who’s who
DESCRIPTION
Jan 2012 HL7 Working Group Cytometry Meeting. Who’s who. Harry Solomon. Interoperability Standards Development Organizations (SDO’s). Four level model of “use” in interoperability. Workflow. business process : tasks. Messaging. exchange : mail. Format. data record : document. - PowerPoint PPT PresentationTRANSCRIPT
Who’s who
Harry Solomon
Jan 2012HL7 Working
GroupCytometryMeeting
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Jan 2012HL7
CytometryMeeting
Interoperability Standards Development Organizations (SDO’s)
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Jan 2012HL7
CytometryMeeting
Four level model of “use” in interoperability
business process : tasks exchange : mail
data record : documentterminology : words
WorkflowMessaging
FormatVocabulary
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Jan 2012HL7
CytometryMeeting
Vocabulary for lab tests and observationsResponsive for new tests/measurements
Vocabulary for medicine, anatomy, procedures, clinical findingsRobust concept model
WorkflowMessagin
gFormatVocabular
y
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Jan 2012HL7
CytometryMeeting
General organization for cytometry; standards committeeFocused on cytometry research, small standards groupExample standards:• Data File Standard for Flow Cytometry (FCS)• Minimum Information about a Flow Cytometry
Experiment• Image Cytometry Experiment Format (proposed)
WorkflowMessagin
gFormatVocabular
y
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Jan 2012HL7
CytometryMeeting
Standards for clinical labsMostly process quality specifications, some interoperability specsExample standards:• Laboratory Automation: Communications With
Automated Clinical Laboratory Systems, Instruments, Devices, and Information Systems
• Laboratory Automation: Data Content for Specimen Identification
• Point-of-Care Connectivity
WorkflowMessagin
gFormatVocabular
y
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CytometryMeeting
Interoperability standards for healthcareBroadest healthcare standards organization, robust information modeling frameworkExample standards:• HL7 v2 ADT (Patient Demographics), Orders,
Observations (Results), Lab Automation Control• HL7 v3 Reference Information Model• Clinical Document Architecture• Electronic Health Record Functional Model
WorkflowMessagin
gFormatVocabular
y
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CytometryMeeting
Interoperability standards for medical imaging Supports bulk binary data, persistent object model, department workflow, universally implemented in radiologyExample standards:• Microscopic Image, Whole Slide Image• Modality Worklist / Performed Procedure Step• Storage Commitment
WorkflowMessagin
gFormatVocabular
y
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Jan 2012HL7
CytometryMeeting
Integrating the Healthcare Enterprise, a pubilc-private collaboration promoting standards-based interoperabilityUse cases from professional society participants (CAP, NAACCR) drive implementation guides, Connectathons, demonstrationsExample standards:• Anatomic Pathology Workflow Profile• Physician Reporting to Public Health – Cancer
Registry• Cross-Enterprise Document Sharing Profile
WorkflowMessagin
gFormatVocabular
y
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Jan 2012HL7
CytometryMeeting
Cooperation
HL7 cooperative agreements / MoU’s / affiliations with all other SDO’sHL7 & DICOM – Joint Working Group (IIWG/WG-20) meets at 3 annual HL7 WGMsDICOM & LOINC / IHTSDO – DICOM submits proposed concepts for coding
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CytometryMeeting
HL7 v2
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CytometryMeeting
HL7 v2 Messaging Standard: What
HL7 Messaging Standard - An Application Protocol for Electronic Data Exchange in Healthcare EnvironmentsEnables disparate healthcare applications to exchange clinical and administrative dataDefines the data content and provides the layout of messages that are exchanged between applications based upon a particular trigger event
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CytometryMeeting
HL7 Version 2 Messaging
SENDINGAPPLICATION(Patient Administration)
RECEIVINGAPPLICATION(Lab System)
ADMIT MESSAGE (ADT)
ACKNOWLEDGEMENT (ACK)
TRIGGER EVENT:Patient is Admitted!
PID attributesSEQ ELEMENT NAME1 Set ID - Patient ID2 Patient ID3 Patient ID List4 Alternate Patient ID5 Patient Name6 Mother’s Maiden Name7 Date/Time of Birth8 Sex9 Patient Alias
ETC.
….PID|||12345||Lorenzi^Virginia||19811231|F…
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CytometryMeeting
HL7 specification terms
Message - an ordered collection of segments, associated with a trigger eventTrigger event - a real world cause for the exchange of dataSegment - an ordered collection of data elements that typically share a common subject• Specifies whether the data element is required or optional and
whether it may repeat.Data element - a unit of exchanged meaning, with a data type and suggested length, and possibly a table of valid valuesData types - encoding of meaning in a constrained character string, or constructs of component data types• Limited to two levels of defined construct (components,
subcomponents)
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Example HL7 v2 ADT Message
MSH|^~\&|ADMIN|MCM|LABADT|MCM|198808181126|SECURITY|ADT^A01^ADT_A01|MSG00001|P|2.4| <cr>EVN|A01|198808181123||<cr>PID|1||PATID1234^5^M11^ADT1^MR^MCM~123456789^^^USSSA^SS||JONES^WILLIAM^A^III||19610615|M-||C|1200 N ELM STREET^^GREENSBORO^NC^27401-1020|GL| (919)379-1212| (919)271-3434||M||PATID12345001^2^M10^ADT1^AN^A|123456789|9-87654^NC|<cr>NK1|1|JONES^BARBARA^K|WI^WIFE||||NK^NEXT OF KIN<cr>PV1|1|I|2000^2012^01||||004777^LEBAUER^SIDNEY^J.|||SUR||-||ADM|A0-|<cr>
Patient William A. Jones, III was admitted on August 18, 1988 at 11:23 a.m.His wife, Barbara K. Jones is a related family member (next of kin).He has been assigned to room 2012, bed 01 on nursing unit 2000.To be attended by doctor Sidney J. Lebauer (ID# 004777) for surgery.
Character based, similar to mag tape records
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Example HL7 v2 ADT Message
MSH|^~\&|ADMIN|MCM|LABADT|MCM|198808181126|SECURITY|ADT^A01^ADT_A01|MSG00001|P|2.4| <cr>EVN|A01|198808181123||<cr>PID|1||PATID1234^5^M11^ADT1^MR^MCM~123456789^^^USSSA^SS||JONES^WILLIAM^A^III||19610615|M-||C|1200 N ELM STREET^^GREENSBORO^NC^27401-1020|GL| (919)379-1212| (919)271-3434||M||PATID12345001^2^M10^ADT1^AN^A|123456789|9-87654^NC|<cr>NK1|1|JONES^BARBARA^K|WI^WIFE||||NK^NEXT OF KIN<cr>PV1|1|I|2000^2012^01||||004777^LEBAUER^SIDNEY^J.|||SUR||-||ADM|A0-|<cr> Message
Type – 3 char code for the type of message sent
Trigger Event – 3 char code for the real world event causing the message
Segment Type – 3 char code for the logical group of information
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CytometryMeeting
HL7 implementation architecture
“The Standard is written from the assumption that an event in the real world of healthcare creates the need for data to flow among systems. The real-world event is called the trigger event.” “HL7 does not explicitly support, but can be used with, systems that support store and forward and data broadcast facilities.”
HL7 push model issues• Handling multipoint ACKs• Offline systemsTypical implementation withstore and forward interface engine
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CytometryMeeting v2 Table of Contents
Chapter 1 - IntroductionChapter 2 - Control (Conformance added v2.5)Chapter 3 - Patient AdministrationChapter 4 - Order EntryChapter 5 - Query (in Chap 2 in v2.2-v2.3.1)Chapter 6 - Financial ManagementChapter 7 - Observation ReportingChapter 8 - Master Files (added v2.2)Chapter 9 - Medical Records (Document Mgmt) (added v2.3)Chapter 10 - Scheduling (added v2.3)Chapter 11 - Patient Referral (added v2.3)Chapter 12 - Patient Care (added v2.3)Chapter 13 - Clinical Laboratory Automation (added v2.4)Chapter 14 - Application Management (added v2.4)Chapter 15 - Personnel Management (added v2.4)Chapter 16 - eClaims (added v2.6)Chapter 17 - Materials Management (added v2.6)
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Look at ToC’s for Chapters 3, 4, 7, 13
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HL7 CDA
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HL7 Clinical Document Architecture
The scope of the CDA is the standardization of clinical documents for exchange.A clinical document is a record of observations and other services with the following characteristics:• Persistence• Stewardship• Potential for authentication• Wholeness• Human readabilityA CDA document is a defined and complete information object that can exist outside of a message, and can include text, images, sounds, and other multimedia content. A CDA is not an isolated finding or measurement, or an aggregation of documents
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Key Aspects of the CDA
CDA documents are encoded in Extensible Markup Language (XML)CDA documents derive their meaning from the HL7 v3 Reference Information Model (RIM ) and use HL7 v3 Data TypesA CDA document consists of a header and a body• Header is consistent across all clinical documents - identifies
and classifies the document, provides information on patient, provider, encounter, and authentication; allows document management, compilation of an individual patient's clinical documents into an electronic patient record
• Body contains narrative text / multimedia content (level 1), optionally structured into sections with coded titles and tagged narrative content (level 2), optionally augmented by coded equivalents to narrative (level 3)
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CDA Release 2 Information Model
Header Body
ParticipantsSections/Headings
Clinical Statements/Coded Entries
ExtlRefsContext
Doc ID&Type
StartHere
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CytometryMeeting
CDA Structured Body
Structured Body
SectionText
SectionText
SectionText
SectionText
SectionText
SectionText
EntryCoded statement
EntryCoded statement
EntryCoded statement
Arrows are Act Relationships • Has component, Derived from, etc.Entries are coded clinical statements• Observation, Procedure, Substance administration, etc.
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Narrative and Coded Info
CDA structured body requires human-readable “Narrative Block”, all that is needed to reproduce the legally attested clinical contentCDA allows optional machine-readable coded “Entries”, which drive automated processesNarrative may be flagged as derived from Entries • Textual rendering of coded entries’ content, and contains no
clinical content not derived from the entries General method for coding clinical statements is a hard, unsolved problem• CDA allows incremental improvement to amount of coded
data without breaking the model
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Narrative and Coded Entry Example
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Implementation Guides
CDA is a very generic structure focused on human-readable content• Great for minimally marked-up documents• Not much required to render narrative
contentMachine processing (more powerful apps) requires standardization of CDA structures and entries• Implementation guides for specific clinical
uses• Templates for documents, sections, entries
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PCC Technical Framework
EDR
Continuity of Care Document Ancestry HL7 RIM
Data TypesVocabulary
CDA
CRS
CCR
CCD
ClinicalStatement
Model
XDS-MS(R3)
C32
APS
EDES
FSA
2004 - 2006
1998 - 2004
2002 - 2005
2003 – 2007
O&ODomainModelGenomicsDomainModelPatient Care
DomainModel
Other DomainModels
2005 - 2006
2005 - 20062006 -
20072006 - 2007
2006 - 2007
C37
2006 - 2007
ASIG1999 - 2007
XDS-MS (R1)
2006 - 2007
2006 - 2007
2006 - 2007
2007 - 2008
2007 - 2008
2007 - 2008
CDA4CDT2007
XD*-LAB
QED2007 - 2008
XPHRC83
C80
2008
Inherits from
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CytometryMeeting
CDA Consolidation
Need one-stop shop for CDA templatesConsolidated CDA implementation guide incorporating HL7, IHE, and Health Story projectsFunded by ONCHITBasis for care coordination interoperability under Meaningful Use Stage 2 incentives (2014)Balloted through HL7 May 2011, Approved as DSTU December 2011
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DICOM
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Scope of DICOM Standard
The International Standard for Medical Imaging and related informationStandard object formats for images, waveforms, derived structured data (measurements and assessments)Workflow management in the imaging departmentService-based network protocol over TCP/IP; media interchange
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DICOM Key Features
Object-oriented, persistent information objectsTagged data elements, binary encodingClient-server network services, service negotiation Image compression by encapsulationConformance Statements
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DICOM Image Information Object Definition
PatientModule
PatientStudy
Module
GeneralSeriesModule
GeneralStudy
Module
Frame ofReferenc
eModule
GeneralEquipme
ntModule
GeneralImageModule
ImagePlane
Module
Contrast/
BolusModule
ImagePixel
Module
ModalityImageModule
Multi-frame
Module…VOI
LUTModule
SOPCommonModule
PatientInformation
StudyInformation
SeriesInformation
Image(Instance)
Information
Patient NamePatient ID
Patient SexPatient Birthdate
Study Unique ID
Accession NumberStudy
Date/TimeStudy
DescriptionReferring MD
Rows/ColumnsBits per PixelPhotometric
DICOM Composite
Information Model
Hierarchy
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CytometryMeeting
DICOM Network Services
Information object exchangeReliable object storage (commitment)Object repository (PACS) query / retrieveModality worklist query Performed procedure step status notificationImage print
Application protocol riding on TCP/IP
(at same level as FTP, HTTP)
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Data Element Encoding
0020000DhexUI 1.2.840.1.113709.9.0.0.5743.14575602.126hex
Study InstanceUnique Identifier
(0020,000D)
Instance UID encoded as “dotted decimal”
Data Set
Data Element
Tag Value Length Value Field
optional field - dependent on negotiated Transfer Syntax
ValueRepresen
-tation
Data Elem. Data Elem.Data Elem. Data Elem.
order of transmission
Attributes are the logical concepts associated with an information entity
Data elements are how attributes are encoded in an information object
Similar to TIFF
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Part of a DICOM object(0008,0005) CS 30 ISO 2022 IR 13\ISO 2022 IR 87
(0008,0008) CS 22 ORIGINAL\PRIMARY\AXIAL
(0008,0016) UI 26 1.2.840.10008.5.1.4.1.1.2
(0008,0018) UI 58 1.2.392.200036.9116.2.6.1.48.12393615.1211874194
.564494(0008,0020) DA 8 20080527
(0008,0021) DA 8 20080527
(0008,0022) DA 8 20080527
(0008,0023) DA 8 20080527
(0008,0030) TM 10 163836.000
(0008,0031) TM 10 164306.390
(0008,0032) TM 10 164039.850
(0008,0033) TM 10 164040.397
(0008,0050) SH 8 5162581
(0008,0060) CS 2 CT
(0008,0070) LO 8 TOSHIBA
…(7FE0,0010) OW 52428
8 00 00 00 00 ff ff ff ff 00 0f 4c 4a 49 46 00 01...
Tags in increasing numeric orderValue length always an even numberAttributes related to modules and
information model levels NOT contiguous
PatientInformation
StudyInformation
SeriesInformation
Image(Instance)
Information
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The Service-Object Pair (SOP) Class
The unit of interoperability and conformanceService: network function between user (client)
and provider (server)• Store (transfer), query, move, create, notify …∴ SOP Classes represent functionality on
information objects • Store a CT image • Store an MR image• Find (list) all studies for a patient • Find the worklist for a
modality• Move a set of images • Create an image print job• Request/Notify the secure storage of images• Notify the performance of a procedure step
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CytometryMeeting
DICOM Network Negotiation
First step application level handshake in setting up Association (network connection)
Agreement on SOP Classes, roles (client/server), image compression, security
One message roundtrip (initiator to acceptor and back)
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Storage Commitment
“Object Storage” is basic DICOM service for network transfer of images – but has no required receiver behavior• C-STORE acknowledgment simply means the objects were
received whole• Objects can be successfully received by an image archive
system, but a system failure could cause them to be lost prior to reliable storage
Storage Commitment provides an explicit acknowledgment of reliable storage of specific objects• The sending system can then safely delete objects from local
store, e.g., auto-purgeStorage Commitment may incur a substantial delay• E.g., after overnight copy to tertiary storage
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Storage and Storage Commitment
Modality Transmits Images (or other Objects) to PACS:
C-STORE transfer of images (acknowledged)Modality Issues Storage Commitment Request to PACS:
N-ACTION including List of objects to be committed (acknowledged)
PACS Notifies Modality of Success (or Failure) :N-EVENT-REPORT including List of objects committed (acknowledged)
PACSModality
③
①
①
②
②③
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DICOM Query/RetrieveAllows a system to query another system for a list of available images (query)Also allows a system to request another system to send images (retrieve)
Query Request
Retrieve Request
Image(s) Send
Store Response(s)
Retrieve Response
Query Match(es)PACS
Query/RetrieveSCP
Query/RetrieveSCU
Workstation
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Managed Workflow Concepts
PROCEDURE STEP : The smallest unit of managed workin the workflow
Scheduled Procedure Step: ‘A unit of work to do’Performed Procedure Step: ‘A unit of work done’
ORDER : A request for departmental service
REQUESTED PROCEDURE : Unit of work resulting in one Report
with associated codified, billable acts
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Workflow structuring is user oriented
ORDER:A request for departmental service
(Accession Number)
REQUESTED PROCEDURE : Unit of work resulting in one Report
with associated codified, billable acts(Requested Procedure ID)
PROCEDURE STEP :The smallest unit of managed
workin the workflow
(modality worklist entry)
CLINICIANOR REFERRING DOC:
The Imaging Dept Customer
RADIOLOGIST/ PATHOLOGIST :
In Charge of producing the Report
TECHNOLOGISTIn charge of
acquiring images, etc.
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Simple WorkflowOne Order – One Procedure – One Study – One Report
AcquisitionModality
ORDERA request for DepartmentalService
Imaging Department
Set of Codifiab
le,Billable,
Acts
One or more series of images
PerformedProcedure
StepRequestedProcedure
ScheduledProcedure
Step
Report
DICOMModality Worklist
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CytometryMeeting
AcquisitionModality
AcquisitionModality
Multiple Modality Steps
ORDERA request for DepartmentalService
Imaging Department
Set of Codifiab
le,Billable,
Acts
One or more series of images
PerformedProcedure
Step P1
ScheduledProcedure
Step B
RequestedProcedure
ScheduledProcedure
Step A
Report
One or more series of images
PerformedProcedure
Step P2
DICOMModality Worklist
DICOMModality Worklist