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, Alex Towbin, Ken Parsons, Paul Lipton, ...
• Editor: Dawn Cram
• Mentors: Elliot Silver, Kevin O'Donnell
• Contributors: See Support & Resources
• Domain: Radiology

Summary

Increasing amounts of medical imaging is done outside the context of an ordered procedure. Such "encounter-based imaging" needs robust integration, data management and workflow similar to what order-based imaging enjoys via the SWF Profile.

A new Encounter-Based Imaging Workflow Profile could specify how to integrate the devices to capture appropriate context, link to related data, populate relevant indexing fields and ensure the images are accessible and well knit into the medical record.

Experts from Duke, U Miami, Mayo, and Northwestern have already authored several whitepapers outlining this problem and considerations in solving it. It has been the subject of several conference sessions. These experts have agreed to participate in the profile development and contribute their institutional experience tackling this problem and encourage their vendors to participate.

As with SWF, an IHE solution could avoid the costs and incompatibilities of the proprietary solutions that are already starting to emerge.

2. The Problem

Encounter-based Imaging (a burgeoning area of activity) is needs to be supported as well as Order-based Imaging (aka Scheduled Workflow).

EBI needs the same kind of committee analysis we did for SWF:

• Use Cases - what are the different ways encounter-based imaging is performed
• Metadata - what context details need to be captured, stored, conveyed (to support capture, search and review)
• Linkage - what other artifacts/results do the images need to be linked to, and how
• Organization - how is the data organized to meet the needs of its users, how do the images fit into the medical record (sometimes images augment a procedure - surgical video, sometimes images are the procedure - diagnostic)
• Communication - what notifications and "loop-closures" are needed
• Data Transfer - what protocols should be used for the different artifacts

Even with many vendors converging on similar concepts, the SWF exercise in the late 90's was valuable to tease out subtle details, resolve elements of disagreement and confusion in the implementer community, and nail 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.

Costs of Status Quo: Sites have highlighted EBI related problems like:

• Images Absent from or Scattered throughout EHR
• Silo-ization of the medical imaging record
• 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

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

• Order Placement:

• Procedure codes are appropriate for some encounter based imaging but an order per se is not necessary (and would disrupt their 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.

• Loop Closure

• 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.

• 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

• Capture Process

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

• Although downstream usage of the data can't be completely ignored.
• 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)

History: At SIIM 2016, Dawn Cram, Chris Roth and Alex Tobin gave presentations highlighting the issue and Elliot Silver recognized a profile proposal in the making.

3. Key Use Cases

• 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 Video (e.g. Surgery, the video isn't ordered)
• Sleep Lab Video (More likely to be ordered?)

Use Case 1: Basic Encounter-Based Imaging

Numerous departments capture clinical photos for documentation, follow up care, and in some cases, diagnostics (such as dermascope or OCT). Capture devices include digital cameras, smartphones and tablets and run on platforms including iOS, Android and camera specific operating systems.

Option 1a: Unmanaged capture (bad)

• images lack a source of metadata so only an image is captured lacking important details like:
  • patient demographics, visit/encounter details/context, body part examined
• linking image content in the EHR or HIS, and future retrieval, and multidisciplinary relativity is virtually impossible without cumbersome and sometimes inaccurate manual indexing workflows
• downstream EHR image consumers need this information to know if clicking through a hyperlinked set of images will be valuable for them or not, and having a relevant procedure name helps them greatly decide that.
• many image creators need this metadata for teaching file granularity purposes (to identify a set of images as a specific body part, and differentiate it from other images from the same encounter).
• hospital credentialing people need to see what procedures providers are performing to make sure they are performing in the scope of their work (this was a big issue at one of the contributor institutions)
• providers want to know what kind of case volumes they had, and driving analytics later requires a level of specificity to orders metadata current unavailable without the cumbersome workflows.

Option 1b: Require order placement (bad)

• cumbersome workflow for clinical care providers
  • they must interrupt their clinical workflow to interact with a different system and generate order details, some of which are irrelevant, others should be generated automatically

Option 1C: Encounter-based imaging (good)

• use the systems/information associated with the current patient encounter to generate the needed context details and populate them in the image artifacts created.
• the images (clinical photos) that will be taken are not known prior to the visit, but rather, are at the provider's discretion during the visit.
  • Patient makes appointment for Dermatology visit.
  • Patient arrives for Dermatology visit and is registered/checked in, as a patient class of OP (outpatient)
  • EHR or HIS triggers an ADT^A04 release
  • Provider may or may not decide to take clinical photos of the patient during the visit to document disease processes, pathologies or disorders.
    • If the provider decides to take clinical photos for evidentiary or diagnostic reasons (ie - dermascope), image content may include photos of multiple body parts.

Use Case 2: Surgical documentation

During a surgical case, and pre and post-surgery, various image capture devices/modalities are used to document the procedure and provide diagnostic information required to monitor patient care or ensure xxx during the procedure. Scope video and still images, US (usually performed by anesthesia), external photography (often used by plastics), and ECG monitoring are some of the image content captured pre, during, and post procedure following an encounters based workflow. Orders are not a required element clinically and capture is either at the discretion of the Surgeon, as with video capture, or is inherently part of the procedure itself as with ECG monitoring.

There may be some common needs between this and the Cardiac Cath Workflow profile.

Other imaging may be requested of a diagnostic specialty by the Surgeon pre, during, or post procedure, requiring an orders based workflow, as with x-rays performed by Radiology, OCT performed by Ophthalmology or Neurodiagnostic monitoring.

This creates a two-fold problem where:

• placing orders for the image content performed at the discretion of the provider creates a cumbersome workflow, often requiring manual reconciliation intervention by staff following the procedure
• all imaging associated with the procedure is divided across orders which may not be tied to the surgical visit/encounter, since the orders placed for the requesting department often generate their own visit/encounter.

Additional complexity is noted when the procedure is performed on a patient already admitted as an inpatient. Whereas when an ambulatory surgical patient is registered/arrived specifically for a surgical visit/encounter an ADT^A01 (admit) or ADT^A04 (registration), depending upon EHR or information system and technical build) will be triggered and can follow the same workflow as with an outpatient Dermatology visit, an already admitted inpatient will trigger an ADT transfer which does not include the encounter/visit number of the admitting surgical department.

Use Case 3: Inpatient Imaging

Photos and other images captured on inpatients by unit. Orders are not a required element clinically and capture is at the discretion of the care provider and may be used to document various states of wounds, bedsores, or other disorders.

The DICOM MWL SCP requires update of patient location following unit transfers for MWL distribution. The Storage SCP requires update of patient location following unit transfers and retention of all unit locations through an admission encounter for reconciliation workflows and including exception workflows.

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

Relevant Whitepapers:

• Order-based vs Encounter-based Imaging - JDI Whitepaper
• A Foundation for Enterprise Imaging - JDI Whitepaper
• The Workflow Challenges of Enterprise Imaging
• SIIM-HIMSS Enterprise Imaging Workgroup - White Papers
• Internet-Ready_SWF_-_Proposal started to consider encounter-based imaging as well.

5. Technical Approach

New integration profiles needed

• Encounter-Based Image Workflow Profile, modeled in part on SWF.b (order-based workflow)

Impact on existing integration profiles

• Once we see what EBIW looks like, figure out if there are useful groupings or options in other profiles.

Existing actors

• Likely reuse several from SWF.b, PAM, etc.

New actors

• Encounter-oriented Modality Actor?

• If the profile needs to isolate requirements specific to Encounter-mode

Existing transactions

• Might re-use several SWF.b and PAM transactions for storage, MPPS, patient registration.
• PDQm, WIC and MHD-I transactions could also be useful or we could group with those profiles.

New transactions (standards used)

• Likely a few new transactions that are variations of existing transactions, e.g. Patient Encounter Management (ITI-31) with additional requirements to queue up the metadata for image capture.

Breakdown of tasks

• Digest the Whitepaper Collection

• Decide "target market"

• Greenfield-sites vs existing; new tech vs adapt old tech (entrenched product habits); "maturity" of industry

• Discuss/Confirm use case list to decide in/out of scope and details
• Extract/model the technical use cases

• Finalize scope to keep one year tractable (what now, what left til later)
• Decide what parts of SWF to borrow (same submission and commitment of images)

• Establishing encounter/patient/context, conveying metadata, capturing/storing image data, indexing/archiving images, finding/accessing/using images
• Whitepapers provide a starting point for this too.

• Get a summary writeup (1 or 2 page) from Duke, Miami, Mayo of their approach to compare/contrast

• Consider if alternative mechanisms are warranted for metadata transfer to modality

• HL7, DMWL, both? FHIR? IHE PDQm? SMART?

• Analyze Procedure metadata and linking to other results

• e.g. surgical report, accession #s for other ordered procedures

• Review DICOM Tags and semantics in the context of EBI

• Consider mapping semantics between JPEG tags and DICOM tags (need acquisition date, be careful not to use IPC modification date)

• Decide how to bring these artifacts into clinical notes/clinical record/documentation workflow

• Separable task: Review other profiles used with SWF (PDI, XCA-I, BIR, IRWF, etc) for EBIW compatibility

• e.g. Dermatology patient brings USB stick with some JPEGs for Encounter-based import using IRWF
• List conventions like "Use admit date as the procedure date"; "Find procedure context by searching EMR for entries at/near image capture time"

• Separable task: Diagram Diagnostic Imaging, Procedural Imaging and Evidence Imaging

• Delineate EBI vs Enterprise Imaging vs mobile vs consumer vs lightweight vs web APIs vs ...

• Separable task:

6. Support & Resources

The work already done in the SIIM-HIMSS Enterprise Imaging group and elsewhere has already coalesced a number of collaborators, many of whom have helped on the proposal and are interested in working on the profile.

Already joining the proposal preparation calls:

• Healthcare: Chris Roth (Duke), Dawn Cram (U Miami), Ken Persons (Mayo), Matt Hayes (Northwestern),
• Vendors: Dan Rice (Ricoh USA), David Clunie (Pixelmed), Elliot Silver (McKesson), John Hansen (Merge), Kevin O'Donnell (Toshiba), Kinson Ho (McKesson), Mike Bressack (Karl Storz), Rob Mitchell (Merge), Thomas Pickard (ImageMoverMD)

In addition to the whitepapers, the Healthcare participants bring their experiences (clearer understanding of the needs, things that did and didn't work well) from their existing projects to tackle this in practice.

7. Risks

• Scope risk - taking on too much work overall - nail down a useful chunk for this cycle early on
• Niche risk - solving an instance of the problem instead of the broad class

• IHE Rad cochairs will reach out to IHE imaging (Eyecare, Cardiology, Pathology, Endoscopy, Dental) to make sure they are engaged in the requirements and work. Historically they have successfully borrowed heavily from IHE Rad work.

• Option risk - trying to incorporate/allow too many different mechanisms/technologies - needs the usual IHE attempt to balance inclusion against convergence to reduce the development/maintenance/coordination load.
• EMR Participation - this profile must consider EMR interactions so we need their participation but that's traditionally been sparse in IHE Rad.

• Ken Persons and Thomas Pickard will reach out to Matt Doyle from Epic
• Mike Bressack can talk to Cerner
• Elliot Silver will talk to McKesson EMR
• Rob Mitchell will contact Julie Pekarek <jpekarek@us.ibm.com> to see if the E-Orders Coalition can be used as a recruiting/engagement channel

• Reach out to IHE (imaging) - Eyecare, Cardiology, Pathology, Endoscopy, - Cochair Action Item

8. Open Issues

• Issue: Order-based but finesse auto-placement of the order VS work from clean/minimal slate?
  • Possible order-based approach
    • Arrival/Registration of the patient triggers an HL7 ADT^A04 event containing visit information
    • DICOM MWL SCP generates an encounter worklist entry based on the HL7 ADT^A04
    • Capture device (DICOM MWL SCU) at the visit/encounter location queries the worklist and uses Patient/Visit rather than Patient/SPS/Service Request to populate the images
    • Consider required Order-based imaging attributes in an Encounter-based context:
      • PatientID (0010,0020) and PatientName (0010,0010) populated as usual
      • Accession number (0008,0050) will/may be blank or null
      • Admit date/time (0038,0020)/(0038,0021) replaces scheduled procedure date/time (0040,0002)/(0040,0003)
      • Selection of body part (using DICOM codes) is done on capture device.
      • ScheduledProcedureStepSequence (0040,0100) must not be empty
      • ScheduledProcedureStepDescription (0040,0007) better known by acquisition device (e.g. body part/region/etc selection also used in series and/or study description)
      • Visit/encounter number (admission ID (0038,0010)) used by SCU in image headers to Storage SCP
      • For multiple body part selection, should each body part be a new Series, or a whole new Study?
    • If a new "encounter" is spawned for each acquisition, how do you relink those that are really part of the same actual encounter
  • Possible non-order-based approach

• Should we design for gateway devices
• How are images encoded

• DICOM only, separate img & metadata, both?
• Consider single image, image sets, video (send vs streaming)
• Consider both capture and downstream display apps and integrating with the clinical review workflow
• What does DICOMweb buy us for storing DICOM and delivering/presenting consumer formats?

• Should imags be linked to reports or pasted directly into them?
• What is the scope of uniqueness for Encounter/Visit numbers?

• And do they link to Accession#s for inpatients?

• Issue: Is this a "Radiology Profile?
  • Historically 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

• Issue: Should this be multiple profiles
  • It could be a grouping of profiles rather than a complete profile
    • e.g. EBIW + WIC + Documentation WF and maybe something where SWF & EBIW meet

• Issue: Bias toward older (DICOM/HL7) VS newer (DICOMweb/FHIR) technologies?
  • Consider focusing primarily/exclusively on FHIR and DICOMweb?

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

• Issue: Assume the acq apps follow the profile in detail VS Assume the VNA do most of the work

9. Tech Cmte Evaluation

<The technical committee will use this area to record details of the effort estimation, etc.>

Effort Evaluation (as a % of Tech Cmte Bandwidth):

• 35% for ...

Candidate Editor: Dawn Cram