September, 2005Cardio - June 2007 Cardiology Workflow Cath, Echo, and Stress Workflow

September, 2005 Cardio - June 2007

Cardiology WorkflowCardiology WorkflowCath, Echo, and Stress Cath, Echo, and Stress

WorkflowWorkflow

2Cardio - June 2007

AgendaAgenda

Cardiology WorkflowsCardiology Workflows Cath WorkflowCath Workflow Echo WorkflowEcho Workflow Stress Workflow Stress Workflow

3Cardio - June 2007

The ProblemThe Problem

This is a piece of a This is a piece of a typical cardiology typical cardiology workflow.workflow.

Any questions? (!)Any questions? (!)

Workflow is the Workflow is the linchpin to data linchpin to data

integrityintegrity

4Cardio - June 2007

IHE Workflow ConceptsIHE Workflow Concepts

PROCEDURE STEPPROCEDURE STEP : : The smallest unit of managed work:The smallest unit of managed work:

ScheduledScheduled Procedure Step: ‘A unit of work Procedure Step: ‘A unit of work to do’to do’

PerformedPerformed Procedure Step: ‘A unit of work Procedure Step: ‘A unit of work donedone’’

IHE uses three UNAMBIGUOUS IHE uses three UNAMBIGUOUS HL7/DICOMHL7/DICOM terms for terms for all all

workflow management (cardiology, radiology, lab, etc.)workflow management (cardiology, radiology, lab, etc.)

ORDERORDER : : A request for departmental service(s)A request for departmental service(s)

REQUESTED PROCEDUREREQUESTED PROCEDURE : A unit of work resulting in Clinical Report : A unit of work resulting in Clinical Report (with associated codified, billable acts) (with associated codified, billable acts)

5Cardio - June 2007

3 Levels are Role Oriented3 Levels are Role Oriented

ORDER:ORDER:A request for departmental serviceA request for departmental service

(Accession Number)(Accession Number)

REQUESTED PROCEDURE : REQUESTED PROCEDURE : Unit of work resulting in Clinical ReportUnit of work resulting in Clinical Report

with associated codified, billable actswith associated codified, billable acts(Requested Procedure ID)(Requested Procedure ID)

PROCEDURE STEP :PROCEDURE STEP :The smallest unit of managed workThe smallest unit of managed work

in the workflowin the workflow(Modality Worklist entry)(Modality Worklist entry)

CLINICIANCLINICIANOR REFERING DOC:OR REFERING DOC:

The imaging dept customerThe imaging dept customer

CARDIOLOGIST : CARDIOLOGIST : In charge of producingIn charge of producing

the Reportthe Report

TECHNOLOGISTTECHNOLOGIST(and CARDIOLOGIST)(and CARDIOLOGIST)In charge of acquiring In charge of acquiring

images, etc.images, etc.

6Cardio - June 2007

Simple Workflow – Simple Workflow – e.g., Echoe.g., Echo

ORDERA request for DepartmentalService

RequestedProcedure

Imaging Department

ReportSet of

Codifiable,Billable,

ActsAcquisition Modality

ScheduledProcedure

Step

DICOMModality Worklist

One or more series of images

PerformedProcedure

Step

7Cardio - June 2007

AcquisitionModality

AcquisitionModality

Multiple Modality StepsMultiple Modality Steps

ORDERA request for DepartmentalService

Imaging Department

Set of Codifiable,

Billable, ActsOne or more series of images

PerformedProcedure

Step P1

ScheduledProcedure

Step B

RequestedProcedure

ScheduledProcedure

Step A

Report

One or more series of images

PerformedProcedure

Step P2



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General Workflow ActorsGeneral Workflow Actors

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]



Order Placer

Acquisition Modality

ImageManager

Image Archive

Dept System Scheduler /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]

Time Client

Time Client

9Cardio - June 2007

Workflow Interaction Model - 1Workflow Interaction Model - 1

ADTOrder Placer

ImageManager


Placer Order Mgmt - New [Rad-2]

Department System Scheduler/ Order Filler

Procedure Scheduled [Rad-4]

Register/Admit Patient

Create Order

Schedule Procedure

PatientRegistration [Rad-1]

Select Patient

Query Modality Worklist [Rad-5]

10Cardio - June 2007

Workflow Interaction Model - 2Workflow Interaction Model - 2Image

Manager/Image Archive


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]


Order Placer

Order Status Update [Rad-3]

UpdateSchedule

Acquisition Modality n




Perform Acquisition Modality Images/Evidence Stored

[Card-2]

Step Completed [Rad-7]


AgendaAgenda

Cardiology WorkflowsCardiology Workflows

Cath WorkflowCath Workflow Echo WorkflowEcho Workflow Stress Workflow Stress Workflow

Content Display RequirementsContent Display Requirements Stress EchoStress Echo StressStress Nuclear CardiologyNuclear Cardiology


Cath LabCath Lab

1

23 4

56 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


Use CasesUse Cases Case C1:Case C1: Patient Registered at ADT and Procedure Patient Registered at ADT and Procedure

Ordered at the Order PlacerOrdered at the Order Placer Case C2:Case C2: Patient Registered at ADT and Procedure Patient Registered at ADT and Procedure

Ordered at DSS/OFOrdered at DSS/OF Case C3:Case C3: Patient Registered at ADT and Procedure Patient Registered at ADT and Procedure

Not OrderedNot Ordered Case C4:Case C4: Patient Registered at DSS/OF and Patient Registered at DSS/OF and

Procedure OrderedProcedure Ordered Case C5:Case C5: Patient Not Registered Patient Not Registered Case C6:Case C6: Patient Updated During Procedure Patient Updated During Procedure Case C7:Case C7: Change Rooms During Procedure Change Rooms During Procedure Case C8:Case C8: Cancel Procedure Cancel Procedure Case C9:Case C9: Post-Procedure Evidence Creation Post-Procedure Evidence Creation Case C10: Case C10: EP Ablation / Implantation LabEP Ablation / Implantation Lab

The Unknown The Unknown Patient CasePatient Case

ALL Use Cases Must be SupportedALL Use Cases Must be Supported

Exception of C10 only required for EP LabException of C10 only required for EP Lab


Case C1: Patient Registered at ADT and Case C1: Patient Registered at ADT and Procedure Ordered at the Order PlacerProcedure Ordered at the Order Placer

Clinical ContextClinical Context

Corresponds to traditional Radiology workflowCorresponds to traditional Radiology workflow Order placed in central systemOrder placed in central system Also deals with case where emergency Also deals with case where emergency

identifier has been createdidentifier has been created Common identifiers known ahead of timeCommon identifiers known ahead of time

IHE ContextIHE Context

MPPS in Progress from first modality used to MPPS in Progress from first modality used to update worklists for othersupdate worklists for others


Case C2: Patient Registered at ADT andCase C2: Patient Registered at ADT and Procedure Ordered at DSS/OF Procedure Ordered at DSS/OF

Clinical ContextClinical Context Slight difference to Case 1Slight difference to Case 1 Order placed NOT in central system but in departmentOrder placed NOT in central system but in department Department system provides info to Central ordering Department system provides info to Central ordering

system system Typical of many institutes, relieves need for HIS terminal Typical of many institutes, relieves need for HIS terminal

in labin lab

IHE ContextIHE Context Filler Order Management (New Order) transaction [RAD-3] Filler Order Management (New Order) transaction [RAD-3]

is sent from Department System Scheduler/Order Filler to is sent from Department System Scheduler/Order Filler to the Order Placer.the Order Placer.


Case C3: Patient Registered at ADTCase C3: Patient Registered at ADT and Procedure Not Ordered and Procedure Not Ordered

Clinical ContextClinical Context Slight difference to Case 2Slight difference to Case 2 Procedural information is NOT entered at the departmental Procedural information is NOT entered at the departmental

systemsystem The first modality must initiate the process of creating common The first modality must initiate the process of creating common

procedure identifiers (usually hemo)procedure identifiers (usually hemo) The common procedure identifiers are created by the The common procedure identifiers are created by the

departmental system based on the information available from departmental system based on the information available from the first modalitythe first modality

Can generate a “generic cath procedure” if no coded procedural Can generate a “generic cath procedure” if no coded procedural type is availabletype is available

IHE ContextIHE Context Upon receiving the first MPPS the DSS/OF will auto generate a Upon receiving the first MPPS the DSS/OF will auto generate a

Requested Procedure and its associated Scheduled Procedure Requested Procedure and its associated Scheduled Procedure Steps utilizing the Study UID provided in the first MPPS. All Steps utilizing the Study UID provided in the first MPPS. All other modalities use the Query Modality Worklist transaction.other modalities use the Query Modality Worklist transaction.


Case C4: Patient Registered at DSS/OFCase C4: Patient Registered at DSS/OF and Procedure Ordered and Procedure Ordered

Clinical ContextClinical Context This case accommodates the emergency case where there is This case accommodates the emergency case where there is

not enough time to register the patient on ADT systemnot enough time to register the patient on ADT system A temporary patient identifier is created at the department levelA temporary patient identifier is created at the department level The order placer is notified only after the patient is registered The order placer is notified only after the patient is registered

and manually reconciled on the department system and manually reconciled on the department system

IHE ContextIHE Context The DSS/OF assigns a temporary Patient ID with a temporary The DSS/OF assigns a temporary Patient ID with a temporary

name and schedules the required proceduresname and schedules the required procedures The DSS/OF does not send the Filler Order Management (New The DSS/OF does not send the Filler Order Management (New

Order) transaction to the Order Placer until the patient is Order) transaction to the Order Placer until the patient is registered on the ADT system and reconciliation occurs on the registered on the ADT system and reconciliation occurs on the DSS/OF. DSS/OF.


Case C5: Patient Not RegisteredCase C5: Patient Not Registered

Clinical ContextClinical Context This is the Emergent Case where the patient information is not This is the Emergent Case where the patient information is not

known or there is not enough time to enter the informationknown or there is not enough time to enter the information A temporary ID is assigned by the department and entered at the first A temporary ID is assigned by the department and entered at the first

modality and forwards that information to the departmental system to modality and forwards that information to the departmental system to be shared with the other modalitiesbe shared with the other modalities

Like in C4 information is sent to the Order Placer post patient Like in C4 information is sent to the Order Placer post patient registration and reconciliation on the departmental systemregistration and reconciliation on the departmental system

IHE ContextIHE Context Patient ID and name are selected based upon locally (usually Patient ID and name are selected based upon locally (usually

department) base rulesdepartment) base rules The first modality will send an MPPS with the appropriate information The first modality will send an MPPS with the appropriate information

to the DSS/OF which will in turn generate the appropriate requested to the DSS/OF which will in turn generate the appropriate requested procedure(s) using the Study UID assigned by the first modalityprocedure(s) using the Study UID assigned by the first modality


Case C6: Patient Updated During ProcedureCase C6: Patient Updated During Procedure

Clinical ContextClinical Context An unidentified patient may have been registered at the ADT An unidentified patient may have been registered at the ADT

and brought into the cath lab with the temporary IDand brought into the cath lab with the temporary ID During the procedure the patient information is updated on the During the procedure the patient information is updated on the

ADT which sends the patient update informationADT which sends the patient update information This can results is some of the information been associated with This can results is some of the information been associated with

the temp ID and the rest with the permanent IDthe temp ID and the rest with the permanent ID The case defines how the reconciliation occurs.The case defines how the reconciliation occurs.

IHE ContextIHE Context The modality may have requested information from the DSS/OF The modality may have requested information from the DSS/OF

prior the patient updateprior the patient update The Image Manager needs to update the items stored to Image The Image Manager needs to update the items stored to Image

Archive as well as any subsequent items receivedArchive as well as any subsequent items received..


Case C7: Change Rooms During ProcedureCase C7: Change Rooms During Procedure

Clinical ContextClinical Context

This is the case when the patient is moved due to any of the This is the case when the patient is moved due to any of the following reasons:following reasons:

The change from a diagnostic to interventional procedureThe change from a diagnostic to interventional procedure The need to use the current room for another patientThe need to use the current room for another patient Equipment failureEquipment failure

NOTE: This case does not cover the scenario where a patient is NOTE: This case does not cover the scenario where a patient is moved to the holding area from a procedure room. moved to the holding area from a procedure room.

IHE ContextIHE Context

Each modality will issue a MPS (Completed or Discontinued)Each modality will issue a MPS (Completed or Discontinued) The DSS/OF will reassign the requested procedure to the new roomThe DSS/OF will reassign the requested procedure to the new room In the event the DSS/OF does not reassign, each modality in the In the event the DSS/OF does not reassign, each modality in the

new room would use the broad Modality Worklist Querynew room would use the broad Modality Worklist Query This insures consistency of the Study UID for all informationThis insures consistency of the Study UID for all information


Image Manager Acquisition

Modality Room 1

Department System Scheduler/ Order Filler

Modality Procedure Step Discontinued [Rad-7]

Modality Procedure Step Discontinued [Rad-7]



AcquisitionModality n

Room 1


Perform Acquisition

Perform Acquisition

AcquisitionModality Room 2

AcquisitionModality n Room 2







Perform Acquisition

Perform Acquisition




Reassign Procedure

UpdateSchedule

UpdateSchedule

Case 7: Change Rooms During ProcedureCase 7: Change Rooms During Procedure


Case C8: Cancel ProcedureCase C8: Cancel Procedure

Clinical ContextClinical Context This case allows for the information systems to keep track of This case allows for the information systems to keep track of

cancelled procedures allowing the cath lab staff to appropriately cancelled procedures allowing the cath lab staff to appropriately respond to queries regarding that patient.respond to queries regarding that patient.

IHE ContextIHE Context When the procedure is cancelled within the department the When the procedure is cancelled within the department the

DSS/OF notifies the Order Placer system and Image ManagerDSS/OF notifies the Order Placer system and Image Manager The length of time this procedural information is maintained is The length of time this procedural information is maintained is

determined by local policy.determined by local policy.


Case C9: Post-Procedure Evidence CreationCase C9: Post-Procedure Evidence Creation

Clinical ContextClinical Context Allows for imaging and other procedural data to be analyzed Allows for imaging and other procedural data to be analyzed

post-procedure using specialized software (e.g., QCA, QLV, post-procedure using specialized software (e.g., QCA, QLV, derived images)derived images)

This case does NOT apply to core lab analysis for clinical trials This case does NOT apply to core lab analysis for clinical trials or outcome analysisor outcome analysis

IHE ContextIHE Context This analysis must be performed on a station that groups the This analysis must be performed on a station that groups the

Image Display and Evidence Creator ActorsImage Display and Evidence Creator Actors The Evidence Creator notifies the IM/IA and DSS/OF of the The Evidence Creator notifies the IM/IA and DSS/OF of the

activity via the MPPS In Progress and Complete transactionsactivity via the MPPS In Progress and Complete transactions The Evidence Creator stores its evidence to the IM/IA via the The Evidence Creator stores its evidence to the IM/IA via the

Storage Commit Transaction.Storage Commit Transaction.


Case C10: Case C10: EP Ablation / Implantation LabEP Ablation / Implantation Lab

Clinical ContextClinical Context Allows for the wide array of specialized equipment used in the Allows for the wide array of specialized equipment used in the

EP labEP lab Provides demographic and time synchronizationProvides demographic and time synchronization

IHE ContextIHE Context Initial implementation is an extension of the CATH profileInitial implementation is an extension of the CATH profile Support for use cases C1 – C9 Support for use cases C1 – C9 Emergency use cases C3 and C5 are highly unusual in the EP Emergency use cases C3 and C5 are highly unusual in the EP

lab.lab.


AgendaAgenda

Cardiology WorkflowsCardiology Workflows Cath WorkflowCath Workflow

Echo WorkflowEcho Workflow Stress Workflow Stress Workflow


Echo WorkflowEcho Workflow

The “drive-by echo” – The “drive-by echo” – Cardiologist to sonographer in CCU: Cardiologist to sonographer in CCU: “While you’re here, do a TTE on bed 3”“While you’re here, do a TTE on bed 3”

Unordered, unscheduled examUnordered, unscheduled exam Machine disconnected from Machine disconnected from

networknetwork

Stress echo –Stress echo –After exam, sonographer creates new After exam, sonographer creates new quad displays of stages and viewsquad displays of stages and views

No intrinsic value addNo intrinsic value add Data is redundantly copied to Data is redundantly copied to

storage in quad formatstorage in quad format


Case E1:Case E1: Patient Registered at ADT and Procedure Ordered Patient Registered at ADT and Procedure Ordered

Case E2:Case E2: Intermittently Connected Modality Intermittently Connected Modality

Case E3:Case E3: Intermittently Connected Modality with Ad Hoc Intermittently Connected Modality with Ad Hoc

Procedure, Patient Registered, Scheduled ProcedureProcedure, Patient Registered, Scheduled Procedure


Procedure, Patient Registered, Unscheduled ProcedureProcedure, Patient Registered, Unscheduled Procedure


Procedure, Patient Unregistered, Unscheduled ProcedureProcedure, Patient Unregistered, Unscheduled Procedure

Case E6:Case E6: Stress Echo Staged Protocol Stress Echo Staged Protocol

Case E7:Case E7: Echo Measurements Evidence Creation Echo Measurements Evidence Creation

The Drive-by The Drive-by Echo CaseEcho Case

Use CasesUse Cases

The Stress The Stress Test CaseTest Case


Case E1:Case E1: Patient Registered at ADT and Patient Registered at ADT and Procedure OrderedProcedure Ordered

Clinical ContextClinical Context Corresponds to traditional Radiology workflowCorresponds to traditional Radiology workflow Order placed in central systemOrder placed in central system Also deals with case where emergency identifier Also deals with case where emergency identifier

has been createdhas been created Common identifiers known ahead of timeCommon identifiers known ahead of time

IHE ContextIHE Context The Scheduled Procedure Steps are obtained by The Scheduled Procedure Steps are obtained by

the modality through Query Modality Worklist, the the modality through Query Modality Worklist, the acquisition is performed and statused thought acquisition is performed and statused thought Modality Performed Procedure Step.Modality Performed Procedure Step.


Case E2:Case E2: Intermittently Connected Modality Intermittently Connected Modality

Clinical ContextClinical Context Allows for the mobile workflow typical of TTE and TEEAllows for the mobile workflow typical of TTE and TEE Assumes the modality is only intermittently connected to the Assumes the modality is only intermittently connected to the

networknetwork Also covers the case of the modality being turned offAlso covers the case of the modality being turned off

IHE ContextIHE Context Process flow identical to Case E1Process flow identical to Case E1 Must be paired with an Image Manager/Image Archive that Must be paired with an Image Manager/Image Archive that

also supports Intermittent Connectivityalso supports Intermittent Connectivity MPPS are stored and sent when connection establishedMPPS are stored and sent when connection established Image Manage must queue N-Event Report messages for Image Manage must queue N-Event Report messages for

storage commitment storage commitment


Case E3:Case E3: ICM with Ad Hoc Procedure, Patient ICM with Ad Hoc Procedure, Patient Registered, Scheduled ProcedureRegistered, Scheduled Procedure

Clinical ContextClinical Context This extends Case E2 to allow for a scheduled procedure This extends Case E2 to allow for a scheduled procedure

but the modality can’t query the worklist since it is not but the modality can’t query the worklist since it is not connected to the networkconnected to the network

IHE ContextIHE Context The modality will treat this as unscheduled procedureThe modality will treat this as unscheduled procedure The patient ID and demographics must be manually enteredThe patient ID and demographics must be manually entered The modality must create the Study Instance UIDThe modality must create the Study Instance UID Manual matching process at DSS/OF to reconcile the Manual matching process at DSS/OF to reconcile the

scheduled and performed procedure informationscheduled and performed procedure information Post match the DSS/OF will reconcile with the Image Post match the DSS/OF will reconcile with the Image

Manager to correct for the Study Instance UIDManager to correct for the Study Instance UID


Case E4:Case E4: ICM with Ad Hoc Procedure, Patient ICM with Ad Hoc Procedure, Patient Registered, Unscheduled ProcedureRegistered, Unscheduled Procedure

Clinical ContextClinical Context This is the drive by echo or Stat echo performed without an This is the drive by echo or Stat echo performed without an

order placed in the systemorder placed in the system

IHE ContextIHE Context This case is identical to other unscheduled procedure casesThis case is identical to other unscheduled procedure cases Modality creates the Study Instance UIDModality creates the Study Instance UID When connected the modality will send a MPPS in ProgressWhen connected the modality will send a MPPS in Progress DSS/OF will generate an exception for reconciliationDSS/OF will generate an exception for reconciliation Patient demographic reconciliation should occur Patient demographic reconciliation should occur

automatically based on patient IDautomatically based on patient ID The Image Manager will use the Patient Update transaction The Image Manager will use the Patient Update transaction

to update the demographicsto update the demographics


Case E5:Case E5: ICM with Ad Hoc Procedure, Patient ICM with Ad Hoc Procedure, Patient Unregistered, Unscheduled ProcedureUnregistered, Unscheduled Procedure

Clinical ContextClinical Context This case is similar to Case E4 except the patient is not yet This case is similar to Case E4 except the patient is not yet

registered. (Emergency Admit)registered. (Emergency Admit)

IHE ContextIHE Context Temporary Name and ID entered into the modalityTemporary Name and ID entered into the modality DSS/OF will generate an exceptionDSS/OF will generate an exception Manual match of the temporary ID with the Patient Manual match of the temporary ID with the Patient

Registration informationRegistration information Patient Update sent to the Image ManagerPatient Update sent to the Image Manager


Case E6:Case E6: Stress Echo Staged Protocol Stress Echo Staged Protocol

Clinical ContextClinical Context Allows for appropriate identification of Stages and Views Allows for appropriate identification of Stages and Views

during a stress echoduring a stress echo

IHE ContextIHE Context Similar to Case E1Similar to Case E1 Type of stress protocol is specified in the Scheduled Type of stress protocol is specified in the Scheduled

Protocol Code Sequence or Scheduled Step DescriptionProtocol Code Sequence or Scheduled Step Description Within the “perform acquisition” activity there are several Within the “perform acquisition” activity there are several

stages but typically considered the same procedure stepstages but typically considered the same procedure step A status of “Discontinued” can indicate technical failure to A status of “Discontinued” can indicate technical failure to

reach the end point of the exam.reach the end point of the exam.


Case E7:Case E7: Echo Measurements Evidence Echo Measurements Evidence CreationCreation

Clinical ContextClinical Context Measurements are normally obtained during the Measurements are normally obtained during the

acquisition on the modality. acquisition on the modality. This case supports the ability to obtain additional This case supports the ability to obtain additional

measurements on the clinical workstation post measurements on the clinical workstation post acquisition and update the study data.acquisition and update the study data.

IHE ContextIHE Context This case is similar to Cath C9This case is similar to Cath C9 The actor participates in both the ECHO and ED The actor participates in both the ECHO and ED

profilesprofiles Generation of a DICOM SR with reference to originalGeneration of a DICOM SR with reference to original


AgendaAgenda

Cardiology Workflows GeneralCardiology Workflows General Cath WorkflowCath Workflow Echo WorkflowEcho Workflow

Stress WorkflowStress Workflow


Amazing FactsAmazing Facts

Your heart beats about Your heart beats about

70 beats per min70 beats per min 4200 beats per hour4200 beats per hour 100,800 beats per day100,800 beats per day 35 million times in a year. 35 million times in a year. Or more than 2.5 billion beats in your life Or more than 2.5 billion beats in your life

time. time.

AND IT ONLY TAKES ONE AND IT ONLY TAKES ONE IRREGULAR BEAT TO KILL IRREGULAR BEAT TO KILL YOUYOU

Now that I got your Now that I got your attention again!attention again!


So what is Stress Testing?So what is Stress Testing?

Uses exercise or medication to Uses exercise or medication to increase the work of the heart – increase the work of the heart – incremental stagesincremental stages

Continuous 12 lead ECG Continuous 12 lead ECG monitoring during studymonitoring during study

Looking for changes in ECG (ST Looking for changes in ECG (ST segments)segments)

Used as a screening tool, oUsed as a screening tool, or to r to test effectiveness of therapytest effectiveness of therapy

May include imaging at different May include imaging at different stages of stress; multiple views stages of stress; multiple views of heartof heart

Includes comparisons to Includes comparisons to previous studiesprevious studies


Use CasesUse CasesCase S1:Case S1: Cardiac Stress Test, ECG Only Cardiac Stress Test, ECG Only

Limited use with lower sensitivities and specificitiesLimited use with lower sensitivities and specificities

Screening tool onlyScreening tool only

Case S2:Case S2: Cardiac Stress Test with Imaging Cardiac Stress Test with Imaging

More common use caseMore common use case

Echocardiography or Nuclear cardiology imagingEchocardiography or Nuclear cardiology imaging

Exercise or pharmaceutical stressExercise or pharmaceutical stress


Stress ImagingStress Imaging

Stress EchoStress Echo Began in the early – mid 1990’sBegan in the early – mid 1990’s Observation of wall motion and ejection fractions with the heart Observation of wall motion and ejection fractions with the heart

under stressunder stress High specificity for correlating ischemia to functional High specificity for correlating ischemia to functional

abnormalitiesabnormalities Can be done with exercise, but mainly pharmaceuticalCan be done with exercise, but mainly pharmaceutical

Nuclear StressNuclear Stress Most often combined with exercise or pharmaceuticalMost often combined with exercise or pharmaceutical stressorstressor Use of radioisotope to detect presence and resolution of Use of radioisotope to detect presence and resolution of

ischemic regions of the heartischemic regions of the heart Scan immediately post stress inductionScan immediately post stress induction Scan 4 hours to 1 day laterScan 4 hours to 1 day later Resolution of ischemic area determines viability of muscleResolution of ischemic area determines viability of muscle


Cases S1 and S2Cases S1 and S2

Patient known and registered in all cases; exam Patient known and registered in all cases; exam scheduled in all cases scheduled in all cases

Echo operates as in Case E6Echo operates as in Case E6

Nuclear scanner follows Radiology Scheduled Nuclear scanner follows Radiology Scheduled Workflow ProfileWorkflow Profile

ECG monitor is a DICOM modality ECG monitor is a DICOM modality Gets modality worklist, notifies modality performed Gets modality worklist, notifies modality performed

procedure step, data in DICOM formatprocedure step, data in DICOM format

Multi-modality synchronization using Consistent Multi-modality synchronization using Consistent Time ProfileTime Profile

Documents

September, 2005Cardio - June 2007 Cardiology Workflow Cath, Echo, and Stress Workflow