Scheduled Workflow 2.0 - Radiology Order Management - Brief Proposal

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IHE Profile Proposal (Short)

1. Proposed Profile: Orthopaedic Image

Domain: Radiology, Orthopaedic Surgery

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.

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.

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 referrer. However, 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

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).

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 report. The 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.

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 manufacturer. Typically, 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.

4. Standards & Systems

Systems Impacted:

RIS, PACS, Clinical Workstations, Orthopaedic Surgery Workstations Relevant Standards:

Integration Profiles: Portable data for Imaging, Consistent presentation of Images "" Stabdards""


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

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 reimbursement. From 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:

• 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.

• 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

• 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. 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.