Foreign Exam Management - Detailed Proposal
1. Proposed Workitem: Foreign Exam Management Detailed Proposal
- Proposal Editor: David Heaney
- Editor: <Name of candidate Lead Editor for the Profile, if known>
- Date: N/A (Wiki keeps history)
- Version: N/A (Wiki keeps history)
- Domain: Radiology
2. The Problem
The current Import Reconciliation Workflow Profile does not cover many of the use cases or feature functionality desired by customers:
- Import of prior exams (via pre-fetch 'pull' or 'push' or from removable media)
- Users often want 'priors' to be handled differently by an Image Manager/Archive
- flushed from the system rather than archived
- configurable behavior on the timing for this flushing that differs from normal workflow exams
- flushing of foreign exam Study records from database rather than just deletion of image files/objects
- requirements around when and when not a new exam order is needed for such a foreign study
3. Key Use Case
A White Paper on foreign exam management had been circulated in the XDS Implementation Group. This outlines a number of use cases and scenarios. Here is a link to that white paper:
4. Standards and Systems
IRWF SWF XDS-I.b MIMA IOCM
5. Discussion
1. Proposed Workitem: Import Reconciliation Workflow Enhancement
- Proposal Editor: Peter Kuzmak
- Editor: <Name of candidate Lead Editor for the Profile, if known>
- Domain: Radiology
2. The Problem
A patient has an imaging study performed at one facility and has the study exported to portable media. Later, the patient takes the media to a different institution. The study on that media may need to be imported into that new institution’s imaging system. This would be done to avoid a repeat examination, or so that the study can be on file for reference purposes.
Importing prior studies is best performed by creating a new order on the institution’s imaging system and then associating the DICOM objects from the prior study with it. In this way the prior study is actually inserted into the imaging system’s electronic health record (EHR) and is properly indexed so that it can be identified and later retrieved as needed.
Currently, importing prior DICOM studies into the institution’s systems is a very slow labor intensive process. The user loads the media into the drive and then waits for the commercial importer product to read all the DICOM files. The user then has to work on one study at a time. First, the user has to review the study on the commercial importer. The user then has to go to the institution’s RIS and place an order for an equivalent radiology study. Then, the user would has to go back to the commercial importer and use DICOM Modality Worklist to retrieve the order, have the commercial importer update the DICOM images with the institution’s patient and order information, and have them sent to the institution’s imaging system. Finally, the user has to go back to the institution’s RIS to update the study status to indicate that it is completed. Processing a single study this way takes anywhere from 10 to 30 minutes (estimate from Department of Veterans Affiars). And the user would has to repeat this effort for each study on the portable media that needs to be imported. This is a rather overwhelming task, given the volume of studies that need to be imported. The result is that the prior studies are often not imported and examinations are unnecessarily repeated.
The process to import prior DICOM studies can be automated to eliminate many of the manual steps. The DICOM importer application can place the order on the RIS for the equivalent radiology study, use the order information for import reconciliation, send the images to the institution’s imaging system, and then update the status of the study on the RIS to indicate that it was completed.
The automated process is much more efficient for the user and prior studies are more likely to be imported. This means that repeat examinations can be avoided and prior studies are on file for reference purposes.
3. Key Use Case
The classic problem is how to deal with the prior study that was performed while the patient was being treated at another facility. The patient brings the CD containing the prior study when the patient went to the local institution for treatment. The patient’s clinician (provider) determined that the outside images/studies are clinically significant and need to be included in the patient’s EHR as reference images. The solution involves importing an outside study that is unknown to the local system.
Importing prior studies is performed by creating a new order on the institution’s imaging system and then associating the DICOM objects from the prior study with it.
Currently, the user loads the media into the drive and then waits for the commercial importer product to read all the DICOM files. The user then has to work on one study at a time. First, the user has to review the study on the commercial importer. The user then has to go to the institution’s RIS and place an order for an equivalent radiology study. Then, the user would has to go back to the commercial importer and use DICOM Modality Worklist to retrieve the order, have the commercial importer update the DICOM images with the institution’s patient and order information, and have them sent to the institution’s imaging system. Finally, the user has to go back to the institution’s RIS to update the study status to indicate that it is completed. The user has to repeat this effort for each study on the portable media that needs to be imported.
The process to import prior DICOM studies can be automated to eliminate many of the manual steps.
The workflow of the import process can be designed to operate like an online merchandise ordering application where the user adds items to a shopping cart and then proceeds to checkout.
All of the interactive item selection is done first and then is followed by an automatic database update commit transaction. First the HIS/RIS patient and equivalent radiology procedure are manually identified for each prior study. Then the DICOM importer process automatically places the order on the RIS for each the equivalent radiology study, uses the order information for import reconciliation, sends the images to the institution’s imaging system, and then updates the status of the study on the RIS to indicate that it was completed.
4. Standards and Systems
This would be an enhancement to Import Reconciliation Workflow (IRWF).
This enhancement consists of two parts.
The first is the ability to identify the patient and the equivalent radiology procedure and modifiers for the prior study. The second is the ability to place the order for the equivalent radiology procedure for the prior study, trigger the filling of the order, obtaining the study information for the order, performing the reconciliation, sending the reconciled DICOM objects to the imaging system, and updating the status of the created study afterwards.
The key to this enhancement is the ability to remotely place to create the equivalent study on the RIS that the prior study can be associated with. In order to do this the importer process has to function as the order placer and then trigger the order filler to create the study. This is probably going to require a new transaction.
Part 1
Identify the patient - Patient Data Query (IT-PDQ)
Identifying the equivalent RIS radiology procedure & modifier(s) - TBD (HL7 MFB ?)
Part 2
Placing the order for the equivalent radiology procedure for the prior study -
Scheduled Workflow RAD-3
Triggering the filling of the order - A new transaction is probably needed
Obtaining the study information - Scheduled Workflow RAD-4 (This might be part of the order filler trigger transaction.)
Performing the reconciliation - IRWF RAD-61
Sending the reconciled DICOM objects to the imaging system - IRWF RAD-61
Updating the status of the created study - IRWF RAD-61 - MPPS Complete
5. Discussion
A DICOM importer using the automated process was deployed nation-wide at the Department of Veterans Affairs in September 2010. (A paper describing this work has been accepted by SIIM JDI - Streamlining Importation of Outside Prior DICOM Studies into an Imaging System - J Digit Imaging, August 2, 2011).
One of our VA users recently reported the following about the new application:
"The new process is fantastic... Not manpower intensive or laborious. We can import 80+ radiology studies in less than 2 hours... the old process we had would be at least 15-18 hours for that many studies." (The underlines in the original.)
This site treats polytrauma patients that are transferred from DoD to the VA for long term care. Approximately 1100 prior studies from the DoD are imported at this VA Medical Center each month.
We had a real problem in the VA prior to the creation of this DICOM importer application - the amount of data that needed to be imported exceeded the available manpower. So it wasn't being done. As a result, the images were lost and radiology examinations were unnecessarily repeated. Now we are able import all of the DICOM images and make them part of the VA patient record.
We think that this work is important because is addresses one of the major unsolved problems with import reconciliation workflow: how to efficiently handle the importing of prior studies. Portable DICOM media will be around for a long time. That's why I think IHE needs to take it on.