Transcript radiology & it - Villanova University

RADIOLOGY & IT
Merger or Collision ?
David P. Mayer, MD,MS,FACR
Clinical Professor of Radiology
Drexel University College of Medicine
RADIOLOGY & IT
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OUTLINE
What is Radiology?
Connectivity & Image
Management
Alphabet Soup: DICOM;PACS
and IHE et al.
The Future of IT & Radiology
Summary
Diagnostic Radiology
Re-Defined: The use of various
imaging tools to examine the body
in order to guide patient treatment
There is an information chain that
connects the patient and referring
Doctor to the Radiology Department
which responds with useful diagnostic
information
“Radiology is an applied IT field”
Diagnosis?
“You’ve got Questions,
We’ve got answers!”
Email &
Fax
Results
Digital Image:
A Dx Puzzle
Radiology: “Information Steps”
The
Radiologist
Works HERE!
Imaging Tools:
CT Scanning (CAT Scan)
MRI (Magnetic Resonance Imaging)
Ultrasound
Angiography & Interventional
X-ray & Fluoroscopy
Mammography & etc.
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CT Scanning
Ultrasound
MRI
Diagnostic Radiology: IT Issues
Imaging Challenges:
Xs Digital Data (225K Cases/yr=3Tb/yr)
Future = Video Display (Film is “dead”)
Digital transmission via Inter and IntraNet
Disseminated Access is Required
Demands  Xs Bandwidth; Redundancy; 3-5
Megapixel Display @ >500:1 contrast; Long
term Image & Data Archival; Rapid Access
with report info & Demographics;
Standardized format- i.e. DICOM; Image
Manipulation tools; etc.
Computer Data
Byte
= 8 bits or 256 shades of gray
Kilobyte = 1024 Bytes
Megabyte = 1024 Kbytes (KB)
Gigabyte = 1024 Mbytes (MB)
Terabyte = 1024 Gbytes (GB)
Average Word processing Doc < 100KB
Average (Digital) Radiology Exam =25MB
Single Digital X-Ray =10 MB
Network Standards
PACS data loads are huge
Requires high speed/high capacity
network
@ 100 – 1000Mb/sec
MHS data volume/year ~ 3TBytes/yr
Data Multiplication: exams move
many times across the network
Diagnostic Radiology: IT Issues
Read-to-write ratio: In healthcare because many different
medical professionals repeatedly access the same data.
Data lifecycle: Process by which you can move data from online
storage, to near online, to tape, to archive—is specific to
healthcare.
Recall data: Captured years earlier & Accessed very quickly.
Disparate data: Generated, captured, and stored in different
locations & different applications, with different Dx modalities.
Requirement: Link the images with the patient's chart, pharmacy
records, billing information, etc..
Health Insurance Portability and Accountability Act
(HIPAA):
1. Providers must communicate information between different
stakeholders in the system including doctors, hospitals,
insurance companies, and the Federal government
2. Information must be secure at every step in the process.
Diagnostic Radiology
PACS: “Picture Archival &
Communication System”
DICOM: A Digital Communication
Standard between Diagnostic
Modalities & PACS
IHE: “Integrating the Healthcare
Enterprise”
“Radiology is an applied IT field”
PACS & Diagnostic Radiology
PACS: “Picture Archival &
Communication System”
Provides a means to move, display
and store images generated by
radiology or other hospital depts.
Radiology “product”: The
interpretation of an image
Interpretations MUST be timely!
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PACS
“Any image, anywhere,
anytime – and fast”
Northwestern Memorial Hospital,
Chicago, Illinois
PACS
Key Components:
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Modality Interfaces
Network Backbone
Database Management System
Image Management System
Long term Archive
Diagnostic Workstations
Clinical Workstations
Web server Access to images
PACS
Advantages: Redundant Archives; Cost savings: Film,
Chemicals, Storage Space; Manpower, & Time !!!
Potential Increased productivity
Reduced Turnaround time
Reduced Retakes & Lost Films
Easier consultation & Stat reporting
Disadvantages: Large Capital $ outlay; Requires new
work paradigm; Clinician cooperation?; Reinvestment
are required
Cultural shift: Age and Medical Specialty
dependent
PACS: 2006-7
Hospitals w/o PACS:
The question shifts from “if” to “when”
Approx. 50% of US Hospitals
Hospitals w/ PACS:
Upgraded systems:
IHE Networking
Upgraded data handling capabilities
Upgraded computers & monitors to
LCD’s
PACS: 2006-7
Upgraded systems:
99.99% Network & PACS Uptime:
Redundancy; “self healing”
99% uptime = 1 failed day/100d
Requirements:
HL7; DICOM; IHE standards
HIS+RIS+PACS:
“seamless” & “bidirectional”
Modality “worklist” (MWL) etc.
Wireless systems??
PACS: 2006-7
Upgraded systems:
PACS is “Not just for Radiology”:
Cardiology & Pathology E.M.A.
[“-ologies” : common data storage]
Data Storage requirements:
e.g. MD-CT: 64+ slices; Digital Mammo;
ultrasound video clips; High res. MRI;
Faster Spinning media archive access
3D renderings
PACS: 2006-7
PACS: 2006-7
Upgraded systems:
“Off the shelf” hardware
“Software only” solutions
Mergers:
Images with Voice Recognition
generated reports
Hospital-wide Image & Data
Clinical Data w/ Images
Surgical templates w/ images
Healthcare IT Issues
IT Government Oversight:
HIPAA: Audit trails required
FDA
State & Local Health Regulations
HIPAA:
1. Electronic Data format standards:
2. Privacy: Integrity & Confidentiality of
patient info. Flexibility vs. privacy
3. Security: Storage, Transmission and
Display Data protection.
*PHI (Protected Health Information)
requires User Authentication
*Every data access must be logged
*Secure Storage & Transmission
PACS: 2006-7
Upgraded systems:
HIPAA Compliant security systems
Site requirements:
PACS administrator
Voice recognition Administrator
Teamwork:
Healthcare IT Dilemma
Securing clinical Information systems
“CIA Triad”: Confidentiality; Integrity &
Availability
Confidentiality: Staff & Pt. Data must be
protected
Integrity: Correct & Complete data;
Legal & HIPAA: sanctions
Availability: Timely and secure access;
Mission criticality: 24/7/365
Tradeoff:
Protected Info. vs. Ease-of-use
HIPAA – Its Impact on Radiology
Cost estimates: $2B-43B
Security for Radiology Reports & Images
Digital environment:
Authentication: “Who are you” ?
Encryption: “Encode the data”
Access: “Need to know” basis
DICOM
(Digital Image Communication in Medicine):
A standard for image communication in the
medical field, that is supported by most
vendors of digital imaging devices (CT,
MR, digital X-Ray, ultrasound, etc.).
DICOM standard includes a detailed description
of the patient information with the images
and the way the images are sent
between different devices:
e.g. between a CT scanner and a PACS
(Picture Archival and Communication System)
DICOM 3 (Current level):
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ACR & NEMA: Formed joint committee
to develop Digital Imaging
standards
Other participating organizations:
IEEE, HL7, ANSI, JIRA, etc.
Allows Gateway to HL7, www
HIS/RIS – PACS Communication:
 Optimal: Bidirectional interface
between HIS/RIS & PACS
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Minimizes data entry errors
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Est. 15% of medical data entries have errors !!!
Faster reporting and image availability
Pre-fetching of old reports & exams
Modality Work List: Data   Scanner
DICOM
Note:
“
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Gary Wendt, MD
i.e. The devil is in the details !
DICOM http://medical.nema.org/
Many Capabilities are included under the
“DICOM” name [e.g. 12 DICOM “Classes”]
DICOM Verification Service Class
DICOM Storage Service Class
DICOM Query/Retrieve Service Class
DICOM Study Content Notification Service Class
DICOM Patient Management Service Class
DICOM Study Management Service Class
DICOM Results Management Service Class
DICOM Print Management Service Class
DICOM Media Storage Service Class
DICOM Storage Commitment Service Class
DICOM Basic Worklist Management Service Class
DICOM Queue Management Service Class
RIS
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Radiology Information System
Patient registration order entry
Data analysis
Management reporting
Scheduling & Billing data
Exam & Patient tracking (incl. Mammo)
Transcription
Integration: IHE; HIPAA; PACS
RIS
Radiology Information System
8. Patient info merges w/ Images:
Allergies; lab values & Hx
9. Internet linkage
10. Mammography: (Unfunded federal
mandate) MQSA Regulations
DICOM
Note:
All new imaging modalities (e.g. CT,
Ultrasound, MRI, Digital X-Ray etc.) are
available with DICOM compatibility
Older imaging equipment require ($$$)
upgrades or interfaces to the DICOM std.
There are numerous “levels” or “classes”
to DICOM compatibility
DICOM continues to evolve  IHE
What is IHE?
"Integrating the Healthcare Enterprise" (IHE),
is a multi-year initiative, sponsored by the
Radiological Society of North America (RSNA)
and the Healthcare Information and
Management Systems Society (HIMSS), whose
single purpose is to bring together medical
equipment and information products from
different manufacturers for developing an
efficient and seamless workflow between
multiple products from multiple vendors
while improving the clinical and
economic efficiencies of hospital-wide
connectivity.
Note that the IHE is not a
Standards organization. The IHE
uses existing standards, such as
DICOM and HL-7, for developing
workflow solutions for the
healthcare enterprise
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Partners
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Supporting organizations providing
expertise, technology and guidance
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American College of Physicians
Centers for Disease Control & Prevention
CDISC
Duke University Medical Center
Food & Drug Administration
OASIS
Massachusetts Medical Society
National Institute for Standards & Technology
UC David, Medical Informatics
Participants
IHE
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Integrating the Healthcare Enterprise
Multi-year initiative
Creates framework for seamless passage of
health information
Provides framework for implementing
relevant standards: e.g. “Connectathon”
1998: RSNA & HIMSS provides leadership
Drives the adoption of standards to address
specific clinical needs
Does NOT create new standards
Ensures higher level of practical
interoperability
Clinical Domain Expansion: Cardiology,
Medication Mgnt. And Clinical Engineering
From Continuity of Care scenario
Imaging Integration, Tumor Reporting, Claims Processing
Imaging
RIS
Dictation
Server
Repository
PCP
EMR
eForms
Workstation
Payer
Broker
Broker
Registry
Pathology
Tumor
Registry
Surgery Hospital
Brokered Claim; Registry Discovery
For patient chart and Tumor Registry; CCR back to PCP
Continuity of Care (e.g.
Tumors)
Imaging Integration, Tumor Reporting, Claims Processing
EMR
Imaging
Virtual EHR
PCP
Transform
eForms
Tumor Registry/repository
Virtual EHR
Hospital
Secure
transport
Lab
EMR
EMR
Dictation
Imaging
Highlights
Firsts:
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Annotated Electro-cardiogram, submissions
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CDA College of American Pathology tumor report,
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CDA Continuity of Care Record (CCR)
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Clinical Document Architecture Release 2 (ballot draft)
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Distributed, standards-based decision support
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Document-based HIPAA claims attachments
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End-to-end, standards-based electronic clinical
trial data submission
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End-user Authentication profile
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Hyperlink between electronic document and
PACS image
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Nationally Notifiable Disease report
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Open-source metadata registry for ubiquitous
access to distributed information
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Patient Information Cross-reference profile
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Patient Synchronized Applications
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Retrieve Information for Display profile
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Re-use of electronic clinical documents to support a
claim
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Structured Product Labeling
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Third-party brokered claims attachments
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Version 3/CDA Templates
The HL7-IHE Demo…
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Creates the future of machine
interoperability through human
interoperability
• We identify barriers to Interoperability
and
• And we engineer breakthroughs.
IHE INTEGRATION PROFILES
IHE Components (1)
Scheduled Workflow : flow of information for
the key steps (registration, ordering,
scheduling, acquisition, distribution and
storage)
 Patient Information Reconciliation method for
reconciliation of information for unidentified or
mistakenly identified patients
 Consistent Presentation of Images ensures a
consistent view of images and annotations
across different displays and media
 Presentation of Grouped Procedures
management of images for multiple procedures
in a single acquisition step (e.g. spiral CT: chest
& abdomen)
 Access to Radiology Information mechanism for
sharing radiological images and information
across department boundaries
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IHE Components (2)
Key Image Note addition of textual notes and
pointers to key images in a series
 Simple Image and Numeric Reports standard
way of creating, managing, storing and viewing
reports that include images, text and numerical
values
 Charge Posting information about procedures
available to billing systems allows consistent
and timely billing of technical and professional
charges
 Basic Security establishes enterprise-wide
security infrastructure for meeting privacy
requirements (such as HIPAA)
 Post-processing Workflow supports workflow
steps such as Computer-Aided Detection (CAD),
Imaging Processing, and Image Reconstruction
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Teleradiology
Teleradiology programs allow the sending
of pictures between different stations in
different locations.
MR Image from the brain
Teleradiology
Teleradiology programs allow the sending
of pictures between different stations in
different locations.
CT
MRI
X-Ray
Productivity in Radiology: Why?
Procedure volume increasing by 3.5-5%/yr
Supply of radiologists increasing by 2%/yr
Between 1995 - 2000
MRI Exams increased by 19%:
CT Exams increased by 10%:
Case complexity & Slices: 64 slice CT !!!
Clinical expectations are also increasing !!
Diagnostic Radiology
SUMMARY: The Future of Medicine
Digital based image acquisition,
interpretation and distribution
Continued integration of imaging
with demographic & clinical data
Computer Assisted Diagnosis (CAD):
[the real “Tricorder”]
Diagnostic Radiology
SUMMARY: The Future of Medicine
Computer Assisted Diagnosis (CAD):
[the first real “Tricorder”??]
Working CAD systems:
Mammography
Clinical Trials:
CT Scanning: Chest
Chest X-Rays
The Tricorder Site, 2001, www.tricorder.cjb.net
Questions ????
Office: 610-237-4353
Pager: 888-966-9716
[email protected]