS
Dr Neelam DugarChairman of
2013 provides most NHS Trusts with an opportunity to review their PACS implementations.
Image Display PACS
Requesting Ordercomms
Reporting RIS
1 Report- 3 IT Systems
Let us first review our NHS workflow and see what is lacking or what can be done batter.Radiology department deals with 3 distinct IT systems to produce the report, which is the end product of our department.1.Ordercomms –which gives us the electronic request2.Image Display or PACS3.Radiology Information System or RIS
Primary Report Review or Second Opinions
Radiologist Report- 2 Types
There are 2 types of reportsPrimary report & Supplementary report or 2nd opinion
import awesome
The Anglerfish Songby Hank Green
Yes it's true that I once went through lifeAs a guy who always had to rhyme life with strifeYes, I've been burned and I've been spurnedAnd through it all, yes, I have learnedThat love is not about whether you get stabbedBut how slow the knife gets turned
But my friends I've found an animalWho doesn't feel this painAnd my life is so much better Now that I can feel the same
Because you can't hate the nightIf you've lived your whole life without lightAnd you can't hate the dishIf you've only ever eaten fishAnd you can't feel aloneIf it's all you've ever known
Yeah the deep sea anglerfishHas no reason to be happyBut it has no frikkin' ideaWhat else to be
DFTBA!
neenasdesign
!!!!!!
Single Sign On
Let us look at the primary reporting workflow of radiologists. As Single Sign-on has been implemented, with a single log-in & password the radiologist is logged into 4 IT systems. Ordercomms, RIS, PACS & EPR
NHS No: 0123456789Hospital No: PAT12Surname: BLOGGS
Forename: JOEDate of Birth: 27 Mar
Sex: MaleAddress: 1, AB2 3CDClinician: Harry Potter
Location: A PlaceClinical Data: :-)
Radiology PACS
Ordercomms
RIS EPR
Single Sign On
Let us look at the reporting workflow of radiologists. As Single Sign-on has been implemented, with a single log-in & password the radiologist is logged into 4 IT systems. Ordercomms, RIS, PACS & EPR
PACS
PACSTITLE OF SUBJECT
PACS
PACS
RIS
RIS
RIS Reporting Worklist for ND
URGENT
1. Joe Bloggs-Chest CT2. Bob Wilson-CT Abdomen
NON-URGENT1. Hannah -Floris-MRI Pelvis
2. Joanne Hampson-MRI Neck
Reporting Worklist
On RIS she creates a list of exams that have been allocated to her for reporting.
TITLE OF SUBJECT
PACS- Current Chest X-Ray
Current Chest X-ray
PACS- Previous Chest X-Ray
Previous Chest X-ray
Reporting Workflow
Reporting Workflow
Ordercomms Joe BloggsChest X-ray
Clinical History: Shortness of breath
RIS Imaging History
Chest X-Ray Chest CT
MRI
DD/VR
Report: Bilateral chronic shadowing suggestive of PMF
Show EPR
Reporting Workflow:Automatic Context Synchronization Automatic display of Relevant Prior
Due to automatic context synchronization with PACS, the current chest xray for reporting appears on the middle monitor. The previous chest xray appears on the right monitor due to automatic display of relevant prior.Left monitor with RIS shows the clinical history on Ordercomms with integrated Voice Recognition or digital dictation for recording the report.
PACS
PACSTITLE OF SUBJECT
PACS
PACS
RIS
RIS
RIS Reporting Worklist for ND
URGENT
1. Joe Bloggs-Chest CT2. Bob Wilson-CT Abdomen
NON-URGENT1. Hannah -Floris-MRI Pelvis
2. Joanne Hampson-MRI Neck
Back to Reporting Worklist
Once report is complete she can move to the next patient on the worklist.
TITLE OF SUBJECT
PACS-CT Abdoment EPR- XDS Registry
EPRPACSPACSEPR
1. ECG
2. Endoscopy
3. Blood Results
4. Histology
Future: Access to Hospital EPR(Manual Context Sync)
Reporting Workflow
Reporting Workflow
Ordercomms Joe Bloggs
CT AbdomenClinical History: Acute
abdominal pain
RIS Imaging History
Chest X-Ray Chest CT
MRI
DD/VR
Show EPR
In future with adoption of vendor neutral standard like XDS, the radiologist will have access to XDS based EPR. Here CT appearances look like Acute pancreatitis.
TITLE OF SUBJECT
PACS-CT Abdomen EPR- XDS Registry
EPRPACSPACSEPR
Future: Access to Hospital EPR(Manual Context Sync)
Blood Amylase-- 1,500
Reporting Workflow
Reporting Workflow
Ordercomms Joe Bloggs
CT AbdomenClinical History: Acute
abdominal pain
RIS Imaging History
Chest X-Ray Chest CT
MRI
DD/VR
Show EPR
Due to 1 click access to blood results on EPR, a confident diagnosis of pancreatitis can be made
Access to EPR improves...
PATIENT Safety
This improves radiologists reporting accuracy & patient safety.
REVIEW: Cancer MDTM
Now let us look at 2nd opinion reporting. Cancer Multi-disciplinary team meetings have revolutionized cancer care within UK.
PATHOLOGISTRADIOLOGIST
RESPONSIBLE CONSULTANT
SURGEON/PHYSICIAN/ONCOLOGIST
1. REVIEW2. DISCUSSION3. DECISION4. DOCUMENTATION
MDTM PROCESS
The MDTM involves review of the clinical information, radiology & pathology. This is followed by discussions, decision & documentation .
56 year old femaleAbdominal pain Weight lossCT ScanBiopsy
SURGEON/PHYSICIAN/ONCOLOGIST
PATHOLOGISTRADIOLOGIST RESPONSIBLE CONSULTANT
MDTM TRIPLE REVIEW
1
2 3
Radiologist then records a 2nd more refined opinion as a report
TITLE OF SUBJECT
PACS- Current Chest X-Ray
Current Chest X-ray
PACS- Previous Chest X-Ray
Previous Chest X-ray
Reporting Workflow
Reporting Workflow
Ordercomms Joe Bloggs2nd Opinion
Chest X-rayAdditional information:Loss of weight, smoker
RIS Imaging History
Chest X-Ray Chest CT
MRI
DD/VR
Report: Bilateral chronic shadowing suggestive of
PMF
Show EPR Report: Appearances are
identical to previous film performed --?PMF
2nd Opinion RecordingIT Workflow Support
Second opinions may also be requested via Ordercomms.
TITLE OF SUBJECT
PACS- Current Chest X-Ray
Current Chest X-ray
PACS- Previous Chest X-Ray
Previous Chest X-ray
Reporting Workflow
Reporting Workflow
Ordercomms Joe Bloggs2nd Opinion
Chest X-rayAdditional information:Loss of weight, smoker
DD/VR
Report: Bilateral chronic shadowing suggestive of
PMF
Addendum Report: Given the history of Smoker and
weight loss, I would recommend a CT scan
Request Second OpinionReview at MDTM
RIS : Addendum Given the history of Smoker
and weight loss, I would recommend a CT for further
assessment
In this case, additional information of weightloss & smoker is provided to the radiologist. Thus the radiologist includes a second opinion recommending a CT scan.
Well, yes, we could just fix it in Photoshop, but your arm would still be
broken...
The Death of PACS?
PACS has been the single most successful clinical IT system in NHS in UK. Will we really have a PACS in the future?
BIRTH OF A TRUE
EPR
1. Ordercomms
2. Endoscopy
3. Blood Results
4. Histology
5. Cardiology
6. Audiology
7. Radiology images
8. Clinical Letters/ Discharge Summaries
Patient :Joe Bloggs
I Believe that we will see the death of PACS as we see it today, as we will see radiology images included within a a true EPR.
Past: Fragmented Digital Radiology Record
No DICOM
CT Viewer CR Viewer MRI Viewer
Let us look at the history of Radiology PACS & see how it has evolved and why is it so successful. 10-15 years ago in the absence of DICOM standard, each machine vendor used proprietary image formats Thus we had a CT MiniPACS, MR MINIPACS, CR MiniPACS etc
Print To Film
Past: Integrated Film Record
These proprietary formats resulted in a fragmented digital image record Hence we printed to film to produce an integrated film record
DICOM and PACS
Today...
Due to global adoption of DICOM as the vendor neutral standard for radiology images, we saw emergence of an integrated digital radiology image record popularly called PACS.
Today--PACS & PPR(PPR=Paper Patient Record)
However, today we have a PACS (a digital record for radiology images) & PPR (Paper patient record). Let us see if there are lessons that can be learnt.
X-Ray Packets
Many of us remember the xray film packets of the past. The ouside of the packet had patient demographics & an index of the images contained within the packet.
REQUEST CARDREPORT
Inside X-Ray Packets
Inside were the films & a report folder. The report folder contained the request card & the report These documents had a proper document format which was well laid out & easy to read.
Reports: Poor document display
No request card
PACS FAILURE
However, PACS has failed us today due to poor document display for reportsNo request cards displayed either with the images.
Maternity/A&E System
Discharge Letters
Clinical Correspondence
Clinical Letters
Pathology System
Pathology reports
Critical Care System
ECGLaboratory SystemLab Reports
Ophthalmology Camera
Retinal scans
Audiology System
Audiometry report
EDISEmergency discharge
PAST: Digital Data Silos
Print to Paper/Film
Let us look at the bigger picture. A secondary care hospital with multiple departmental systems. In the past, despite having digital systems we continued to print to paper & films due to lack of standards
Today: PACS and PPR
Today due to adoption of open DICOM standards we have an integrated digital record for radiology images popularly called PACS*But we continue to print to paper for the rest of the patients clinical record. So today we have PACS & PPR.
PACS Radiology Data Silo
However, Today PACS is producing a radiology data silo as it is separate from the rest of the clinical record.
Medical Image Standard= DICOM
The success of today’s PACS due to the widely adopted Medical Image Standard of DICOM
EPR- XDS Registry
EPRPACS
1.ECG ECG
2. Blood Results
3. Clinic Letter
Document Standard=HL7 CDA
The globally emerging standard for medical documents is CDA of HL7. Clinical Document Architecture. It is important we move to document standard for GP referral letters, clinic review letters, lab results, radiology reports etc
Clinical Document Architecture (CDA)=HL7
1. Machine Readable
Headers—Patient, Sender, Receiver , Document,
Coded –optional extras dependent on doc type (modality, accession no. date of doc creation etc for radiology)
2. Human Readable
body of report(Narrative)
• Defining Question
• Findings
• Conclusion
• Recommendation
CDA has both machine & human readable content.Request card & Radiology reports are clinical documents in use in radiology. However, the concept is transferrable to any clinical document type.
Header: Computer Read(XML)
Document TypeSenderReceiverPatient
Body: Human Read
(Narrative)Defining the Question
Findings
Conclusion
Recommendations
Optional: Coded Entries
(differ with doc types)
This is a graphical representation of a radiology report with a CDA document analogy superimposed. For a Radiology Report Template to work, it must bring together the Clinical best practices with IT architecture.CDA as Report Templates satisfy both Clinical & IT needs.Header information is consistent & has Patient, Sender, Recipient & Document InformationBody incorporates the clinical template--Def ining the clinical question, f indings, Conclusion & reccomendationsCoded entries allows f lexibilty to record other information relevant to document type. e.g operator details, exam room etc We must encourage our RIS & Ordercomms Vendors to support CDA structure.
GP/Hospital Referral Letters
Clinic Letters
Discharge Summaries
Prescriptions
Requests
Investigation Reports
Images (radiology, pathology, cardiology, ophthalmology etc)
XDS Registry=
Medical Indexing
XDS Registry provides a patient centric indexing of medical images & documents produced in multi-vendor systems—provided the images & documents are produced in a standard formats of DICOM & CDA.
XDS Metadata Submission Set Radiology Image (by PACS) Radiology Report (by RIS) Radiology Request (By Ordercomms)
Source Patient Info-Name Patient Name Patient Name Patient NameSource Patient Info-DOB DOB DOB DOBSource Patient Info-Sex Sex Sex SexSource ID PAS No. PAS No. PAS/NHS (depending on source)Patient ID NHS No. NHS No. NHS No.HealthcareFacilityTypeCode Location of imaging Location of reporting Patient Location at Request---Outpatient/
Inpatient/GPAuthor-Name Probably fixed hospital/machine name -
could be radiographer or Export System name
Reporter Name Requester
Legal Authenticator In UK, same as Author In UK, same as Author In UK, same as AuthorAuthor-Role Reporter Grade-Cons, Junior doc,
RadiographerReporter Grade-Cons, Junior doc, Radiographer
Requester Grade-Cons, Junior doc, Nurse
Author--Speciality Radiology Radiology Requesting Dept—(General Medicine/Surgery etc)
Author--Institution Hospital Name Hospital Name Hospital/GP surgeryHealthcareFacilityPracticeCode Probably NACS code Probably NACS code Probably NACS codeDocumentClassCode(High level Category) Radiology Image Radiology Report Radiology RequestDocumentTypeCode(fine level category) National Exam Codes National Exam Code National Exam CodeTitle of Document Human readable description - e.g. CT Head Human readable description - e.g. CT Head Human readable description - e.g. request for
CT HeadDocument Unique ID in source system Internal unique ID (Accession is not unique!) Internal unique ID Internal unique IDCreation Time Date & Time of KOS publication Date & Time of Report Authorised Date & Time when Request CompletedService Start Time Date & Time of start of Image Acquisition Date & Time of Report Date & Time of RequestService Stop Time Date & Time of end of Image Acquisition Date & Time of Report Authorised Date & Time of RequestEvent Code ?? ?? ??LanguageCode en-GB (or cy-GB!) en-GB (or cy-GB!) en-GB (or cy-GB!)MimeCode Application/dicom Vary by type - pdf, doc, text etc. Vary by type - pdf, doc, text etc.ConfidentialityCode ?? ?? ??FormatCode 1.2.840.10008.5.1.4.1.1.88.59/1.2.840.10008.2.6.1 "TEXT" or "PDF" Vary by type - pdf, doc, text etc.
EntryUUID in XDS Assigned internally - never seen by users Assigned internally - never seen by users Assigned internally - never seen by users
XDS Submission Set
This is the XDS submission set for PACS, RIS & Ordercomms. All the XDS submission datafields already exist on the source systems and it should not be difficult for any supplier to adopt XDS.
XDS Registry=Medical Indexing
EPR- XDS Registry
EPRPACS
1. ECG
2. Endoscopy
3. Blood Results
4. Histology
XDS-I
By Source systems adopting the EPR standard of XDS/XDS-I, NHS will move to patient centric filing of medical images & documents.The analogy is very similar to DICOM adoption by modality vendors in the early 1990s.Most global PACS vendors ARE already XDS-I complaint.
1. ECG
2. Endoscopy
3. Blood Results
4. Histology
Future: PPR to EPR
Print to XDS
In the future with adoption of XDS & XDS-I we will see emergence of EPRs in NHS.We will see the incorporation of radiology images & reports into a patient centric EPR.
FUTURE: EPR SUCCESS(Lessons learnt from PACS)
Maternity/A&E System
Discharge Letters
Clinical Correspondence
Clinical Letters
Pathology System
Pathology reports
Critical Care System
ECGLaboratory SystemLab Reports
Ophthalmology Camera
Retinal scans
Audiology System
Audiometry report
EDISEmergency discharge
CONNECT Existing Departmental
Systems with Open Standards
1. ECG
2. Endoscopy
3. Blood Results
4. Radiology
Print to XDS/XDS-I
I hope that in the future we will learn the lessons from the success of PACS, & use standards to connect departmental systems *using the global emerging EPR standard of XDS & XDS-I to create an XDS based EPR.
Future:XDS EPR
1. ECG
2. Endoscopy
3. Blood Results
4. Radiology
1. ECG
2. Endoscopy
3. Blood Results
4. Radiology
In the future we should see the emergence of XDS based EPR using the ethos of the PACS success.
Text
DICOMPush
DICOM Push via
IEP
Today: COMMUNICATION(Radiology images)
There is something else we can learn from PACS & DICOM standard.Today transport of radiology images from 1hospital to another is electronic –Using global standard of DICOM Push
Post
GP
Snail mail
Today: COMMUNICATION(Request card & Radiology reports)
Paper and Post
However transfer of documents still is largely based on paper & postDue to lack of standards adoption for documents
document types
NHS HospitalSEND
Discharge summaries
Clinic Letter
Lab results
Investigation Reports (radiology, endoscopy,histopathology etc)
GP SurgerySEND
Referral Letter
Lab Requests
Investigation Reports (radiology, endoscopy,histopathology etc)
Today: PAPER DOCUMENTS
It is very easy to group the types of documents exchanged between organizations into document types:1.Referral Letters2.Discharge Letters3.Clinic Letters4.Lab Requests & reports5. Radiology Requests & reports etc
Transport method --Standard Web exchange protocols—SMTP
USES in RADIOLOGY—Document Transport:
Electronic Radiology Request—From GP system to Trust Ordercomms
Radiology Report---From RIS to GP system
XDR of IHE: Cross-enterprise Reliable Exchange of Documents
XDR=Envelope
CDA=Letter
XDR is a standard for a web-based point to point transfer of clinical documents.XDR could be used to transfer radiology requests from GPs to hospitals& also transfer radiology reports to GP systemsXDR CDA combination is similar to DICOM Push
XDRXDR
GP
CDACDA
Future: XDR & HL7-CDADocuments Push
REPORT:
Hospital to
GP system
REQUEST: GP system
to Hospital
Future is about vendor neutral plug & play interoperability using global standards to communicate.
XDR
NHS HospitalSEND
Discharge summaries
Clinic Letter
Lab results
Investigation Reports (radiology, endoscopy,histopathology etc)
GP SurgerySEND
Referral Letter
Lab Requests
Investigation Reports (radiology, endoscopy,histopathology etc)CDA
CDA
Future: Healthcare ITDocuments Exchanged
The very same concepts of HL7-CDA & XDR can be applied to all other documents exchanged between primary & secondary care
REQUEST CARD
REPORT
Past: Image, request & report
In the past we had very high standards. The patients film packet contained films, request card & the report These documents had a proper document format which was well laid out & easy to read.
TITLE OF SUBJECT
PACS- Current Chest X-Ray
Current Chest X-ray
PACS- Previous Chest X-Ray
Previous Chest X-ray
Reporting Workflow
Reporting Workflow
RIS Imaging History Chest X-Ray Chest CT MRI
DD/VR
Show EPR
Show EPR
REPORT
REQ
REPORT
REQ
CDA Req
Future PACS: CDA displayRequest card & report
We must not let IT undermine the high clinical standards.
TITLE OF SUBJECT
PACS- Current Chest X-Ray
Current Chest X-ray
PACS- Previous Chest X-Ray
Previous Chest X-ray
Reporting Workflow
Reporting Workflow
RIS Imaging History Chest X-Ray Chest CT MRI
DD/VR
Show EPR
Show EPR
REPORT
REQ
REPORT
REQ
Future PACS: CDA displayRequest card & report
CDA REPORT
In future radiology reports must have a proper document structure when displayed by PACS.
XDS Registry
Image & Document Creation
Image & Document
Display
STORAGE/ARCHIVE:
1. DICOM Archives2. XDS Repositories
Let us go back to our EPR discussions, Hospital IT Systems have 4 LayersImage & document creators—departmental systems like RISes, modalities etcImage & document displays---EPRs, PACSXDS Registries & DICOM Directories& Storage layer
Past: No Standards
Single VendorNo standards
20 years ago with no standards—each vendor tied you down to all 4 layers. We all remember the fragmented miniPACS systems
DICOM Directory
Present: DICOM Standard
Choice
PACS Vendors3 Layers
Today due to DICOM standard we have a choice of modalities. The PACS vendor cannot dictate what CT scanner/MRI scanner or ultrasound machine we have to buy.
XDS Registry
Choice Choice
Choice Choice
Future: XDS/XDS-I
Adoption of XDS will offer the user community more choice of best of breed vendors forModalityRegistryStorageDisplay
IT Concerns: Data Tsaunami
IT departments are concerned about the increasing costs of managed storage required by PACS.
EXPENSIVE Managed storage
Clinical standard: 3secs access
Infrastructure: kept updated
Whilst storage hardware reduces in price, managed storage remains expensive as patient data needs to be accessible in a timely manner, one cannot just store patient data & forget about it.
FUTURE PACS
It is naive to think that taxpayers can afford to store digital patient data forever in managed storage. Future PACS systems MUST be able to implement a rules based data culling.
PACS--RULES for CULLING
• PATIENT LEVEL
• 8 years after last visit
• 25 years after birth
• Manual extension (medicolegal, oncology research trials etc)
• EXAM LEVEL
• 25 years for obstetric exam
• Manual extension (slow growing tumours, hip replacements etc)
PACS must have 2 data culling dates:a. Patient level date of deletionb. Exam Level date of deletionWhenever there is a mis-match in the date of deletion for the same exam: The later date must be used.Same logic WAS applied for date of culling in film packet days.
IntegratedPaper
Record
Fragmented Digital Record
Today Due to a fragmented digital clinical record due to lack of document standard *we have had a integrated paper record
XDS RegistryIndexing
1. ECG
2. Endoscopy
3. Blood Results
4. Histology
XDS: Integrated Electronic Record
Adoption of XDS gives us a opportunity* to create an Electronic Patient record from the very departmental systems that currently exist.
1. Ordercomms
2. Endoscopy
3. Blood Results
4. Histology
5. Cardiology
6. Audiology
7. Radiology images
8. Clinical Letters/ Discharge Summaries
Patient :Joe Bloggs
EPR Viewer (XDS/XDS-1 Consumer)
This slides provides a graphical view of an XDS based EPR. Suppliers like Forcare, GE etc already have XDS displays available off the shelf.
Hospital XDS
RegistryIndexing
Maternity System
Clinical Letters
Pathology System
Cardiology PACS
Laboratory System
Ophthalmology PACS
RISRadiology PACS
XDS EPR- Local Patient Centric View
XDS standard adoption would provide a local patient centric EPR view in each hospital, *without the need to replace your existing functionally rich departmental systems.
XCA Concepts
Majority
NHS Patients—Locally held information is adequate
Sometimes
Ad-hoc access to Information -- outside the local IT boundaries✓Clinical decision making✓Avoid repeat investigations
For the vast majority of cases we treat in Primary or secondary care, the locally held clinical information with the available referral letter is adequate to make management decisions or issue a report (in case of radiology).However, in a small minority access to information held in other organizations becomes important.
XCAHospital GLocal XDS Registry
GP Local XDS Registry
Hospital BLocal XDS Registry
GPLocal XDS Registry
Hospital ELocal XDS Registry
GP Local XDS Registry
Hospital ALocal XDS RegistryGP
Local XDS Registry
XCA Model- Ad-hoc access
XCA or Cross community access-- which is an extension of XDS standard, will allow for regional or cancer-network or national patient related ad-hoc access to information. Patient centric access to information is timely & Prevents delays in patient management.
District General Hospital
XDS Registry
ClinicClinicClinicWardWardWard
X-ray Lab
Tertiary Hospital
XDS Registry
ClinicClinicClinicWardWardWard
X-ray Lab
GP Surgery
ClinicClinicReferWardWardReq.
XCA
Patient Portal
NHS Number
XDS Registry
XCA
XCA
XCA will allow for ad-hoc access to patient information outside the traditional information governance boundaries--.
District General Hospital
XDS Registry
ClinicClinicClinicWardWardWard
X-ray Lab
Tertiary Hospital
XDS Registry
ClinicClinicClinicWardWardWard
X-ray Lab
GP Surgery
ClinicClinicletterWardWardReq.
XCA
Patient Portal
NHS Number
XDS Registry
XCA
XCA
Using the same XCA concepts patients can have access to their clinical documents which maybe held in different hospitals & GP surgery—in a patient centric manner.
import awesome
The Anglerfish Songby Hank Green
Yes it's true that I once went through lifeAs a guy who always had to rhyme life with strifeYes, I've been burned and I've been spurnedAnd through it all, yes, I have learnedThat love is not about whether you get stabbedBut how slow the knife gets turned
But my friends I've found an animalWho doesn't feel this painAnd my life is so much better Now that I can feel the same
Because you can't hate the nightIf you've lived your whole life without lightAnd you can't hate the dishIf you've only ever eaten fishAnd you can't feel aloneIf it's all you've ever known
Yeah the deep sea anglerfishHas no reason to be happyBut it has no frikkin' ideaWhat else to be
DFTBA!
neenasdesign
!!!!!!
Single Sign On
Let us look at the workflow of radiologists in the future. With implementation of Single sign on—a radiologist is able to log on to 4 IT systems RIS, PACS, Ordercomms & EPR with a single windows log-in & password (rather than 4 log-in & passwords)
NHS No: 0123456789Hospital No: PAT12Surname: BLOGGS
Forename: JOEDate of Birth: 27 Mar
Sex: MaleAddress: 1, AB2 3CDClinician: Harry Potter
Location: A PlaceClinical Data: :-)
Radiology PACS
Ordercomms
RIS EPR
Single Sign On
Let us look at the workflow of radiologists in the future. With implementation of Single sign on—a radiologist is able to log on to 4 IT systems RIS, PACS, Ordercomms & EPR with a single windows log-in & password (rather than 4 log-in & passwords)
PACS
PACSTITLE OF SUBJECT
PACS
PACS
RIS
RIS
RIS Reporting Worklist
URGENT
1. Joe Bloggs---CXR2. Bob Wilson-CT Head Sarah Jenkins-CT
Chest
NON-URGENT1. Hannah -Floris-CT Head2. Joanne Hampson-CT Neck3. James Bond- CT abdomen and Pelvis
XCA Model- Ad-hoc access
Radiologist draws up a reporting worklist on RIS.
TITLE OF SUBJECT
PACS- Current Chest X-Ray
Current Chest X-ray
PACS- Previous Chest X-Ray
Previous Chest X-ray
Reporting Workflow
Reporting Workflow
RIS Imaging History Chest X-Ray Chest CT MRI
DD/VR
Show EPR
Show EPR
REPORT
REQ
REPORT
REQ
CDA Request
Reporting Workflow:Automatic Context Synchronization Automatic display of Relevant prior
With automatic context synchronization current Chest xray appears on middle monitor on PACS. Previous CXR appears on the right PACS monitor due to automatic display of relevant prior.
TITLE OF SUBJECT
PACS-CT Chest 3D PLUG-IN
EPRPACSPACSEPR
Future: PLUG-INS(DICOM 118 standard)
Reporting Workflow
Reporting Workflow
Ordercomms Joe Bloggs
CT AbdomenClinical History: Acute Chest
pain
RIS Imaging History
Chest X-Ray Chest CT
MRI
DD/VR
Show EPR
3D View
Nowadays specialist softwares are appearing for post processing of thin CT, CAD, Orthopaedic templating etc. These are generally from small innovative vendors. Adoption of vendor neutral plug-ins is key to future proofing of PACS replacements. It is important to buy a PACS from a vendor who supports DICOM 118 standard. Here is a 3rd party Cardiac CT analyisis plug-in.
TITLE OF SUBJECT
PACS-Mammogram CAD PLUG-IN
EPRPACSPACSEPR
Future: PLUG-INS(DICOM 118 standard)
Reporting Workflow
Reporting Workflow
Ordercomms Joe Bloggs
MammographyClinical History: Breast
Screening
RIS Imaging History
Chest X-Ray Chest CT
MRI
DD/VR
Show EPR
CAD
Similarly, here is a 3rd party mammography CAD plug-in.
TITLE OF SUBJECT
PELVIC XRAY Ortho Templating PLUG-IN
EPRPACSPACSEPR
Future: PLUG-INS(DICOM 118 standard)
Reporting Workflow
Reporting Workflow
Ordercomms Joe Bloggs
MammographyClinical History: Breast
Screening
RIS Imaging History
Chest X-Ray Chest CT
MRI
DD/VR
Show EPR
O T
Here is a 3rd party Orthopaedic templating plug-in. With time, it is likely that many of these plug-ins will become a part of a standard PACS software (rather than an optional extra from the suppliers or a a 3rd party)
1. Ordercomms
2. Endoscopy
3. Blood Results
4. Histology
5. Cardiology
6. Audiology
7. Radiology images
8. Clinical Letters/ Discharge Summaries
Patient :Joe Bloggs
Future PACS: XDS-1 Consumer=EPR Access
In the future PACS will be XDS-I consumer & will have access to images & reports registered to an XDS registry, which means PACS will have access to EPR.
TITLE OF SUBJECT
PACS-CT Abdoment
PACSEPR
Reporting Workflow
Reporting Workflow
Ordercomms Joe Bloggs
CT AbdomenClinical History: Acute
abdomenal pain
Imaging History Chest X-Ray Chest CT MRI
RIS
DD/VR
EPR- XDS Registry
EPRPACS
1. ECG
2. Endoscopy
3. Blood Results
4. HistologyShow EPR
REQ
REPORT
CDA Request
Access to Hospital EPR(PACS=XDS Consumer)
As previously shown CT suggests acute pancreatitis. As the PACS is XDS Consumer, radiologist has access to blood results on PACS display.
TITLE OF SUBJECT
PACS-CT Abdoment EPR- XDS Registry
EPRPACSPACSEPR
Reporting Workflow
Reporting Workflow
Ordercomms Joe Bloggs
CT AbdomenClinical History: Acute
abdomenal pain
Imaging History Chest X-Ray Chest CT MRI
RIS
DD/VR
Blood Results
Blood Amylase-- 1,500
Show EPR
CDA Request
REQ
REPORT
RIS or PACS =XDS consumerAccess to Hospital EPR
By reviewing blood amylase levels, a confident diagnosis of acute pancreatitis can be made—thus improving patient care.
TITLE OF SUBJECT
PACS- Current Chest X-Ray
Current Chest X-ray
PACS- Previous Chest X-Ray
Previous Chest X-ray
Local Imaging History1. Chest X-Ray2. Chest CT3. MRI
Local Imaging History1. Chest X-Ray2. Chest CT3. MRI
Reporting Workflow
Reporting Workflow
Request Card/Ordercomms-CDA
Local Imaging History Chest X-Ray
Chest CT MRI RIS
DD/VR
CDA REQ
Today: Radiologists’Workflow(Automatic Context Sync)
Today a reporting radiologist has access to local imaging history.
TITLE OF SUBJECT
PACS- Current Chest X-Ray PACS- Previous Chest X-Ray
PACSEPRPACSEPR
Reporting Workflow
Reporting Workflow
National Imaging History Chest X-Ray
Chest CTPET CT
MRI RIS
DD/VR
National Imaging History XDS1. Chest X-Ray2. Chest CT3. PET CT
National Imaging History XDS1. Chest X-Ray2. Chest CT3. PET CT
CDA REQ
Future Radiologists’ Workflow(XCA=National Image Sharing)
In future she will have access to national imaging history if required through XCA model.
TITLE OF SUBJECT
Current Screening Mammogram EPR: XDS Consumer compliant
PACS- Rad..EPRPACS- Bre...PACS- Rad...
Breast Screening
Breast Screening
National Breast
Screening System (NBSS)
1. ECG
2. Endoscopy
3. Blood Results
4. Histology
Breast Screening PACS:XDS Consumer=EPR access
Here the breast screening PACS is XDS consumer compliant & has access to EPR.
TITLE OF SUBJECT
Cardiology PACS EPR- XDS Consumer
EPRPACSPACSEPR
Cardiology Workflow
Cardiology Workflow
1. ECG
2. Endoscopy
3. Blood Results
4. Histology
Cardiology Information
System
DD/VR
National Cardiology History1. Cardiac Angiogram2. ECG3. Echocardiogram
Cardiology PACS:XDS consumer=EPR access
Similarly a Cardiology PACS is XDS consumer compliant & has access to EPR.
TITLE OF SUBJECT
Ophthalmology PACS EPR- XDS Consumer
EPRPACSPACSEPR
Ophthalmology Information System
Ophthalmology Informati...
1. ECG
2. Endoscopy
3. Blood Results
4. Radiology
Ophthalmology Information
System
DD/VR
Ophthalmology PACS: XDS consumer=EPR access
Similarly a Ophthalmology PACS is XDS consumer compliant & has access to EPR.
EPR- XDS Based Registry
EPRClinical Letters System
Clinical Letters System
DD/VR
Clinical Letters System
1. ECG
2. Endoscopy
3. Blood Results
4. Radiology
Clinical Letters System:XDS consumer=EPR access
Similarly a Clinic Management System is XDS consumer compliant & has access to EPR.
EPR- XDS Based Registry
EPRCritical Care System
Critical Care System
DD/VR
Critical Care
System
1. ECG
2. Endoscopy
3. Blood Results
4. Radiology
Critical Care System:XDS consumer=EPR access
Similarly a Critical Care System is XDS consumer compliant & has access to EPR.
20131. Patient Centric EPR (XDS-I/XCA-I)
2. Vendor Neutral Plug-ins (DICOM 118) 3. Data Culling
I believe 3 concepts will define PACS replacements in 2013--EPR access, Plug-ins & data culling.
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