Difference between revisions of "Encounter Based Imaging Workflow - Brief Proposal"

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==2. The Problem==
 
==2. The Problem==
  
Encounter-based Imaging (a burgeoning area of activity) needs to be supported as well as Order-based Imaging (aka [[Scheduled Workflow]]).
+
Encounter-based Imaging (a burgeoning area of activity) needs to be supported as well as Order-based Imaging (aka [[Scheduled Workflow]]) but today it is not.
 +
:* Time is lost on awkward workflow and data capture and lack of automation
 +
:* Images are Absent from or Scattered throughout the EMR
 +
:* Silo-ization of the medical imaging record
 +
:* Images Placed in Paper Record or Scanned into EMR without metadata
 +
:* Images Not Available to the Care Team
 +
:* Limited Data Sharing with Affiliated Hospitals
  
 
EBI needs the same kind of committee analysis we did for SWF:
 
EBI needs the same kind of committee analysis we did for SWF:
Line 24: Line 30:
  
 
An EBI exercise and profile could provide similar benefits in the expanded medical imaging community.
 
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 Data Sharing w/ Acquired & Affiliated Hospitals
 
:* Time spent on awkward workflow and data capture and lack of automation
 
 
'''Specific Technical Gaps''' (e.g. relative to Scheduled Workflow):
 
:* Marshalling and conveying metadata:
 
::* Procedure codes are appropriate for some encounter-based imaging but an order per se is not necessary (and would disrupt their workflow)
 
::* Well-populated metadata is critical, but '''patient metadata''' comes from the EMR, '''encounter metadata''' may come from a Practice Management System or Department System, and '''procedure metadata''' may need to be entered at the time of capture.
 
::* Order worklists are an effective tool for delivering good metadata to a smart acquisition system, but encounter-based imaging and devices may need other mechanisms.
 
 
:* 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)
 
 
:* 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
 
 
:* Facilitate Image Consumption
 
::* In Order based there is an order and a report to close the loop
 
::* Recognize some images are results (diagnostic procedure), some images are documentation (augment another procedure)
 
:::* 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==
 
==3. Key Use Case==
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* Point of Care Ultrasound
 
* Point of Care Ultrasound
  
===Use Case 1: Imaging with Simple Devices (non-DICOM)===
+
===Use Case 1: Imaging with Simple Devices (often non-DICOM at initial point of capture)===
  
Many departments capture clinical photos for documentation, follow up care, and diagnostics.  
+
Many departments capture clinical photos for documentation, follow up care, and diagnostics.
Capture devices include digital cameras, smartphones and tablets and run on platforms including iOS, Android and camera-specific operating systems.
+
 +
Capture devices include digital cameras, smartphones and tablets (using iOS, Android and camera-specific OS).
  
* 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 Provider interacts with some kind of "Encounter Management" system in the course of the patient visit.  It might be part of the EHR, or a practice management package, etc.
* 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, may be used to document various states of wounds, bedsores, or other disorders.
 
* Orders are not a required element clinically.
 
* Example:
 
** 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 as evident of care or for diagnostic reasons (ie - dermascope), image content may include photos of multiple body parts.
 
  
Note: Basic video capture and store is part of scope. Advanced video management (e.g. annotation, point of interest, editing, etc.) are out of scope.
+
* Patient makes appointment for Dermatology visit.
 +
* Patient arrives and is registered/checked in as an outpatient (OP)
 +
* At the Provider's discretion, clinical photos are taken to document disease processes, pathologies or disorders.
 +
** Image content may include photos of multiple body parts.
 +
** Image content may include basic video storage. (Advanced video management like editing and annotation is out of scope)
 +
** Orders are not a required element clinically
 +
* Patient demographics (from the EHR), Encounter metadata (from the EHR or visit management system) and Procedure metadata provide the context details which are combined with the captured image pixels and stored in the medical record.
  
===Use Case 2: Point of Care Ultrasound (DICOM modalities in unordered workflow)===
+
===Use Case 2: Point of Care Ultrasound (DICOM modalities in "Order-less" workflow)===
TODO: Write some text here
 
  
===Future Use Cases===
+
Traditional DICOM modalities (capable of Modality Worklist, C-Store, Storage Commitment) are also used in workflows where the imaging procedure is not explicitly Scheduled or Ordered. E.g. Point of Care Ultrasound for the following scenarios:
As part of keeping the scope practical, the following logical applications and use cases are listed but identified as being '''out of scope''' for the first profile.
 
  
* Ophthalmology
+
* '''Inpatient Status Check'''
* Otolaryngology
+
** A registered inpatient is in their bed in a ward
* Podiatry
+
** An ultrasound is performed to determine the state of the bladder (empty, partial, full), or confirm placement of a PIC line or needle
* ER/Trauma
+
** Key point: imaging is not "diagnostic" in the sense of radiology but rather evidentiary or for simple assessment
* Dentistry
+
*** Such an image might still be referred to radiology if something strange was observed.
* Sports Medicine
 
* Pathology Samples
 
* Procedure Video (e.g. Surgery, the video isn't ordered)
 
* Sleep Lab Video (More likely to be ordered?)
 
  
====Use Case x1: Surgical Documentation====
+
* '''Emergency Room Evaluation'''
 +
** Patient presents in the Emergency Room and is registered with an ER designation (between in-patient and out-patient)
 +
** ER physician decides to capture US images proving a certain disorder, disease state or procedural evidence such as soft tissue infection
 +
** The imaging may be diagnostic, but it is "interpreted locally" rather than in a subsequent reading step.
  
Pre, during, and post-surgery, images document the procedure and provide diagnostic information. Examples include scope video and still images, ultrasound, external photography and video, and ECG. The workflow is encounter-based since orders are not required and capture is either at the discretion of the Surgeon or is inherently part of the surgical procedure.  
+
* '''Outpatient Supplemental Information'''
 +
** Patient makes scheduled visit to Breast Surgeon for abnormal lump detected by PCP.  
 +
** Patient arrives and is registered/checked in as outpatient
 +
** Surgeon decides to take ultrasound images to evaluate/characterize the lump or document no evidence of lump.
  
Challenges include:
+
If the patient & encounter metadata, and perhaps some procedure metadata, can be pre-staged, the modality could use Worklist to obtain and apply the full metadata to the image at the time of capture in the same way as done for scheduled/ordered imaging (like Radiology). The imaging protocol (selected on the US device) might provide body part, procedure type and purpose of imaging.
* additional complexity or cumbersome workflow is very unwelcome in the surgical environment
 
* other imaging pre, during, and post-surgery '''is''' order-based and often performed by another department, e.g. x-rays performed by Radiology, OCT performed by Ophthalmology or Neurodiagnostic monitoring.
 
* surgical imaging 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.
 
* surgery on an already admitted inpatient triggers an ADT transfer which may not include the encounter/visit number of the admitting surgical department.
 
:* conversely, registration/arrival of an ambulatory surgical patient triggers an ADT^A01 (admit) or ADT^A04 (registration) and can follow the same workflow as an outpatient Dermatology visit
 
  
Some needs and mechanisms from the [[Cardiac Cath Workflow]] profile may be relevant here.
+
[[Encounter-based_Imaging_Workflow#High_Level_Workflow|Supporting Diagrams for the above two use cases]]
  
====Use Case x2: Patient provided images====
+
===Future Use Cases===
Images captured and provided by the patient are increasingly part of care.
+
As part of keeping the scope practical, several use cases (See Discussion) were identified as explicitly being '''out of scope''' for the first profile.
 
 
They have advantages such timeliness (being captured at the moment a symptom presents), convenience (they can be captured without the patient or a caregiver having to travel), and frequency (they can provide a daily record while only visiting the clinic every two weeks).
 
 
 
They also introduce challenges to collecting quality images with accurate metadata given that the patient is untrained in clinical procedures, does not have access to the provider IT systems and is using an "uncontrolled" device.  It is also necessary to convey the images to the care provider and integrate them properly into the patient medical record.
 
 
 
====Use Case x3: Post-Acquisition Processing====
 
After the images are captured, sometimes there are additional image processing steps that need to be performed. For example:
 
* Annotation
 
* QA
 
* Color correction
 
  
 
==4. Standards and Systems==
 
==4. Standards and Systems==
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Potential Standards
 
Potential Standards
 
:* Existing Profiles: PAM, WIC, SWF, MHD-I, XDS*, CARD IEO
 
:* Existing Profiles: PAM, WIC, SWF, MHD-I, XDS*, CARD IEO
:* DICOMweb
+
:* DICOM (DIMSE), DICOMweb
:* DICOM (DIMSE)
+
:* HL7, FHIR
:* HL7
+
:* Consumer media formats: JPEG, MPEG, PDF, RAW, etc
:* FHIR
 
:* Consumer formats: JPEG, MPEG, PDF, RAW, etc
 
  
 
Relevant Whitepapers:
 
Relevant Whitepapers:
Line 163: Line 117:
 
* IHE is a good venue to solve the encounter-based workflow problem because currently there are many proprietary ad-hoc workflows trying to deal with similar problems. As a start, IHE can create a profile to establish basic encounter-based imaging workflow that are broadly applicable to many specialties. Future enhancements can be introduced for additional support for various specialties.
 
* IHE is a good venue to solve the encounter-based workflow problem because currently there are many proprietary ad-hoc workflows trying to deal with similar problems. As a start, IHE can create a profile to establish basic encounter-based imaging workflow that are broadly applicable to many specialties. Future enhancements can be introduced for additional support for various specialties.
  
* '''Scope Management''': Instead of addressing the full spectrum of challenges related to encounter-based imaging workflow, the focus of this proposal is to address the following questions:
+
'''Scope Management''': Instead of addressing the full spectrum of challenges related to encounter-based imaging workflow, this proposal will:
:* Focus on the two key use cases identified. See Key Use Cases section for further discussion
+
:* Address two key use cases  
 
:* Define the minimal necessary set of metadata (related to the patient, encounter, procedure, etc.) associated with those use cases
 
:* Define the minimal necessary set of metadata (related to the patient, encounter, procedure, etc.) associated with those use cases
 
:* Identify the source(s) of each piece/set of metadata
 
:* Identify the source(s) of each piece/set of metadata
:* Try to limit to two pathways to aggregate and combine the metadata and pixels for the two identified use cases
+
:* Aggregate and combine the metadata and pixels for the two identified use cases
:* Address notification to EMR when study becomes available
+
:* Notify the EMR when study becomes available
 +
:* Address basic clinical usage of the images, but consider deferring more complex downstream activities in the first release.
  
* During the design, we would keep the clinical usage of the images in mind, but the profile may not address some of the downstream activities in the first release.
+
'''Specific Technical Gaps''' (e.g. relative to Scheduled Workflow):
 +
:* Marshalling and conveying metadata:
 +
::* Procedure codes are appropriate for some encounter-based imaging but placing an order is not necessary (and would disrupt their workflow)
 +
::* Well-populated metadata is critical, but '''patient metadata''' comes from the EMR, '''encounter metadata''' may come from a Practice Management System or Department System, and '''procedure metadata''' may need to be entered at the time of capture.
 +
::* Worklists are an effective tool to deliver good metadata to smart devices, but encounter-based imaging and devices may need other mechanisms.
  
* '''Niche risk''' - solving an instance of the problem instead of the broad class
+
:* Capture Process
:* e.g. Is the point-of-care US solution developed applicable to point-of-care endoscopy/photography?
+
::* Usage varies in the different departments/use cases
:* 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.
+
:::* Be clear what IHE will/will not do (e.g. define standard tag/location but not standard procedure codes)
:* focus on general metadata, not device/specialty specific, but allow extension from specialty specific code (e.g. dermatology anatomy codes)
 
:* might need domain specialty attributes
 
  
* '''EMR Participation''' - this profile must consider EMR interactions so we need their participation but that's traditionally been sparse in IHE Rad.
+
:* Data flow
:* Ken Persons and Thomas Pickard will reach out to Matt Doyle from Epic
+
::* should get the same end result as if the clinician placed the order
:* Mike Bressack can talk to Cerner
+
:::* Want to support the same analytics, access/indexing of the imaging
:* Elliot Silver will talk to Cerner
 
:* 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, PCD (patient identification for encounter-based workflow) - '''Cochair Action Item'''
+
:* Facilitate Image Consumption
:* They have already engaged domain vendors and adapted SWF.  Their experience/advice will be important.  Specifically, they understand their domain details.
+
::* Understand downstream usage of the data.
:* Invite other domains to present their workflow and see how harmonize/divert this solution compared to what they have already had
 
 
 
* If we build it, will they come? Will image vendors implement this?
 
:* Miami, Duke have found definite interest from the vendors (perhaps by focussing on a specific group, ophth/endo?)
 
 
 
* Vendors may stick with proprietary solution that already exist and unwilling to switch to a standard-based solution
 
:* Solution of this profile tries to be aligned with existing solution
 

Latest revision as of 17:42, 11 August 2017

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

  • Proposal Editor: Kevin O'Donnell / Kinson Ho
  • Proposal Contributors: Elliot Silver, Christopher Roth, Dawn Cram, Alex Towbin, Ken Persons, Paul Lipton, ...
  • Editor: Kevin O'Donnell / Kinson Ho
  • Contributors: See Support & Resources
  • Domain: Radiology

2. The Problem

Encounter-based Imaging (a burgeoning area of activity) needs to be supported as well as Order-based Imaging (aka Scheduled Workflow) but today it is not.

  • Time is lost on awkward workflow and data capture and lack of automation
  • Images are Absent from or Scattered throughout the EMR
  • Silo-ization of the medical imaging record
  • Images Placed in Paper Record or Scanned into EMR without metadata
  • Images Not Available to the Care Team
  • Limited Data Sharing with Affiliated Hospitals

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 (study, series?)
  • Communication - what notifications and "loop-closures" are needed
  • Data Transfer - what protocols should be used to move the different pieces of data and metadata

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.

3. Key Use Case

  • Dermatology
  • Wound Care/Management
  • Infectious Diseases
  • Burn Care
  • Plastic Surgery
  • Nursing/Clinic Photography
  • Point of Care Ultrasound

Use Case 1: Imaging with Simple Devices (often non-DICOM at initial point of capture)

Many departments capture clinical photos for documentation, follow up care, and diagnostics.

Capture devices include digital cameras, smartphones and tablets (using iOS, Android and camera-specific OS).

The Provider interacts with some kind of "Encounter Management" system in the course of the patient visit. It might be part of the EHR, or a practice management package, etc.

  • Patient makes appointment for Dermatology visit.
  • Patient arrives and is registered/checked in as an outpatient (OP)
  • At the Provider's discretion, clinical photos are taken to document disease processes, pathologies or disorders.
    • Image content may include photos of multiple body parts.
    • Image content may include basic video storage. (Advanced video management like editing and annotation is out of scope)
    • Orders are not a required element clinically
  • Patient demographics (from the EHR), Encounter metadata (from the EHR or visit management system) and Procedure metadata provide the context details which are combined with the captured image pixels and stored in the medical record.

Use Case 2: Point of Care Ultrasound (DICOM modalities in "Order-less" workflow)

Traditional DICOM modalities (capable of Modality Worklist, C-Store, Storage Commitment) are also used in workflows where the imaging procedure is not explicitly Scheduled or Ordered. E.g. Point of Care Ultrasound for the following scenarios:

  • Inpatient Status Check
    • A registered inpatient is in their bed in a ward
    • An ultrasound is performed to determine the state of the bladder (empty, partial, full), or confirm placement of a PIC line or needle
    • Key point: imaging is not "diagnostic" in the sense of radiology but rather evidentiary or for simple assessment
      • Such an image might still be referred to radiology if something strange was observed.
  • Emergency Room Evaluation
    • Patient presents in the Emergency Room and is registered with an ER designation (between in-patient and out-patient)
    • ER physician decides to capture US images proving a certain disorder, disease state or procedural evidence such as soft tissue infection
    • The imaging may be diagnostic, but it is "interpreted locally" rather than in a subsequent reading step.
  • Outpatient Supplemental Information
    • Patient makes scheduled visit to Breast Surgeon for abnormal lump detected by PCP.
    • Patient arrives and is registered/checked in as outpatient
    • Surgeon decides to take ultrasound images to evaluate/characterize the lump or document no evidence of lump.

If the patient & encounter metadata, and perhaps some procedure metadata, can be pre-staged, the modality could use Worklist to obtain and apply the full metadata to the image at the time of capture in the same way as done for scheduled/ordered imaging (like Radiology). The imaging protocol (selected on the US device) might provide body part, procedure type and purpose of imaging.

Supporting Diagrams for the above two use cases

Future Use Cases

As part of keeping the scope practical, several use cases (See Discussion) were identified as explicitly being out of scope for the first profile.

4. Standards and Systems

Potential Systems

  • Image Acquisition Devices (both Lightweight and Heavy/Integrated)
  • Image Archiving Devices
  • Electronic Medical Record Systems
  • Practice Management Systems
  • Encounter Management System (office/departmental system that provides the encounter context)
  • QA System
  • Encounter Imaging Consumer

Potential Standards

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

Relevant Whitepapers:

Relevant Current and Past Activities:

5. Discussion

  • IHE is a good venue to solve the encounter-based workflow problem because currently there are many proprietary ad-hoc workflows trying to deal with similar problems. As a start, IHE can create a profile to establish basic encounter-based imaging workflow that are broadly applicable to many specialties. Future enhancements can be introduced for additional support for various specialties.

Scope Management: Instead of addressing the full spectrum of challenges related to encounter-based imaging workflow, this proposal will:

  • Address two key use cases
  • Define the minimal necessary set of metadata (related to the patient, encounter, procedure, etc.) associated with those use cases
  • Identify the source(s) of each piece/set of metadata
  • Aggregate and combine the metadata and pixels for the two identified use cases
  • Notify the EMR when study becomes available
  • Address basic clinical usage of the images, but consider deferring more complex downstream activities in the first release.

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

  • Marshalling and conveying metadata:
  • Procedure codes are appropriate for some encounter-based imaging but placing an order is not necessary (and would disrupt their workflow)
  • Well-populated metadata is critical, but patient metadata comes from the EMR, encounter metadata may come from a Practice Management System or Department System, and procedure metadata may need to be entered at the time of capture.
  • Worklists are an effective tool to deliver good metadata to smart devices, but encounter-based imaging and devices may need other mechanisms.
  • Capture Process
  • Usage varies in the different departments/use cases
  • Be clear what IHE will/will not do (e.g. define standard tag/location but not standard procedure codes)
  • 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
  • Facilitate Image Consumption
  • Understand downstream usage of the data.