Encounter Based Imaging Workflow - Proposal

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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: TBA
  • Contributors: Dawn, (Alex), Ken, Matt, Paul, (Louis), Elliot, (recruiting some of the acq app vendors and EMRs)
  • Domain: Radiology

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 (sometimes images augment a procedure, sometimes images are the procedure)
  • Organization - how is the data organized to meet the needs of its users, how do the images fit into the medical record
  • 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.

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 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)


3. Key Use Case

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?

<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.>


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

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.

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 (need to also know what was being done at the time of the imaging - procedural context)
Consider focusing primarily/exclusively on FHIR and DICOMweb?
If a new "encounter" is spawned for each acquisition, how do you relink those that are really part of the same real encounter
Issues with semantics clarity between JPEG tags and DICOM tags - acquisition date is what is needed. Be careful not to use modification date from IPC. Standardized mapping needed.
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
Do we assume the acq apps follow the profile in detail or does the VNA do most of the work
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

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