RSNA 20021

Implementation of Implementation of IHE Integration Profiles at the IHE Integration Profiles at the Cleveland Clinic FoundationCleveland Clinic Foundation

Dr. David Piraino, Section Head of Radiology Dr. David Piraino, Section Head of Radiology InformaticsInformatics

RSNA 20022

Conflict of Interest StatementConflict of Interest Statement

• IDX Alpha PartnerIDX Alpha Partner

• Members of Siemens Medical Advisory Members of Siemens Medical Advisory BoardBoard

• No product or vendor endorsements are No product or vendor endorsements are implied by this presentationimplied by this presentation

RSNA 20023

About Cleveland ClinicAbout Cleveland Clinic

• Multispecialty academic medical center and National Referral Center Multispecialty academic medical center and National Referral Center • One of the world’s first group practices, it was formed in 1921 One of the world’s first group practices, it was formed in 1921 • 4 Cleveland physicians came together and set forth their professional 4 Cleveland physicians came together and set forth their professional

standards: “Better care of the sick, investigation of their problems, and standards: “Better care of the sick, investigation of their problems, and further education of those who serve.” further education of those who serve.”

• 2nd largest medical group practice in the world, largest hospital in 2nd largest medical group practice in the world, largest hospital in Ohio, Ohio,

• Nearly 73,000 outpatient visits are recorded each monthNearly 73,000 outpatient visits are recorded each month• 934 staffed-bed hospital934 staffed-bed hospital

– Children’s Hospital, Educational Foundation & Lerner Research InstituteChildren’s Hospital, Educational Foundation & Lerner Research Institute. . • In 2000, 2 million outpatient visits and 51,000 hospital admissions. In 2000, 2 million outpatient visits and 51,000 hospital admissions. • More than 1,100 full-time physicians and scientists More than 1,100 full-time physicians and scientists • 100 specialties and subspecialties. 100 specialties and subspecialties.

RSNA 20024

About Cleveland Clinic RadiologyAbout Cleveland Clinic Radiology

• 8 hospitals8 hospitals

• 15 out patient imaging centers15 out patient imaging centers

• Over 1 million exams per yearOver 1 million exams per year

• Over 700,000 digital exams archived Over 700,000 digital exams archived per yearper year

• Not enough radiologists and Not enough radiologists and technologiststechnologists

RSNA 20025

In order to provide better In order to provide better patient care and provide patient care and provide an efficient operational an efficient operational workflow, the Cleveland workflow, the Cleveland

Clinic Foundation has Clinic Foundation has implemented the implemented the

"Scheduled Workflow" and "Scheduled Workflow" and "Patient Information "Patient Information

Reconciliation" integration Reconciliation" integration profiles. profiles.

These transactions are supportedThese transactions are supportedand are in production or in pilot mode at the and are in production or in pilot mode at the

Cleveland Clinic.Cleveland Clinic.

RSNA 20026

Main BenefitsMain Benefits

• Time savings during patient registration -Time savings during patient registration - MWLMWL• Elimination or at least significant reduction of Elimination or at least significant reduction of

errors during patient registration – errors during patient registration – MWLMWL• Elimination of manual input at RIS terminal - Elimination of manual input at RIS terminal -

MPPSMPPS• Elimination of manual check of archiving the Elimination of manual check of archiving the

images - images - Storage CommitmentStorage Commitment• Reduction of incorrectly identified or “lost” studies Reduction of incorrectly identified or “lost” studies

– – All of the aboveAll of the above

RSNA 20027

Prior to IHEPrior to IHE

• Before the IHE implementations, the Before the IHE implementations, the process was very paper-based and process was very paper-based and there was a great amount of data entry there was a great amount of data entry required. Much of the same information required. Much of the same information was being entered into different systems was being entered into different systems – the HIS, the RIS, the PACS and the – the HIS, the RIS, the PACS and the Modality. This slowed down the Modality. This slowed down the operational workflow.operational workflow.

By using the IHE Technical Framework as a guideline, much of the mapping exercises were shortened as it provided a

common understanding and language between all the different information system, imaging system, and modality vendors.

RSNA 20028

Where are we?Where are we?

• Patient demographics and exam information being Patient demographics and exam information being sent from the HIS to the RIS (ADT/Order Placer sent from the HIS to the RIS (ADT/Order Placer and Order Filler) has been in place for the past 4 and Order Filler) has been in place for the past 4 years.years.

• Implementation of Modality Worklist has been an Implementation of Modality Worklist has been an ongoing process for the past 3 years and is ongoing process for the past 3 years and is currently approaching 100 integrated modalities.currently approaching 100 integrated modalities.

• Storage Commitment and Modality Perform Storage Commitment and Modality Perform Procedure Step are in their initial implementation Procedure Step are in their initial implementation stage in CT.stage in CT.

Ongoing process to implement IHE Integration ProfilesOngoing process to implement IHE Integration Profiles

RSNA 20029

How it WorksHow it Works

• The HL7 ADT Patient Registration and Update, Filler and Order The HL7 ADT Patient Registration and Update, Filler and Order Management transactions are sent from various HIS systems to the Management transactions are sent from various HIS systems to the IDXrad RIS. IDXrad RIS.

• The transactions "Modality Worklist Provided" and "Modality Images The transactions "Modality Worklist Provided" and "Modality Images Stored" are in use in the CT department at the Cleveland Clinic. Stored" are in use in the CT department at the Cleveland Clinic.

• With the recent update of the Siemens CT Scanners these imaging With the recent update of the Siemens CT Scanners these imaging modalities now support the transactions "Modality PPS in Progress", modalities now support the transactions "Modality PPS in Progress", "Modality PPS Completed" and "Storage Commitment". "Modality PPS Completed" and "Storage Commitment".

• With the exception of "Storage Commitment", the IDXrad RIS also With the exception of "Storage Commitment", the IDXrad RIS also supports these transactions.supports these transactions.

• The Siemens image archive supports “Storage Commitment”The Siemens image archive supports “Storage Commitment”

RSNA 200210

Store ImagesStore Images

Storage CommitmentStorage CommitmentStorageStorage

CommitmentCommitment

List of ImagesList of Images

PACS &PACS &ArchiveArchive

RISRIS

ModalityModalityPerformedPerformedProcedure Procedure StepStep

Performed Step:Performed Step:

Status = CompletedStatus = CompletedPerformed CT HeadPerformed CT HeadPat Name/ID, Dose, Pat Name/ID, Dose,

Accession #, Study UIDAccession #, Study UIDComplete List of ImagesComplete List of Images

IHE Scheduled WorkflowIHE Scheduled Workflow

Modality WorklistModality Worklist

WorklistWorklist

Procedure ScheduledProcedure Scheduled

Patient Registration/UpdatePatient Registration/UpdateOrder ManagementOrder ManagementPerformed Step

Status = begun

RSNA 200211

Store ImagesStore Images PACS &PACS &ArchiveArchive

RISRIS

CCF Scheduled WorkflowCCF Scheduled Workflow

Manual Patient EntryManual Patient Entry

WorklistWorklist

Manual PrefetchManual Prefetch

Patient Registration/UpdatePatient Registration/UpdateOrder ManagementOrder ManagementManual Begin

Exam

ModalityModalityPerformedPerformedProcedure Procedure StepStep

Technologists manuallyComplete examination

Technologist check archive

RSNA 200212

Store ImagesStore Images PACS &PACS &ArchiveArchive

RISRIS

CCF Scheduled WorkflowCCF Scheduled Workflow

Modality Work-listModality Work-list

WorklistWorklist

Procedure scheduledProcedure scheduled

Patient Registration/UpdatePatient Registration/UpdateOrder ManagementOrder ManagementPerformed

Procedure“begin”

ModalityModalityPerformedPerformedProcedure Procedure StepStep

Technologists manuallyComplete examination

Storage commitment

RSNA 200213

Standards & MechanismsStandards & Mechanisms• HL7HL7

• ADT Messages (A01-08, A11-13, A38, A40)ADT Messages (A01-08, A11-13, A38, A40)

• ORM MessagesORM Messages

• DICOMDICOM

• Modality Worklist Management (MWL)Modality Worklist Management (MWL)

• Modality Performed Procedure Step (MPPS)Modality Performed Procedure Step (MPPS)

• Storage, Storage CommitmentStorage, Storage Commitment

• Query/Retrieve Query/Retrieve

RSNA 200214

Results CTResults CT

• Modality Work-listModality Work-list– Reduction in miss Reduction in miss

identified studiesidentified studies– Reduction in time Reduction in time

between exam between exam completion and completion and dictation because of dictation because of fewer miss identified fewer miss identified studiesstudies

RSNA 200215

Results CTResults CT

• Modality Perform Procedure StepModality Perform Procedure Step– Currently in pilot Currently in pilot – Provides more accurate begin exam timeProvides more accurate begin exam time– Questions remain about completionQuestions remain about completion

• Billing requirementsBilling requirements• Group procedures give that we have not Group procedures give that we have not

implemented the Grouped Procedure Profileimplemented the Grouped Procedure Profile

RSNA 200216

Results Orthopedic Out Patient Clinic Results Orthopedic Out Patient Clinic

Completion to DictationCompletion to Dictation• Analog filmsAnalog films 120 hours120 hours

• CRCR 60 hours60 hours

• Modality work-listModality work-list 40 hours40 hours

• Work flow changeWork flow change 20 hours20 hours

• Large portion of the delay is “lost” Large portion of the delay is “lost” images from film or incorrectly identified images from film or incorrectly identified studiesstudies

RSNA 200217

TestTest

ImplementationImplementation Issue Issue

The challenge of managing The challenge of managing each vendor's update to each vendor's update to their software was their software was overcome by creating a overcome by creating a fully-functional test fully-functional test environment.environment.

This approach enables Cleveland Clinic to This approach enables Cleveland Clinic to effectively simulate their production environment.effectively simulate their production environment.

ProductionProduction

RSNA 200218

Customer/Vendor CollaborationCustomer/Vendor Collaboration

Step 1.Step 1. Following a controlled change Following a controlled change

management process, each vendor management process, each vendor installs their latest update into the installs their latest update into the test environment. test environment.

Step 2.Step 2. Extensive testing occurs until all Extensive testing occurs until all

vendors and Cleveland Clinic vendors and Cleveland Clinic approve the update; then it is approve the update; then it is scheduled to be placed into scheduled to be placed into production.production.

RSNA 200219

Thinking about the WorkflowThinking about the Workflow

• Need to manage the business Need to manage the business processes and workflow changesprocesses and workflow changes• Business process re-engineering Business process re-engineering requires an intense user education requires an intense user education process which includes user process which includes user feedback. feedback. • For successful integration, it is For successful integration, it is critical to work closely with all users critical to work closely with all users of the solution.of the solution.

RSNA 200220

QuestionsQuestions

Dr. David Piraino – piraind@ccf.orgDr. David Piraino – piraind@ccf.org