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: TBA
Contributors: Dawn Cram, Christopher Roth, (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 Cases

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?

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

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

Technical Approach Ideas

One Proposed solution involves:

A DICOM MWL SCP uses the visit information associated with the HL7 ADT^A04 event triggered upon registration/arrival of the patient to generate an encounter worklist entry
The 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
Considering attributes typically required in Order-based imaging in an Encounter-based context:
- Admit date/time (0038,0020)/(0038,0021) replaces scheduled procedure date/time (0040,0002)/(0040,0003)
- PatientID (0010,0020) and PatientName (0010,0010) populated as usual
- ScheduledProcedureStepSequence (0040,0100) must not be empty, and must contain: ScheduledProcedureStepDescription (0040,0007) (not applicable in encounters-based workflow – not ideal but can provide generic description overwritten by acquisition device based upon series and/or study description from body part/region/etc selection)
- Accession number (0008,0050) will/may be blank or null
- Visit/encounter number (admission ID (0038,0010)) will be provided to the SCU and passed back to the Storage SCP (archive)
- Selection of body part (according to DICOM body part standard) is available on capture device.
- Multiple body part selection can generate a new SUID associated with the image content for each body part selected, and passed to the Storage SCP, along with body part and study description based upon capture device selections.