Presented by Eugene Igras UPDATE Adoption of standards to share diagnostic imaging information in the pan-Canadian EHR DICOM Standards Committee – December

Presented by Eugene Igras

UPDATE

Adoption of standards to share diagnostic imaging information

in the pan-Canadian EHR

DICOM Standards Committee – December 4, 2008

2008 Canada Health Infoway Inc.

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Agenda

• Sharing DI data in the pan-Canadian EHR context

• Adoption of standards in the DI Domain

• Issues to be addressed

• 2008 Events

• Conclusion


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Infoway Diagnostic Imaging Program• Vision

Foster and accelerate the development and adoption of DI solutions to assist healthcare providers in acquisition, collection, storage, management, distribution and viewing patient radiology reports and images (any study, any time, any where) regardless of where the DI tests were conducted and/or the reports transcribed.

• Strategy

Build on existing standard-based PACS / RIS capabilities

Use IHE XDS/XDS-I Integration Profiles to:

Implement Registry & Data Repository (or multiple Repositories)

Enable interoperability with the EHR components, including:• Clinical Viewer• Health Information Access Layer (privacy & security, consent

management)• Registries (Client, Provider, Site and Terminology)

Ensure privacy and security of DI information


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• Improve Access to Services Provide timely access to DI information irrespective of where the images were

acquired and/or the report transcribed

Provide access to a longitudinal record of patient DI history

Improve timeliness and continuity of care

Enable real-time collaboration and clinical consultations

Improve training opportunities

• Improve Productivity & Contain Costs Increase patient throughput, reduce patient transfers and wait times

Provide capabilities for Radiologists to share workload across the region

Reduce DI exams by reducing avoidable retakes

• Improve Quality of Care Improve quality of DI information (accuracy, completeness, consistency)

Reduce radiation exposure

Reduce medical errors

Value Proposition


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Common Approach

Adherence to Infoway DI Program vision Leverage existing RIS and PACS as operational film-less solutions Consolidation of DI data into DI Repository (DI-r) or multiple Repositories Seamless sharing of DI data among authorized users

Provide access to a longitudinal record of patient DI history

Conformance & Compliance to Standards Architecture: EHRS Blueprint v2 Privacy & Security: Jurisdictional privacy protection legislation

Privacy & Security Requirements & ArchitectureISO/IEC 17799

Content & Messaging: HL7 v2.x and v3, CDA, DICOM Terminology: SNOMED CT & other terminology standards IHE Integration Profiles: XDS/XDS-I - to support DI data sharing

PIX/PDQ – to support patient identity/CR with HL7 v3

ATNA – to support securityOther IHE Radiology and IT Profiles

Electronic Business & Internet Standards


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Standards used in DI Domain An array of standards address DI Requirements in Canada

Internet StandardsHTML/XML, HTTP,

PDF, JPEG, MIME, UTF-8 …

Electronic BusinessStandards

ebXML, Web Services

HealthcareContent, Messaging, Terminology

HL7/CDA, DICOM, SNOMED CTLOINC, ICD-10-CA…

EHRS Blueprint v2Privacy & SecurityPrivacy Legislation

IHE Integration ProfilesXDS/XDS-I,

PIX/PDQ, ATNA…


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Scope of the XDS Affinity Domain in the EHR Context

JURISDICTIONAL INFOSTRUCTUREAncillary Data & ServicesRegistries Data

& ServicesEHR Data & Services Data

Warehouse

OutbreakMgmt

PHSReporting

SharedHealth

Record

DrugInformation

DiagnosticImaging

LaboratoryHealth

Information

ClientRegistry

ProviderRegistry

LocationRegistry

TerminologyRegistry

POINT OF SERVICE

Hospital, LTC,CCC, EPR

PhysicianOffice EMR

EHR Viewer

Physician/Provider

BusinessRules

EHRIndex

MessageStructures

NormalizationRules

Security Mgmt

Privacy DataConfig

Services

Physician/Provider

Physician/Provider

Lab System(LIS)

Lab Clinician

RadiologyCenter

PACS/RIS

Radiologist

PharmacySystem

Pharmacist

Public HealthServices

Public Health

Provider

Longitudinal Record Services

HIAL Communication BusCommon Services


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• Leverage and implement IHE integration profiles DI domain

• Co-authored XDS-I content supplement• Funded development of XDS-I MESA tool set• Declared XDS/XDS-I as a pan-Canadian Standard (“Stable for

Use”)• Implement XDS/XDS-I in current DI projects across Canada

Client Registry• Authored a change proposal to IHE PIX/PDQ to support HL7 v3

messaging EHR Infostructure

• Completed a review of IHE ITI integration profiles for consideration as pan-Canadian standards

• Coordinate with IHE to avoid duplication Leverage IHE technical committees to develop new profiles and/or

propose changes to existing profiles e.g. support for v3 messaging Leverage MESA tools for conformance testing Provide resources to IHE International through IHE Canada

Infoway and IHE


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DI Projects Across Canada • Most provinces in Canada

Have deployed digital DI modalities and PACS/RIS solutions

Have completed architecture for DI Repository (or multiple Repositories) integrated with the EHR

Plan to deploy interoperable EHR / DI solutions

All DI Solutions

Span multiple health regions, hundreds of hospitals, and DI clinics

Integrate multi-vendor PACS / RIS environment

Are designed to handle

• Multiple patient identification domains and EMPI services

• Multiple security domains

• Millions of exams per year (e.g., Alberta: over 4.5 million)

Provide services to thousands of users (e.g. Alberta: over 15,000)


10XDS – Actors and Transactions

Provide & Register Document Set

• Submits document sets• Creates and submits documents

description (metadata)

• Stores documents & metadata• Creates & maintains document URI (Uniform Resource Identifier)• Forwards metadata for registration• Supports document retrieval

Register Document Set

Patient Identity Feed

• Stores and maintains metadata• Creates and maintains links to documents• Supports document search (query)• Enforces policies at the time of registration

• Feeds identity of known patients to Document Registry

Query Registry

Retrieve Document

• Initiates search (query)

• Initiates retrieval of documents

DocumentRegistry

DocumentConsumer

DocumentRepository

DocumentSource

Patient Identity Source


11XDS-I – Actors and Transactions

• Receives, stores & maintains metadata• Creates and maintains document index• Supports document search (query)• Enforces policies for registration

DocumentRegistry

DocumentRepositoryImaging

DocumentSource

Provide & Register Document Set


• Feeds identity of known patients to Document Registry

• Initiates search and retrieval of documents

Register Document Set

Retrieve Document

Patient Identity Feed

DocumentConsumer

ImagingDocumentConsumer

WADO Retrieve

Retrieve ImagesRetrieve Presentation StatesRetrieve ReportsRetrieve Key Imaging NoteRetrieve Evidence Documents

• Initiates retrieval of DICOM objects referenced within the manifest

• Creates text / PDF report and/or imaging manifest documents

• Submits document sets with document description (metadata)

• Supports retrieval of DICOM objects

• Stores documents and metadata• Enhances metadata with document

URIs to enable retrieval• Forwards the enhanced metadata for

registration• Supports document retrieval

Query Registry


12Real-world Systems vs. XDS-I Actors

DocumentRegistry


DocumentSource


DocumentConsumer


PACS

Mod

Mod

DI Repository (DI-R)• Stores and maintains a lifetime record of relevant DI data including

• Images and reports

• Key image notes, image processing results & overlay information

• Presentation states and other evidence documents

• Serves as shared operational PACS for greenfield sites

• Supports 2-3 Million exams per year

• Delivers DI data to consumer over a network

• Facilitates seamless sharing of DI information

• Maintains quality and integrity of data

DI-R

PACS

Mod

Mod

Mod

RISMod

Mod


13Real-world Systems vs. XDS-I Actors

PACS

Mod

Mod

DI-R PACS

Mod

Mod

Mod

EMR

Viewer

DocumentRegistry


DocumentSource


DocumentConsumer


RIS Mod


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• How to ensure interoperability of XDS-based systems with other solutions that handle discrete data (e.g., Lab, Drug)? How does an XDS Registry for DI evolve into and/or co-exist with other

indexing scheme?

How to ensure other XDS/XDS-I consumers (e.g., EMR) adopt Document Consumer actor capabilities to access DI content?

• How to provide document sharing capabilities across multiple affinity domains?

• How to ensure data quality attributes (e.g., accuracy, completeness, integrity) are maintained/preserved in a data sharing environment?

• How to provide a uniform clinical terminology given a multitude of terminology schemes and vocabularies?

• How does a jurisdiction approach XDS Affinity Domain policies for consumers that are “associated “with the Affinity Domain (GP, Specialist) but not “in” the Affinity Domain?

Issues To Be Addressed (1)


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Issues To Be Addressed (2)

• Synchronization of shared radiology studies Radiology study split

Radiology study attribute changes

Deletion of a study component (e.g. radiology image)

• Standardized representation of DI study in the XDS Affinity Domain A single manifest

Multiple manifests

• Standardized use of XDS Affinity Domain attributes and metadata

• Division of responsibilities between PACS and DI-r

• Data synchronization between local PACS systems and DI-r

• Linking of documents from multiple repositories and support for consultation workflows including creation of new objects


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Terminology & Classification Systems Current & Future State

AcquisitionModalities

POS Information Systems

Storage & Retrieval• DI-rs• Doc Repositories

Document Sharing• Document Registry

HIAL

CT MRIX-Ray

US

PACS HISRIS EMR /Viewer

Content & Format• Images – DICOM• Discrete DataTerminology/Codes• DICOM (SNOMED RT, LOINC)• ICD-9/10• HL7 v2.x

Current State

Content & Format• Images - DICOM• Reports - DICOM SR, Text, PDF• Discrete DataTerminology/Codes• DICOM (SNOMED RT, LOINC)• ICD-10/10CA• CCI• HL7 v2.x and v3

Content & Format• Images & Manifests - DICOM• Reports - DICOM SR, HL7 CDA R2Terminology/Codes• Implementation-specific

Future State

Content & Format• Registry entries - ebXMLTerminology/Codes• To be standardized

Content & Format• Images & Manifests - DICOM• Reports - DICOM SR, HL7 CDA R2Terminology/Codes • Adopted / Adapted / developed• Harmonized with pan-Canadian

Terminology

Content & Format• Images - DICOM• Reports - DICOM SR, Text, PDF• Discrete DataTerminology/Codes• DICOM (SNOMED CT, LOINC)• ICD-10CA, ICD-PSC• HL7 v3

Content & Format• Images – DICOM• Discrete DataTerminology/Codes• DICOM (SNOMED CT, LOINC)• ICD-10-CA• HL7 v3

Normalization


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Terminology Standardization: Candidate Data Entities

Patient Provider and Delivery Site

• Procedure Requestor, Facility• Request Recipient, Service

Delivery Site Request

• Request Priority Indicator• Clinical Reason for Request• Request Status• Consent Details

Procedure• Modality• Anatomical Site, Position,

Laterality, View Aspect• Contrast Medium• Specimen Details• Preparation Instructions• Procedure Performance Details• Procedure Substitution Details

Clinical Status• Clinical Synopsis• Problem/Diagnosis• Observation• Adverse Reaction• Alert• Severity (of problem, diagnosis

or allergic reaction) DI Study

• Study & Series Details

• Image Instances Report

• Authorship, Review, Approval• Interpretation, Findings, Comments• Evidence

Source: Diagnostic Imaging Data Specification; http://www.nehta.gov.au


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XDS-I Metadata Attributes - Sample

Metadata Attribute / Source Metadata Attribute/ Source

Document Author Attributes Patient Attributes

authorSpecialty / Source system patientId / Imaging Document Source

authorInstitution / Source system sourcePatientId / Source system

authorPerson / Imaging Document Source sourcePatientInfo / Source system

authorRole / Imaging Document Source Service Attributes

authorRoleDisplayName / practiceSettingCode / Imaging Document Source

Document Submission Set Attributes practiceSettingCodeDisplayName /

classCode / Imaging Document Source serviceStartFime, serviceStopTime / Source system

confidentialityCode / Source system typeCode, typeCodeDisplayName / Source system

creationTime / Source system XDS Submission Set Attributes

formatCode / Imaging Document Source authorDepartment, authorInstitution, authorPerson

parentDocumentRelationship /Source system contentTypeCode, contentTypeCodeDisplayName

parentDocumentId / Source system patientId

mimeType / Imaging Document Source sourceId

submissionTime / Source system

uniqueId


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• Integrates information Eliminates fragmentation of data captured and recorded in stand-alone systems through

integration of data across organizations and systems Improves quality of DI information (accuracy, completeness, consistency) Addresses patient privacy and data security in a comprehensive and consistent manner

• Improves Access Provides timely access (anywhere, anytime) to DI information irrespective of where the

images were acquired and the reports transcribed Provides access to a longitudinal record of patient DI history Improves timeliness and continuity of care Enables collaboration among care providers Improves training opportunity

• Improves Productivity Increases patient throughput, reduces patient transfers and wait times Provides capabilities for Radiologists to share workload across the Affinity Domain Reduces DI exams by reducing avoidable retakes

• Improves Quality of Care Reduces radiation exposure Reduces medical errors

XDS-I Value Proposition


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2008 Events

• Infoway Partnership Conferences April 2008 (Toronto)

October 2008 (Montréal)

Standards Collaborative Working Groups SCWG 1 - Population Care SCWG 2 - Individual Care SCWG 3 - Managing the Healthcare System SCWG 4 - Medication Management SCWG 5 - Labs & Diagnostics SCWG 6 - Infostructure & Architecture SCWG 7 - Non-clinical Registries SCWG 8 - Privacy & IT Security Services SCWG 9 – Clinical Terminology

• Project team meetings


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Conclusion

• IHE XDS-I is aligned with the pan-Canadian EHR architecture and accepted as the right approach to achieving seamless sharing of DI documents within the EHR Declared a pan-Canadian Standard “stable for use” All Provinces recognize the value of consolidating DI data in domain

repositories DI projects across Canada adopt XDS-I

• There are still outstanding issues to be addressed by: Infoway invested DI projects Infoway Standards Collaborative (Standards Collaborative Working

Groups) IHE Canada / IHE Vendor community


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Infoway Standards Collaborative

Contact: Grant Gillis ([email protected])

Infoway Solution Architecture Group

Contact: Eugene Igras ([email protected])

Thank you!