1September, 2005 What IHE Delivers

Cardiology – North Cardiology – North American Connectathon American Connectathon

and ACC 2007 IHE and ACC 2007 IHE Interoperability Showcase Interoperability Showcase

Q&A Q&A

IHE Cardiology Webinar Year 3 Sept, 2006IHE Cardiology Webinar Year 3 Sept, 2006

IHE Cardiology EducationIHE Cardiology Education

Teri Sippel Schmidt, ACCTeri Sippel Schmidt, ACC

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Profiles to be Tested at NA Connectathon: Profiles to be Tested at NA Connectathon: January 2007January 2007

Year 2004-2006 (Final Text)Year 2004-2006 (Final Text) Cath Workflow (Cath)Cath Workflow (Cath) Echo Workflow (Echo)Echo Workflow (Echo) Retrieve ECG for Display (ECG)Retrieve ECG for Display (ECG) Evidence Documents (ED) for Cath and EchoEvidence Documents (ED) for Cath and Echo Displayable Reports (DRPT) <<withdrawn for modifications>>Displayable Reports (DRPT) <<withdrawn for modifications>>

Year 2006-2007 (Trial Implementation/ACC IHE Interop 2007)Year 2006-2007 (Trial Implementation/ACC IHE Interop 2007) Stress Test Workflow (STRESS)Stress Test Workflow (STRESS) Implanted Device Cardiac Observations (IDCO)Implanted Device Cardiac Observations (IDCO) Nuclear Medicine (NM) Cardiology OptionNuclear Medicine (NM) Cardiology Option Cross Enterprise Document Sharing (XDS) Cross Enterprise Document Sharing (XDS) Cross Enterprise Document Sharing – Imaging (XDS-I) Cross Enterprise Document Sharing – Imaging (XDS-I) Cross Enterprise Document Sharing – Medical Summary (XDS-MS)Cross Enterprise Document Sharing – Medical Summary (XDS-MS)

Note: all XDS Profiles tested within ITI Domain with additional ACC demo scenario Note: all XDS Profiles tested within ITI Domain with additional ACC demo scenario testing.testing.

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Cardiology Workflow ProfilesCardiology Workflow Profiles

Cardiology Workflows GeneralCardiology Workflows General Cath WorkflowCath Workflow Echo WorkflowEcho Workflow Stress Testing Workflow Stress Testing Workflow

Content Display Requirements – Modality Content Display Requirements – Modality Acquisition and Image Display ActorsAcquisition and Image Display Actors Stress EchoStress Echo Stress TestingStress Testing Nuclear CardiologyNuclear Cardiology

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1. Cath Workflow Use Cases1. Cath Workflow Use Cases Case C1:Case C1: Patient Registered at ADT and Procedure Patient Registered at ADT and Procedure

Ordered at the Order PlacerOrdered at the Order Placer Case C2:Case C2: Patient Registered at ADT and Procedure Patient Registered at ADT and Procedure

Ordered at DSS/OFOrdered at DSS/OF Case C3:Case C3: Patient Registered at ADT and Procedure Patient Registered at ADT and Procedure

Not OrderedNot Ordered Case C4:Case C4: Patient Registered at DSS/OF and Patient Registered at DSS/OF and

Procedure OrderedProcedure Ordered Case C5:Case C5: Patient Not Registered Patient Not Registered Case C6:Case C6: Patient Updated During Procedure Patient Updated During Procedure Case C7:Case C7: Change Rooms During Procedure Change Rooms During Procedure Case C8:Case C8: Cancel Procedure Cancel Procedure Case C9:Case C9: Post-Procedure Evidence Creation Post-Procedure Evidence Creation Case C10: Case C10: EP Ablation / Implantation LabEP Ablation / Implantation Lab

ALL Use Cases Must be SupportedALL Use Cases Must be Supported

Exception of C10 only required for EP LabException of C10 only required for EP Lab

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2. Echo Workflow Use Cases2. Echo Workflow Use CasesCase E1:Case E1: Patient Registered at ADT and Procedure Ordered Patient Registered at ADT and Procedure Ordered

Case E2:Case E2: Intermittently Connected Modality Intermittently Connected Modality

Case E3:Case E3: Intermittently Connected Modality with Ad Hoc Intermittently Connected Modality with Ad Hoc

Procedure, Patient Registered, Scheduled ProcedureProcedure, Patient Registered, Scheduled Procedure

Case E4:Case E4: Intermittently Connected Modality with Ad Hoc Intermittently Connected Modality with Ad Hoc

Procedure, Patient Registered, Unscheduled ProcedureProcedure, Patient Registered, Unscheduled Procedure

Case E5:Case E5: Intermittently Connected Modality with Ad Hoc Intermittently Connected Modality with Ad Hoc

Procedure, Patient Unregistered, Unscheduled ProcedureProcedure, Patient Unregistered, Unscheduled Procedure

Case E6:Case E6: Stress Echo Staged Protocol Stress Echo Staged Protocol

Case E7:Case E7: Echo Measurements Evidence Creation Echo Measurements Evidence Creation

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ViewsViewsApical two chamber

Apical four chamber

Apical long axis

Parasternal long axis

Parasternal short axis

Parasternal short axis at the aortic valve level

Parasternal short axis at the level of the mitral chords

Parasternal short axis at the Mitral Valve level

Parasternal short axis at the Papillary Muscle level

Right Ventricular Inflow Tract View

Right Ventricular Outflow Tract View

Subcostal long axis

Subcostal short axis

Suprasternal long axis

Suprasternal short axis

Stage and ViewsStage and ViewsStage and ViewsStage and Views

Stress Echo OptionStress Echo Option• Stage Number & View Stage Number & View

NumberNumber• Stage Code Sequence & Stage Code Sequence &

View Code SequenceView Code Sequence

Coding

Scheme

Designator

(0008,0102)

Code Value

(0008,0100)

Code Meaning (0008,0104)

SRT P5-01201 Image acquisition at baseline

SRT P5-01202 Pre-stress image acquisition

SRT P5-01203 Mid-stress image acquisition

SRT P5-01204 Peak-stress image acquisition

SRT P5-01205 Image acquisition during recovery

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Benefit: Stress EchoBenefit: Stress EchoViewing ConsistencyViewing ConsistencyBenefit: Stress EchoBenefit: Stress EchoViewing ConsistencyViewing Consistency

8

3. Evidence Documents3. Evidence Documents

Echocardiography Measurement

Patient: Doe, John Technologist: der Payd, N

Measurements:

Mitral valve diameter 3.1cm

- shown in image at [ ]

Ventricular length, diastolic 5.97 cm

- shown in image at [ ]

Ventricular volume, diastolic 14.1 ml

- inferred from [ ]

- inferred from VLZ algorithm

Cath or Echo Measurements – Cath or Echo Measurements – ““Evidence Creator” is an Actor in both Cath Evidence Creator” is an Actor in both Cath and Echo Workflows as well as Evidence and Echo Workflows as well as Evidence DocumentsDocuments

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Evidence DocumentsEvidence DocumentsValue propositionValue proposition

Measurements are Measurements are managedmanaged in same study folder as in same study folder as imagesimages

Data is structured and uses coded concepts and Data is structured and uses coded concepts and vocabulary vocabulary

Coded data can be searched, processed, databased Coded data can be searched, processed, databased (locally, national registry), …(locally, national registry), …

Avoids detour through “paper-space”Avoids detour through “paper-space” extra handling, delay and potential loss of paperextra handling, delay and potential loss of paper additional effort and errorsadditional effort and errors

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Evidence DocumentsEvidence DocumentsTechnical BasisTechnical Basis

Based on:Based on: DICOM Structured Report (SR) ObjectsDICOM Structured Report (SR) Objects Storage CommitmentStorage Commitment Query/RetrieveQuery/Retrieve

Addresses creation/distribution of the contentAddresses creation/distribution of the content

Scheduling and progress reporting is supported Scheduling and progress reporting is supported by also implementing an appropriate IHE by also implementing an appropriate IHE workflow profileworkflow profile

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4. So what is Stress Testing?4. So what is Stress Testing?

Uses exercise or Uses exercise or medication to increase the medication to increase the work of the heart. work of the heart.

Continuous 12 lead ECG Continuous 12 lead ECG monitoring during studymonitoring during study

Looking for changes in ST Looking for changes in ST segmentssegments

Used as a screening toolUsed as a screening tool

Or to test effectiveness of Or to test effectiveness of therapytherapy

Done in Non-Invasive Lab, Done in Non-Invasive Lab, and Cardiologist Officeand Cardiologist Office

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Stress TestingStress Testing

Image Intensive…multiple samples of 12 Image Intensive…multiple samples of 12 lead ECG during the protocollead ECG during the protocol

Summary report usually one page in Summary report usually one page in lengthlength

Physician will do comparisons to previous Physician will do comparisons to previous studiesstudies

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Stress: Protocol and Stage Stress: Protocol and Stage

ProcedureProcedure

ProtocolProtocol

StagesStages

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Stress: Protocol and Stage Stress: Protocol and Stage

Procedure : Exercise StressProcedure : Exercise Stress

Protocol: BruceProtocol: Bruce

Stages:Stages: Standard Bruce has 7 stagesStandard Bruce has 7 stages

• Stage 1: 1.7 mph @ 10 % gradeStage 1: 1.7 mph @ 10 % grade• Stage 7: 6.0 mph @ 22 % gradeStage 7: 6.0 mph @ 22 % grade

Important Note: A procedure can be Important Note: A procedure can be considered complete irrespective of the considered complete irrespective of the

protocol being complete!protocol being complete!

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Stress OptionsStress Options

Stress EchoStress Echo Began in the early – mid 1990’sBegan in the early – mid 1990’s Observation of wall motion and ejection fractions with the Observation of wall motion and ejection fractions with the

heart under stressheart under stress High specificity for correlating ischemia to functional High specificity for correlating ischemia to functional

abnormalitiesabnormalities Can be done with exercise but mainly chemicalCan be done with exercise but mainly chemical

Nuclear StressNuclear Stress Most often combined with exercise or chemical stress Most often combined with exercise or chemical stress

testingtesting Use of radioisotope to detect presence and resolution of Use of radioisotope to detect presence and resolution of

ischemic regions of the heartischemic regions of the heart Scan immediately post Scan immediately post Scan 4 hours to 1 day laterScan 4 hours to 1 day later Resolution of ischemic area determines viability of muscleResolution of ischemic area determines viability of muscle

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Attribute SummaryAttribute Summary

Concept Modality Worklist Echo ECG NM

Requested Procedure

Requested Procedure Code Sequence (0032,1064)

Procedure Code Sequence (0008,1032)

Procedure Code Sequence (0008,1032)

Procedure Code Sequence (0008,1032)

Protocol Scheduled Protocol Code Sequence (0040,0008)

Performed Protocol Code Sequence (0040,0260)

CID 12001*

Performed Protocol Code Sequence (0040,0260)

CID 3261

Performed Protocol Code Sequence (0040,0260)

CID 3261**

Protocol Stage Number

Acquisition Context Sequence (0040,0555) >(109055, DCM, “Protocol Stage”)

Patient State Stage Number (0008,2122)

Stage Code Sequence (0040,000A)

CID 12002*

Acquisition Context Sequence (0040,0555) >(109054, DCM, “Patient State”)

CID 3262

Acquisition Context Sequence (0040,0555) >(109054, DCM, “Patient State”)

CID 3101

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Stress Testing Use CasesStress Testing Use CasesCase S1:Case S1: Cardiac Stress Test, ECG Only Cardiac Stress Test, ECG Only

Limited use with lower sensitivities and specificitiesLimited use with lower sensitivities and specificities

Screening tool onlyScreening tool only

Case S2:Case S2: Cardiac Stress Test with Imaging Cardiac Stress Test with Imaging

More common use caseMore common use case• Echocardiography – requires Consistent Time to combine clinical Echocardiography – requires Consistent Time to combine clinical

data from Stress Monitor and Echo Modality; consistent use of data from Stress Monitor and Echo Modality; consistent use of

Protocol and Stage informationProtocol and Stage information

• Nuclear Medicine – consistent use of Protocol and Stage Nuclear Medicine – consistent use of Protocol and Stage

information; consistent time still importantinformation; consistent time still important

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5. Nuclear Cardiology5. Nuclear Cardiology

Image formatsImage formats Stress and Rest raw data reviewStress and Rest raw data review Stress and Rest processed dataStress and Rest processed data Gated SPECT dataGated SPECT data Quantitative dataQuantitative data Screen captures, “snap shots” Screen captures, “snap shots”

Color mapsColor maps Gray scale is defaultGray scale is default Color overlays can be appliedColor overlays can be applied

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Raw Data ImagesRaw Data Images

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Standard Perfusion DisplayStandard Perfusion Display

StressStress

StressStress

StressStress

StressStress

RestRest

RestRest

RestRest

RestRest

Short axisShort axis

HorizontalHorizontallong axislong axis

VerticalVerticallong axislong axis

““Stress over Rest” DisplayStress over Rest” Display

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Perfusion Display - ColorPerfusion Display - Color

Stress over rest Stress over rest standard Perfusion standard Perfusion Display - with Color Display - with Color map overlaid on the map overlaid on the image image

Note that text may be Note that text may be colorizedcolorized

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Quantitative DisplayQuantitative Display

Output Output from 3from 3rdrd party party quantitative quantitative gated gated software software can be can be displayed displayed

Mapped segmentsMapped segmentsof the heart (ASNCof the heart (ASNCGuidelines)Guidelines)

3D models built3D models builtfrom axial imagesfrom axial images

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Screen CapturesScreen Captures

Screen Screen captures captures can be can be displayed displayed to show to show important important imagesimages

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6. ECG Scope 6. ECG Scope

Make ECG-specific extensions to RIDMake ECG-specific extensions to RIDPlace requirements on ECG source to Place requirements on ECG source to

ensure high-quality ECG documents.ensure high-quality ECG documents.Add ECG-specific request for list of ECGs Add ECG-specific request for list of ECGs

to be returned as XML allowing more client to be returned as XML allowing more client flexibility.flexibility.

Add SVG (vector graphics) as allowed Add SVG (vector graphics) as allowed ECG document format.ECG document format.

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PDFPDF

ECG Source required to support PDF so it ECG Source required to support PDF so it is compatible with existing RID clients.is compatible with existing RID clients.

PDF is a common document type and PDF is a common document type and most computers already have a viewer.most computers already have a viewer.

ECG Source required to use vector ECG Source required to use vector graphics for waveforms in PDF.graphics for waveforms in PDF. Gives high quality line drawings at any screen Gives high quality line drawings at any screen

resolution and zoom factor.resolution and zoom factor. Rasterized (e.g. scanned, bitmapped) ECG Rasterized (e.g. scanned, bitmapped) ECG

“images” not allowed.“images” not allowed.

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Example ECG in PDF FormatExample ECG in PDF Format

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SVGSVG

Scalable Vector Graphics – “XML Scalable Vector Graphics – “XML Graphics for the Web” – a W3C standard.Graphics for the Web” – a W3C standard.

Well suited for line drawings (e.g. Well suited for line drawings (e.g. waveforms) in a XML/Web environment.waveforms) in a XML/Web environment.

Currently supported through web browser Currently supported through web browser plug-ins.plug-ins.

Allows scripting to enable advanced user-Allows scripting to enable advanced user-side display control.side display control.

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Serial Comparison ExampleSerial Comparison Example

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7. Implantable Device Cardiac Observations 7. Implantable Device Cardiac Observations (IDCO)(IDCO)

Enable management of ICD follow-up Enable management of ICD follow-up information in a central system such as an information in a central system such as an Device Clinic Management System or EMRDevice Clinic Management System or EMR

Improve efficiency and quality of related Improve efficiency and quality of related clinical processesclinical processes Single point of access for ICD informationSingle point of access for ICD information Automation of current manual processes for data Automation of current manual processes for data

collection, aggregation and analysiscollection, aggregation and analysis Standardization of workflow processesStandardization of workflow processes Enabling of analyticsEnabling of analytics

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Implantable Cardiac DevicesImplantable Cardiac Devices

Pacemakers – therapy for heart rate problemsPacemakers – therapy for heart rate problems

Defibrillators – therapy for life threatening heart rhythmsDefibrillators – therapy for life threatening heart rhythms

Cardiac Resynchronization – therapy for congestive heart Cardiac Resynchronization – therapy for congestive heart failurefailure

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IDCO Profile Use CasesIDCO Profile Use Cases

In-Clinic Implants or Follow-upsIn-Clinic Implants or Follow-ups Patients present themselves in-clinic for implantation or Patients present themselves in-clinic for implantation or

follow-upsfollow-ups Information is collected using vendor specific “programmers”Information is collected using vendor specific “programmers” Information is sent from interrogation system to a central Information is sent from interrogation system to a central

Device Clinic Management System or EMRDevice Clinic Management System or EMR

Remote Follow-upsRemote Follow-ups Patients devices are interrogated in the home health care Patients devices are interrogated in the home health care

environmentenvironment Information is collected using vendor specific communication Information is collected using vendor specific communication

devices and systemsdevices and systems Information is sent from interrogation system to a central Information is sent from interrogation system to a central

Device Clinic Management System or EMRDevice Clinic Management System or EMR

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IDCO ProfileIDCO ProfileSystems ModelSystems Model

Home Healthcare Environment

Inductive or RF Interrogation

In-Clinic Healthcare Environment

Inductive or RF Interrogation

IHE

TR

AN

SA

CT

ION

IHE TRANSACTION

IHE

TR

AN

SA

CT

ION

Programmer

Device Vendor Environment

IHE TRANSACTION

SecuredNetwork

Transmissions

SecuredNetwork

Transmissions

Another ClinicSecuredNetwork

Transmissions

EHR or DeviceManagement System

Vendo

r Dat

a Tra

nsfe

r

Device Data Information Management System

InterrogationDevice

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8. Cross Enterprise Document Sharing 8. Cross Enterprise Document Sharing (XDS)(XDS)

XDS is the sharing of clinical documents XDS is the sharing of clinical documents between two different Electronic between two different Electronic Healthcare Record (EHR) systemsHealthcare Record (EHR) systems e.g., between a clinic EHR and a hospital based e.g., between a clinic EHR and a hospital based

EHREHR HIPAA requirements consideredHIPAA requirements considered Lifetime patient record, across clinical specialities, Lifetime patient record, across clinical specialities,

consideredconsidered Very applicable to CardiologyVery applicable to Cardiology

34XDS Affinity Domain (NHIN sub-network)

Community Clinic

Lab Info. System

PACS

Teaching Hospital

PACS

ED Application

EHR System

Physician Office

EHR System

XDS Scenario + use of ATNA & CTXDS Scenario + use of ATNA & CTShowcased at HIMSS 2006Showcased at HIMSS 2006

PMS

Retrieve DocumentRetrieve Document

Register DocumentRegister DocumentQuery DocumentQuery Document

XDS Document Registry

ATNA Audit ATNA Audit record repositoryrecord repository CT Time serverCT Time server

Record AuditRecord AuditEventEvent

MaintainMaintainTimeTime

MaintainMaintainTimeTimeRecord AuditRecord Audit

EventEvent

Maintain TimeMaintain TimeProvide & Register Docs

Record AuditRecord AuditEventEvent

XDS Document Repository

XDSDocumen

t Reposito

rySecured MessagingSecured Messaging

35XDS Affinity Domain (NHIN sub-network)

Community Clinic

Lab Info. System

PACS

Teaching Hospital

PACS

ED Application

EHR System

Physician Office

EHR System

XDS Scenario + use of PIX & PDQXDS Scenario + use of PIX & PDQ Showcased at HIMSS 2006 Showcased at HIMSS 2006

A87631

PACS

L-716

Affinity Domain Patient Identity Source

M8354673993

Retrieve DocumentRetrieve Document Provide & Register Docs

Register (using Pt ID)Register (using Pt ID)Query Document (using Pt Id)Query Document (using Pt Id)

Patient Identity Feed

Document Registry

14355M8354673993

L-716

A87631

Patient Identity Feed

PIX Query

PIX Query

Patient Identity Feed

Patient Identity XRef MgrPatient Identity FeedPDQ Query to Acquire Affinity Domain Patient ID

M8354673993

A87631L-716

M8354673993

XDS Document Repository

XDSDocument

Repository

ATNA Audit ATNA Audit record repositoryrecord repository CT Time serverCT Time server

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IHE Patient Care Coordination ProfilesIHE Patient Care Coordination Profiles

Content Integration Profiles (2005) Content Integration Profiles (2005) Medical Summaries (XDS-MS)Medical Summaries (XDS-MS)

• PCP to Specialist ReferralPCP to Specialist Referral• Acute Care Discharge (to PCP)Acute Care Discharge (to PCP)

Unstructured Document Exchange (XDS-pdf)Unstructured Document Exchange (XDS-pdf)

Content Integration Profiles (in-progress 2006)Content Integration Profiles (in-progress 2006) Medical Summaries (XDS-MS)Medical Summaries (XDS-MS)

• PCP to ED ReferralPCP to ED Referral Pre-procedure History & Physical (PPHP) Pre-procedure History & Physical (PPHP) Exchange of Personal Health Record (XPHR)Exchange of Personal Health Record (XPHR) Basic Patient Privacy Consents (BPPC)Basic Patient Privacy Consents (BPPC) Sharing of Lab Reports (XDS-LAB)Sharing of Lab Reports (XDS-LAB)

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XDS for Images (XDS-I)XDS for Images (XDS-I)

Cross Enterprise Sharing of Imaging Cross Enterprise Sharing of Imaging Information (XDS-I) from IHE RadiologyInformation (XDS-I) from IHE Radiology

Options (at least one):Options (at least one): Extensive Set of DICOM Instances Extensive Set of DICOM Instances PDF Report PDF Report Text Report Text Report Multipart Text/PDF ReportMultipart Text/PDF Report

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Q&AQ&A

Any Questions?:Any Questions?: North American Connectathon:North American Connectathon:

• Contract Due Sept 15Contract Due Sept 15thth, 2006, via Kudu web tool , 2006, via Kudu web tool registration (registration (www.ihe.netwww.ihe.net))

• January 15-19, 2007, Chicago, ILJanuary 15-19, 2007, Chicago, IL

American College of Cardiology:American College of Cardiology:• Contract Due Sept 15Contract Due Sept 15thth, 2006, , 2006, www.acc.org/ihe.htmwww.acc.org/ihe.htm• March 24-27, 2006, New Orleans, LAMarch 24-27, 2006, New Orleans, LA