Image Enabled Office Profile - Work Page

Editor:

• Harry Solomon (GE)

1. Summary

An increasing number of clinicians have imaging and diagnostic equipment and electronic medical records in their offices. This equipment needs to be integrated into the office environment workflow, and the imaging results need to be seamlessly integrated into the EMR. Moreover, the office EMR needs to be able to exchange reports and associated images with other providers' EMR systems.

The workflow and result integration efforts of IHE Cardiology have to this point been directed primarily towards the in-patient environment. However, there is a critical need for simplified integration in the ambulatory environment.

Note that the systems in an office environment must in may ways be more technically sophisticated than in an in-patient environment, as they must operate with less IT-savvy human supervision, and combine features that would otherwise be distributed across multiple systems.

2. The Problem

The office IT environment

Ambulatory office Practice Management and Electronic Medical Record (PM/EMR) systems are integrated systems incorporating functions for patient management, prescription (order entry), scheduling, and charting / clinical reporting. However, PM/EMR systems do not typically handle imaging and image management functions, which are typically provided by a different set of vendors. One problem addressed by this profile is establishing standard interfaces to enable effective worklow between the PM/EMR and imaging sides of the house.

Unlike the in-patient environment where comparable functions would likely be implemented by separate ADT, CPOE, departmental, and medical records information systems with HL7 interfaces, PM/EMR systems integrate all those features. They typically have minimal implementations of HL7 standard interfaces; most often, there is some capability for receiving ORU (unsolicited observation) messages for lab results.

Regional integration

The primary professional specialties for the Image Enabled Office include cardiology, radiology, women's health, and orthopedics. In all of these cases, the use of diagnostic imaging in the office is often a prelude to, or a follow up from, a diagnostic or therapeutic procedure in another care setting (ambulatory or in-patient).

Continuity of care across these different practice settings and organizations requires effictive cross-enterprise sharing of clinical documentation, including imaging.

3. Key Use Cases

Echo referral

Andy Carditis, a patient, is referred to Belle Plummer, a cardiologist, for consultation regarding a fever and associated heart murmur (potential infective endocarditis). Dr. Plummer orders blood labs, a resting ECG, and an echo study, which the patient elects to have performed in the cardiology office. The patient and the cardiology office manager schedule the echo for later that day.

At the scheduled time, Sue Skann, the sonographer in the office, preps Mr. Carditis. She uses the ultrasound machine to query for the scheduled exams, and selects Mr. Carditis from the list. She performs the echo study, and makes preliminary measurements on the ultrasound machine. The images and measurements are sent to a local mini-PACS image server.

On an imaging workstation, Dr. Plummer reviews the images and measurements, and notes the vegetation on the mitral valve. She selects a representative image, and saves a reference to it in a note that is stored on the mini-PACS. She defers creating a report until the lab results will have been returned.

The next morning, the lab results are returned electronically and recorded in the office EMR. On the EMR workstation, Dr. Plummer reviews both the lab results and the echo measurements, and creates a report with findings, selected measurements, and the representative image selected the previous day. She orders a two week regimen of intravenous antibiotics, which will be administered by her nurse practitioner. The report is stored in the EMR, and is also sent to the referring primary care physician.

4. Standards & Systems

• IHE scheduled workflow profiles (SWF, CATH, ECHO, STRESS) for image acquisition management (DICOM MWL / MPPS / Storage / Storage Commitment)

• IHE Evidence Documents (ED) and Key Image Notes (KIN) profiles for structured image-based data (DICOM SR)

• IHE Displayable Reports (DRPT) profile for creation/submission of imaging-related report (HL7 MDM)

• IHE XDS, XDS-I, XDR, PIX, PDQ profiles for cross-enterprise medical record sharing

• IHE XDS-MS medical summary for referral and consultation report content – see also proposal for cardiology report content profile based on multi-society Key Data Elements and Definitions for Cardiac Imaging.

• DICOM WADO for web integration of imaging to EMR

5. Technical Approach

Image Manager/Archive is a broadly available class of products in a range of capabilities. This should be an actor separate from PM/EMR. There should be no restriction as to whether this is an on-site or a remotely hosted capability; the transactional interfaces would be the same.

Modality, Image Display, and Evidence Creator actors should operate with no changes from IHE imaging workflow profiles.

PM/EMR will therefore need to provide DICOM MWL capability - possibly through a gateway/broker, but that architecture is up to the vendor. Or should we explicitly define a separable Broker actor fed by HL7 ORM from the PM/EMR, and providing MWL out the other side?

Need to partition actors to allow participation of analysis/reporting applications separate from the EMR, but perhaps running on the same workstation. Reports should also be creatable by an EMR application.

Need to clearly integrate Evidence Documents (DICOM SR) as a direct data source for reporting apps, especially for ultrasound.

Existing actors

• Acquisition Modality

• Image Manager / Image Archive / PPS Manager

• Evidence Creator

• Image Display

• Report Creator (DRPT - creating CDA, or perhaps creating ORU)

Note that combination of Image Display (handling SR as in the ED Profile) and Report Creator will require functionality to copy SR content into the report format (e.g., CDA) for forwarding to the EMR - see text in IHE-Card-Supp-ED-2007. (decision 1/7)

• Content Creator (XDS / XDS-I)

• Content Consumer (XDS / XDS-I)

New actors

• PM/EMR - Practice Manager / Electronic Medical Record - combines functionality of "top-half workflow actors" (ADT, OE, DSS/OF) and Report Manager/Archive actor of DRPT. Note that MWL SCP capability (classically the DSS/OF actor) is part of responsibility of PM/EMR (decision 1/7: not a separate Broker actor)

Existing transactions

• "Bottom half" of Scheduled Workflow transactions

• Evidence Documents transactions

• XDS-I transactions

• DRPT Report Submission

New transactions (standards used)

• Possible need for transaction from Image Manager/Archive to PM/EMR with list of objects of DICOM Study (similar to IAN option in Scheduled Workflow, but using HL7 ORI?). For a list of possible ways this could be done with HL7, see: HL7-based Instance Availability Notification