Encounter Based Imaging Workflow - Proposal

1. Proposed Workitem: Encounter-Based Imaging Workflow (EBIW)

• Proposal Editor: Kevin O'Donnell
• Proposal Contributors: Elliot Silver, Christopher Roth, Dawn Cram, ...
• Editor: TBA
• Contributors: TBA
• Domain: Radiology

2. The Problem

Encounter-based Imaging is presented here as an alternative to Order-based Imaging (aka Scheduled Workflow).

To draft SWF, the committee did a rather involved analysis including:

• Use Cases - what are the different ways order-based imaging is performed
• Metadata - what context details need to be captured, stored, conveyed
• Linkage - what other artifacts do the images need to be linked to, and how

How are the images spliced into the medical record - what are the patterns of capture, search and review

There has to be a context and a link to a "result"

• Organization - how is the data organized to meet the needs of its users
• Communication - what notifications and "loop-closures" are needed
• Data Transfer - what protocols should be used for the different artifacts

Encounter-based Imaging is a burgeoning area of activity, but a similar cross-vendor exercise has not been done.

At the time (late 90's), even with many vendors converging on similar concepts, the SWF exercise was valuable in teasing out subtle details, resolving elements of disagreement and confusion in the implementer community, and nailing down various technical details. It contributed to an extended period of robust departmental interoperability.

An EBI exercise and profile could provide similar benefits in the expanded medical imaging community. It might also avoid silo-ization of the medical imaging record.

Sites have highlighted EBI related problems like:

• Images Absent from or Scattered throughout EHR
• Images Not Available to Care Team
• Images Placed in Paper Record or Scanned into EHR
• Limited Access to Images within EHR Context
• Limited Data Sharing w/ Acquired & Affiliated Hospitals

Gaps (e.g. relative to Scheduled Workflow):

• While image metadata achieved through the placement of an order is unarguably necessary, requiring the placement of an order is not necessary to achieve the same end result when images are captured following an encounters based workflow as addressed in this profile proposal.
• Procedure code is appropriate for some encounter based imaging but an order per se is not (and would disrupt their workflow)
• Data flow should get the same end result as if the clinician placed the order

• Want to support the same analytics, access/indexing of the imaging

• Consider focusing initially on the capture process (there is some risk in the varied usage needs in the different departments/use cases)

• But usage will need to be addressed one way or the other.
• What is the end result of the first profile - e.g. what is passed to the EHR to index, find, display, provide to physicians
• A big gap is labelling/tagging to know the procedure behind the encounter image
• Body part is not well populated (2,000 for some dermatology groups, 1 for others) - device should provide it, but often not well done, also tags are lacking for some purposes
• Sharing tags with order-based makes it easy to pair, but need it to be easy

• Will need to be clear what we will/will not do (e.g. start with standard tag/location but standardizing procedure codes is not typically done yet)

• In Order based there is an order and a report to close the loop

• EBI has multiple kinds of results - endo images, surg notes, all linked to the procedure
• EMR can backfill orders, but the cross result linkage on a different system is a problem, esp when exchanging with other institutions
• DICOM Study is a grouping method, but with a JPEG on a disk, the context/linkage metadata is missing.

3. Key Use Case

<Describe a short use case scenario from the user perspective. The use case should demonstrate the integration/workflow problem.>

<Feel free to add a second use case scenario demonstrating how it “should” work. Try to indicate the people/systems, the tasks they are doing, the information they need, and hopefully where the information should come from.>

EBI Examples:

• Dermatology
• Wound Care/Management
• Infectious Diseases
• Burn Care
• Ophthalmology
• Otolaryngology
• Plastic Surgery
• Podiatry
• ER/Trauma
• Dentistry
• Sports Medicine
• Pathology Samples
• Point of Care Ultrasound
• Nursing/Clinic Photography
• Procedure (Surgery?) Video

• The video isn't ordered. Does Surgery fit the encounter model well?

• Sleep Lab Video

• More likely to be ordered?

4. Standards and Systems

Potential Systems

• Image Acquisition Devices (both Lightweight and Heavy/Integrated)
• Image Archiving Devices
• Electronic Medical Record Systems
• Patient Management Systems?

Potential Standards

• Existing Profiles: PAM, WIC, SWF, MHD-I, XDS*, CARD IEO
• DICOMweb
• DICOM (DIMSE)
• HL7
• FHIR
• Consumer formats: JPEG, MPEG, PDF, etc

5. Discussion

More analysis here: Order-based vs Encounter-based Imaging - JDI Whitepaper

Technical approach thoughts

Perhaps new EBIW profile that parallels SWF

Perhaps expand WIC?

Should this be multiple profiles - e.g. EBIW + WIC + Documentation WF and maybe something where SWF & EBIW meet

Might also be a review of other profiles used with SWF (PDI, XCA-I, BIR, IRWF, etc) to make sure they work with EBIW also

Derm patient brings a USB stick with some JPEGs, how does that flow through IRWF but as an Encounter-based import?

List of conventions

Use admit date as the procedure date

Consider focusing primarily/exclusively on FHIR and DICOMweb?

This goes beyond the definition of Radiology, however RAD profiles have provided a basis for other imaging domains

RAD is the closest thing IHE has to a general Medical Imaging domain

Have TC members who understand the solution technologies well

Need contributors who understand the use cases well

Would be advisable to solicit collaborators from Cardiology, Eyecare, and perhaps ITI

SIIM-HIMSS Enterprise Imaging Workgroup - White Papers

Should the scope include "self-captured" data from patients at home or remote?

Review of DICOM Tags and semantics in the context of EBI

Continue to delineate EBI vs Enterprise Imaging vs mobile vs consumer vs lightweight vs web APIs vs ...

Consider categorization into Diagnostic Imaging, Procedural Imaging, and Evidence Imaging (document current patient state)

A Foundation for Enterprise Imaging - JDI Whitepaper

See Also

Internet-Ready_SWF_-_Proposal