Difference between revisions of "Scheduled Workflow 2.0 - Radiology Order Management - Brief Proposal"

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=IHE Profile Proposal (Short)=
  
=IHE Profile Proposal (Short)=
 
  
==1. Proposed Profile: Orthopaedic Image==
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==IHE Profile Proposal (Short)==
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==1. Proposed Profile: Orders Management - Radiology ==
  
Domain: Radiology, Orthopaedic Surgery
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Domain: Radiology, others
  
 
==2. The Problem==
 
==2. The Problem==
  
There is significant opposition from Orthopaedic referrer groups, who rely on their own interpretation of diagnostic imaging, to the move from film to filmless image delivery. While the advantages of digital image management are accepted at senior cross-professional levels, these have to be delivered to the end user referrer.
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The Scheduled Workflow Integration Profile pioneered the use cases for integrating Systems which specialized in Order Entry/Placement and Order Placement/Department Scheduling with HL-7 v2.3.1. At this time, it was the current “state of integration” for integration order placers with order fillers.  There are gaps. It does not have a sufficient robust feedback mechanism from the order filler to the order placer to handle exceptions and updates by the order filler.  It does not provide adequate granularity for orders placed. These issues are addressed in later versions of HL7. 
  
The opponents of filmless services have valid concerns, due to lack of coordination on the part of the DI profession and the IT industry in providing referrers with standards based and consistent solutions, and in managing and coordinating local change issues.
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In addition the profile needs to be decoupled from acquisitionIn this manner, the integration profile can be better leveraged by non-imaging workflows for Order Management.   
 
 
Image transfer interoperability is profiled in the Portable Data Imaging, Access to Radiology Information and Cross-Enterprise Document Sharing for Imaging  Profiles.  The most popular method of imaging information transfer is CD media.  Portable Data for Imaging has proven successful worldwide as a means for transferring Images from the Radiology Service provider to the end-user referrerHowever, once images are received by the end-user, images may not be easily accessible, or consistently presented in a manner that would be considered usable to the end user.   
 
  
 
==3. Key Use Case==
 
==3. Key Use Case==
  
The Orthopaedic Surgeon receives a CD (or  other  storage  medium) with the patient image data  (2D  or  3D).  The CD is inserted into the PC (or  other  reading  device). 
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This Integration profile leverages the same use cases as scheduled workflow at a high level.  The primary difference is with granularity of the order by the order placer and the feedback returned by the order fillerThis use case was documented in the Japan National Extension.  
 
 
The PC automatically reads the CD and displays an index  of  available  images  for  selection by surgeon(this  list  may  include  tagged  key  images),  and the reportThe  PC  or  reader  displays  the  images  in “true size.”
 
 
 
The  PC  has  a library  of  (2D and 3D) templates of  commonly  used  prostheses  that  can  be  superimposed  on  the patient  images. Ideally,  there  is  also  provision  for  templates of  new  or  additional  prosthesis types  to  be  added  to  the  library.
 
There  are  software  tools  to  enable  the surgeon to manipulate  the  images  of  the prosthesis  on  screen,  and to take measurements for fitting the proper prosthesis. 
 
The surgeon selects the appropriate prosthesis and uses the displayed images to verify that the selected prosthesis is appropriate. 
 
  
With film-based workflow, the orthopaedic surgeon will use the diagnostic image to estimate the size of the prosthesis needed for the operation.  The most common method traditionally has been the surgeon’s visual assessment of a variably-magnified analog film, sometimes  combined  with  ruler measurements  of  features  displayed  on  the  film.
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Some of the other needs do include:
 
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*capability for an order filler to change the order without necessarily canceling the order first, as IHE SWF currently requires.  
In practice, CD  file  formats  and/or  supplied  readers (which  may  attempt to auto-load) are not compatible with the Surgeon’s PC software.  If the CD is compatible, the image directory is difficult to browse.  Generally, CDs will come with viewers provided by the PACS or DI manufacturerTypically, the viewer does not meet the Orthopaedic Surgeon’s basic requirements. Two major issues with the display of the images  are that  they may or may not be displayed at life-size, and that  lossy  compression may  be used.  Both are especially  problematic  if  the  degrees of  magnification, or of  data compression,  are  not  clearly  displayed  with  the  image.  Furthermore, commercially available templating software does  not efficiently meet the orthopaedic surgeon’s needs.
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*Order filler to provide a more granular feedback mechanism indicating when an order is modified, cancelled held or resumedProvisions should include an acceptance mechanism for an order filler to proceed if an order is changed.
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*Order placer to provide a more granular order, including modality and protocol to be   performed
  
 
==4. Standards & Systems==
 
==4. Standards & Systems==
  
'''Systems Impacted:'''
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The existing systems that are involved today, include clinical information systems which are capable of placing radiology orders. And Radiology Information Sysdtems which are capable of order filling.
  
RIS, PACS, Clinical Workstations, Orthopaedic Surgery Workstations
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'''Relevant standards: '''
Relevant Standards:
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HL-7 v2.5 or greater.
  
'''Integration Profiles:'''
 
Portable data for Imaging, Consistent presentation of Images
 
"" Stabdards""
 
 
DICOM
 
 
DICOM Supplement 131 currently in DICOM Committee review, will provide the solution for both 2D and 3D templates.
 
 
Note: DICOM GSPS IOD is available now to create template overlay on 2D for the distribution with the patient data.
 
 
 
==5. Discussion==
 
==5. Discussion==
  
While achieving a degree of acceptance, there has also been initial resistance by some individual referrers, and more recently collective action by professional bodies representing procedural specialists to retain film images, even to the point of engaging the Australian government to force the use of film as a requirement for insurance reimbursementFrom the referrer perspective a perfectly adequate, inexpensive and convenient mode of image management has been replaced by CDs or remote PACS access which have led to:
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This integration profile was identified as a critical need by our Japan National Committee.  It was identified as highly desirable by some of our North American users.  The need became most visible in the IHE Radiology investigation of an HL-7 Versioning Roadmap StrategyWhile the intent of this Integration Profile is not to solve the issue HL-7 versioning Roadmap Strategy for the IHE Radiology Domain, it is intended to meet the current concerns which have identifies HL-7 v2.3.1 as not adequate given today’s workflow internationally. This approach coincides with the proposed Solution 3: New Profile to refactor SWF (Patient, Order and Acquisition) and upgrade to HL7 v2.5  Briefly the proposal is intended to
 
 
• Purchase of expensive hardware for download, viewing and printing images to film;
 
 
 
• Difficulty achieving acceptable images on referrers monitors
 
 
 
• Unreasonable delays  while images are  loaded from CD;
 
 
 
• Difficulty opening and navigating around the discs to find the image and lack of scout films in some cases;
 
 
 
• Having to  learn to use multiple types of proprietary viewing software provided by individual DI services;
 
 
 
• Dealing with the issues of templating and measurement on screen rather than simply using near true-size films;
 
 
 
•     Problems with image portability and viewing in theatre, multiple  consulting  rooms, hospitals, etcPerception that this is a money saving technology change for radiologists and a change management and workflow impost for referrers.
 
Referrers are the “surrogate” customers of radiology services and their concerns, especially in private practice, cannot be ignored for professional and commercial reasons. The immediate and long term benefits to referrers and the relationship between advances in diagnostic imaging and the digital approach are not immediately apparent, whereas the problems are.
 
So is there really a problem?
 
 
 
• Fundamental errors in digital imaging interpretation by referrers have occurred.
 
 
 
• There have been numerous reports from individual practices about resistance to film replacement from a number of procedural specialists, most particularly orthopaedic surgeons.
 
  
• Professional associations and colleges representing disgruntled referrers in Australia have made representations on this issue.
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1. Remove the HL7 Patient Demographics transactions from IHE Radiology and use the IHE ITI Patient Demographics Management (PAM) transaction.
  
• While individual practices  may  negotiate  mutually  acceptable  arrangements  with  their  referrers, many procedural specialists also receive images that were originally requestedby other practitioners and hence  may  not  comply  with the  specialist’s  usual  arrangements
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2. Normalize the remainder of SWF to cover only Acquisition Workflow (AWF). This would include potentially making changes such as: a separate set of transactions should cover the Radiology Order Management (RAD-OM) so that other  Domains can easily change out the HL7 Order information as needed and creating a cleaner delineation between acquisition, post-processing and reporting.  
  
• There is a need for private sector radiologists to be able to interoperate with public services as patients  are frequently  referred  from  one  sector  to the  other This involves transmissions of images and request to the DI service, and of  the report back to the responsible agency for distribution or inclusion in the EHR.
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3. Reviewing the SWF and potentially making changes to improve the profile. This includes making exception handling required as opposed to an option, reviewing the use of MPPS, etc.
Failure of the IHE Radiology and the DI profession to address these issues may result in commercial, non standards/proprietary and expensive solutions emerging in the market. One has already been implemented in a popular GP system involving a significant radiology “pay per image” model.
 

Revision as of 07:06, 1 September 2007

IHE Profile Proposal (Short)

IHE Profile Proposal (Short)

1. Proposed Profile: Orders Management - Radiology

Domain: Radiology, others

2. The Problem

The Scheduled Workflow Integration Profile pioneered the use cases for integrating Systems which specialized in Order Entry/Placement and Order Placement/Department Scheduling with HL-7 v2.3.1. At this time, it was the current “state of integration” for integration order placers with order fillers. There are gaps. It does not have a sufficient robust feedback mechanism from the order filler to the order placer to handle exceptions and updates by the order filler. It does not provide adequate granularity for orders placed. These issues are addressed in later versions of HL7.

In addition the profile needs to be decoupled from acquisition. In this manner, the integration profile can be better leveraged by non-imaging workflows for Order Management.

3. Key Use Case

This Integration profile leverages the same use cases as scheduled workflow at a high level. The primary difference is with granularity of the order by the order placer and the feedback returned by the order filler. This use case was documented in the Japan National Extension.

Some of the other needs do include:

  • capability for an order filler to change the order without necessarily canceling the order first, as IHE SWF currently requires.
  • Order filler to provide a more granular feedback mechanism indicating when an order is modified, cancelled held or resumed. Provisions should include an acceptance mechanism for an order filler to proceed if an order is changed.
  • Order placer to provide a more granular order, including modality and protocol to be performed

4. Standards & Systems

The existing systems that are involved today, include clinical information systems which are capable of placing radiology orders. And Radiology Information Sysdtems which are capable of order filling.

Relevant standards: HL-7 v2.5 or greater.

5. Discussion

This integration profile was identified as a critical need by our Japan National Committee. It was identified as highly desirable by some of our North American users. The need became most visible in the IHE Radiology investigation of an HL-7 Versioning Roadmap Strategy. While the intent of this Integration Profile is not to solve the issue HL-7 versioning Roadmap Strategy for the IHE Radiology Domain, it is intended to meet the current concerns which have identifies HL-7 v2.3.1 as not adequate given today’s workflow internationally. This approach coincides with the proposed Solution 3: New Profile to refactor SWF (Patient, Order and Acquisition) and upgrade to HL7 v2.5 Briefly the proposal is intended to

1. Remove the HL7 Patient Demographics transactions from IHE Radiology and use the IHE ITI Patient Demographics Management (PAM) transaction.

2. Normalize the remainder of SWF to cover only Acquisition Workflow (AWF). This would include potentially making changes such as: a separate set of transactions should cover the Radiology Order Management (RAD-OM) so that other Domains can easily change out the HL7 Order information as needed and creating a cleaner delineation between acquisition, post-processing and reporting.

3. Reviewing the SWF and potentially making changes to improve the profile. This includes making exception handling required as opposed to an option, reviewing the use of MPPS, etc.