Transcript Canada Health Infoway Update - DICOM Standards Committee Dec

UPDATE
Adoption of standards to share
diagnostic imaging information
in the pan-Canadian EHR
DICOM Standards Committee – December 4, 2008
Presented by
Eugene Igras
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
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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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Value Proposition
• 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
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Common Approach
Adherence to Infoway DI Program vision
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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
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Provide access to a longitudinal record of patient DI history
Conformance & Compliance to Standards
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Architecture:
Privacy & Security:
EHRS Blueprint v2
Jurisdictional privacy protection legislation
Privacy & Security Requirements & Architecture
ISO/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 security
Other 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
EHRS Blueprint v2
Privacy & Security
Privacy Legislation
Healthcare
Content, Messaging, Terminology
HL7/CDA, DICOM, SNOMED CT
LOINC, ICD-10-CA…
IHE Integration Profiles
XDS/XDS-I,
PIX/PDQ, ATNA…
Electronic Business
Standards
ebXML, Web Services
Internet Standards
HTML/XML, HTTP,
PDF, JPEG, MIME, UTF-8 …
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Scope of the XDS Affinity Domain in the EHR
Context
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Client
Registry
Ancillary Data & Services
Outbreak
Mgmt
PHS
Reporting
Provider
Registry
Location
Registry
Business
Rules
EHR
Index
Terminology
Registry
EHR Data & Services
Shared
Health
Record
Message
Structures
Diagnostic
Imaging
Health
Information
Laboratory
Normalization
Rules
Longitudinal Record Services
Security
Mgmt
Privacy Data
Hospital, LTC,
CCC, EPR
Physician
Office
EMR
Config
Services
Common Services
Communication Bus
HIAL
Public Health
Services
POINT OF SERVICE
Drug
Information
Data
Warehouse
Pharmacy
System
Public
Health
Provider
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Pharmacist
Radiology
Center
PACS/RIS
Radiologist
Lab System
(LIS)
Lab
Clinician
Physician/
Provider
Physician/
Provider
EHR
Viewer
Physician/
Provider
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Infoway and IHE
• Leverage and implement IHE integration profiles
 DI
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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
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 Provide resources to IHE International through IHE Canada
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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)
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Patient Identity
Source
• Feeds identity of known patients to
Document Registry
Patient Identity Feed
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Stores and maintains metadata
Creates and maintains links to documents
Supports document search (query)
Enforces policies at the time of registration
Document
Registry
Query Registry
Register Document Set
Document
Source
Provide & Register
Document Set
• Submits document sets
• Creates and submits documents
description (metadata)
Document
Repository
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Document
Consumer
• Initiates
search (query)
• Initiates
retrieval of
documents
Retrieve Document
Stores documents & metadata
Creates & maintains document URI (Uniform Resource Identifier)
Forwards metadata for registration
Supports document retrieval
XDS – Actors and Transactions
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Patient Identity
Source
• Feeds identity of known patients
to Document Registry
Patient Identity Feed
• Receives, stores & maintains metadata
• Creates and maintains document index
• Supports document search (query)
• Enforces policies for registration
Document
Registry
Query Registry
Register Document Set
Provide & Register
Document Set
Imaging
Document
Source
• Creates text / PDF report and/or
imaging manifest documents
• Submits document sets with
document description (metadata)
• Supports retrieval of DICOM
objects
Document
Repository
Retrieve Document
WADO Retrieve
• Stores documents and metadata
• Enhances metadata with document
URIs to enable retrieval
• Forwards the enhanced metadata for
registration
• Supports document retrieval
Document
Consumer
Imaging
Document
Consumer
• Initiates search and
retrieval of
documents
• Initiates retrieval
of DICOM objects
referenced within
the manifest
Retrieve Images
Retrieve Presentation States
Retrieve Reports
Retrieve Key Imaging Note
Retrieve Evidence Documents
XDS-I – Actors and Transactions
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Patient Identity
Source
Mod
PACS
Document
Registry
Document
Consumer
Document
Repository
Imaging
Document
Consumer
Mod
Imaging
Document
Source
DI Repository (DI-R)
Mod
• Stores and maintains a lifetime record of relevant
DI data including
RIS
Mod
DI-R
Mod
PACS
• Images and reports
• Key image notes, image processing results & overlay
information
Mod
• Presentation states and other evidence documents
Mod
• 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
Real-world Systems
vs. XDS-I Actors
• Maintains quality and integrity of data
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Patient Identity
Source
Imaging
Document
Source
Document
Registry
Document
Consumer
Document
Repository
Imaging
Document
Consumer
Mod
PACS
Mod
Mod
DI-R
PACS
Mod
Mod
RIS
Mod
EMR
Viewer
Real-world Systems vs. XDS-I Actors
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Issues To Be Addressed
(1)
• How to ensure interoperability of XDS-based systems with other
solutions that handle discrete data (e.g., Lab, Drug)?
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How does an XDS Registry for DI evolve into and/or co-exist with other
indexing scheme?
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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?
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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
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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
Current State
Content & Format
• Registry entries - ebXML
Terminology/Codes
• To be standardized
Document Sharing
• Document Registry
Content & Format
• Images & Manifests - DICOM
• Reports - DICOM SR, HL7 CDA R2
Terminology/Codes
• Implementation-specific
Storage & Retrieval
• DI-rs
• Doc Repositories
POS
Information
Systems
PACS
XRay
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RIS
CT
Content & Format
• Images & Manifests - DICOM
• Reports - DICOM SR, HL7 CDA R2
Terminology/Codes
• Adopted / Adapted / developed
• Harmonized with pan-Canadian
Terminology
Normalization
HIAL
Acquisition
Modalities
Future State
HIS
MRI
EMR /
Viewer
US
Content & Format
• Images - DICOM
• Reports - DICOM SR, Text, PDF
• Discrete Data
Terminology/Codes
• DICOM (SNOMED RT, LOINC)
• ICD-10/10CA
• CCI
• HL7 v2.x and v3
Content & Format
• Images - DICOM
• Reports - DICOM SR, Text, PDF
• Discrete Data
Terminology/Codes
• DICOM (SNOMED CT, LOINC)
• ICD-10CA, ICD-PSC
• HL7 v3
Content & Format
• Images – DICOM
• Discrete Data
Terminology/Codes
• DICOM (SNOMED RT, LOINC)
• ICD-9/10
• HL7 v2.x
Content & Format
• Images – DICOM
• Discrete Data
Terminology/Codes
• DICOM (SNOMED CT, LOINC)
• ICD-10-CA
• HL7 v3
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Terminology Standardization:
Candidate Data Entities
Patient
Provider and Delivery Site
• Procedure Requestor, Facility
• Request Recipient, Service Delivery
Site
Request
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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
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Clinical Synopsis
Problem/Diagnosis
Observation
Adverse Reaction
Alert
Severity (of problem, diagnosis
or allergic reaction)
DI Study
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Study & Series Details
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Image Instances
Report
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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
authorRoleDisplayName /
Document Submission Set Attributes
Service Attributes
practiceSettingCode / Imaging Document Source
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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XDS-I Value Proposition
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Integrates information
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Eliminates fragmentation of data captured and recorded in stand-alone systems through
integration of data across organizations and systems
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Improves quality of DI information (accuracy, completeness, consistency)
Addresses patient privacy and data security in a comprehensive and consistent manner
Improves Access
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•
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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

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Reduces radiation exposure
Reduces medical errors
2008 Canada Health Infoway Inc.
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2008 Events
• Infoway Partnership Conferences
 April 2008 (Toronto)
 October 2008 (Montréal)
Standards Collaborative Working Groups
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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
2008 Canada Health Infoway Inc.
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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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2008 Canada Health Infoway Inc.
Thank you!
Infoway Standards Collaborative
Contact: Grant Gillis ([email protected])
Infoway Solution Architecture Group
Contact: Eugene Igras ([email protected])
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