cardiac catheterization workflow: tom dolan

1

IHE Cardiology IHE Cardiology Profiles for Year 1Profiles for Year 1

Tom Dolan, Philips

Co-editor, IHE Cardiology Technical Committee

IHE Educational Workshop 2004 Dolan – p. 2

Presentation structurePresentation structure

IHE Cardiology profile context– What we are covering and why

Cardiology Catheterization Workflow– Overview, benefits, actors/transactions,

highlights

ASSUMPTIONS– Basic understanding of IHE concepts from

earlier sessions


Three profiles selected for year 1Three profiles selected for year 1Cardiac Catheterization Workflow– Based on IHE Radiology Scheduled Workflow and

Patient Information Reconciliation Profiles

Echocardiography Workflow– Based on IHE Radiology Scheduled Workflow and

Patient Information Reconciliation Profiles

Retrieve ECG for Display– Based on IHE IT Infrastructure Retrieve

Information for Display Profile


Why Why thesethese profiles? profiles?

High return on investment - important integration

problems

Standards in place (DICOM, HL7)

Leverage IHE Radiology and IT Infrastructure

No “political” challenges – just technical

Restricted scope for “quick win”


Cath LabCath Lab

(A) room for improvement !


Cath Workflow ManagementCath Workflow Management Multi-Modality, Multi-Modality, IntraIntra-Lab issues-Lab issues

Multiple re-entry of Patient ID

Error prone

Results fragmented across systems

Custom solutions needed for data sharing

Difficult to manage


Cath Workflow Cath Workflow Management Management ExtraExtra-lab issues -lab issues

Un-ordered cath exams (emergency)Unidentified patientsUncoordinated with Hospital Information SystemDiagnostic and interventional proceduresAd hoc scheduling of cath labsChange of rooms during procedure… and interactions among these issues!


Cardiac Catheterization WorkflowCardiac Catheterization Workflow- What’s in?- What’s in?

Management of cath exams (in-lab portion)– Similar to IHE-Radiology SWF

– Multi-modality, multiple procedure steps

Reconciliation of patient information– Similar to IHE-Radiology PIR

– Unscheduled cath is the norm, not the exception

Time synchronization– Modalities must support IHE-ITI Consistent Time


Pre-cath and post-cath activity

Hemo waveforms and reports*

Procedure logs

QCA/QVA*

Final cath reports*

Supply chain*Archives must support storage, but no actors specified for display

Cardiac Catheterization Workflow- What’s OUT?…for year 1

But on the 5-But on the 5-year year

roadmap!roadmap!

Diagnostic Procedure

Post- Procedure

Events

End of Episode

Event

Long-Term Follow-Up

Intervention (optional)

…

Addressed in Year 1

Admission to

Facility

Pre- Procedure Evaluation

Report

Amended Report

(optional)

Export to Registry

(optional)


Cath actors and transactionsCath actors and transactions

↑↑

↓ Pt. Registration [Rad-1]↓ Patient Update [Rad-12]

Pt. Registration [Rad-1] ↓ Patient Update [Rad-12] ↓

← Placer Order Management [Rad-2]→ Filler Order Management [Rad-3]

ADT

↓ Query Images [Rad-14]↓ Retrieve Images [Card-4]

Image Display

Modality Image/Evidence Stored [Card-2]

Storage Commitment

[Card-3]

↓ Procedure Scheduled [Rad-4]

↓ Procedure Updated [Rad-13]

← Query Modality Worklist [Rad-5]

Performed Procedure

Step Manager

↑ Modality PS in Progress [Card-1]↑ Modality PS Completed [Rad-7]

→ Modality PS in Progress [Card-1]→ Modality PS Completed [Rad-7]

← Modality PS in Progress [Card-1]← Modality PS Completed [Rad-7]

Order Placer

Acquisition Modality

ImageManager

Image Archive

DSS/ Order Filler

↓ Patient Update [Rad-12]

Many actors cooperating in a complete end-Many actors cooperating in a complete end-to-end workflowto-end workflow

Documented in the Technical FrameworkDocumented in the Technical Framework


Actors/Transactions take-awayActors/Transactions take-away

NO new actors– Same actors as Radiology scheduled

workflow

4 “modified” transactions– Existing Radiology-based transactions

have been modified to accommodate cardiology specifics


Cardiac Cath – 8 use casesCardiac Cath – 8 use casesAll use cases must be supported

Case C1: Patient Registered at ADT and Procedure Ordered at the Order Placer

Case C2: Patient Registered at ADT and Procedure Ordered at DSS/OF

Case C3: Patient Registered at ADT and Procedure Not Ordered

Case C4: Patient Registered at DSS/OF and Procedure Ordered

Case C5: Patient Not Registered

Case C6: Patient Updated During Procedure

Case C7: Change Rooms During Procedure

Case C8: Cancel Procedure


Cath Workflow ManagementCath Workflow Management

Technical Framework requirements:– Diagnostic/Interventional may be managed at the Procedure

Step level, or may simply be reported at end of case– Support for ad hoc scheduling, room reassignment, and

multi-modality coordinated identifiers– Backfilling of orders to Order Entry system– Complete patient demographics update capability

Technical Framework recommendation:– Single Requested Procedure for cath procedure (not split

into Diagnostic and Interventional)


BenefitsBenefitsSimplify Management of Cath exams (In Lab)– High-value, high-complexity workflow addressed

Basic lab-centric workflow addressed Worklist-driven for speed and accuracy Solid basis for extension in future

Reuse of existing standards – Similar to IHE-Radiology SWF means savings in

training, development and reduced risk– But cath-specific issues addressed

Aim to remove the integration-barriers compromising efficiency and safety between cath-modalities/vendors


ACTORSACTORSAcquisition Modality – A system that acquires and creates medical images or waveforms while a patient is present, e.g., an X-ray angiography or hemodynamic measurement system. A modality may also create other evidence objects such as Structured Report Documents containing measurements.

ADT – A system responsible for adding and/or updating patient demographic and encounter information (Admission/Discharge/Transfer). In particular, it registers a new patient with the Order Placer and Department System.

Department System Scheduler/Order Filler – A department-based (for instance, Cardiology or Radiology) information system that provides functions related to the management of orders received from external systems or through the department system’s user interface.

Image Archive – A system that provides long term storage of evidence objects such as images, presentation states, Key Image Notes and Evidence Documents.


ACTORSACTORSImage Display – A system that offers browsing of patients’ studies. In addition, it may support the retrieval and display of selected evidence objects including sets of images, presentation states, Key Image Notes, and/or Evidence Documents.

Image Manager – A system that provides functions related to safe storage and management of evidence objects. It supplies availability information for those objects to the Department System Scheduler.

Order Placer – A hospital or enterprise-wide system that generates orders for various departments and distributes those orders to the correct department.

Performed Procedure Step Manager – A system that re-distributes the Modality Performed Procedure Step information from the Acquisition Modality to the Department System Scheduler/Order Filler and Image Manager.

Time Client – A system unit that synchronizes its time of day clock to the correct time provided by a time server


TRANSACTIONSTRANSACTIONSPatient Registration – The ADT system registers and/or admits a patient and forwards the information to other information systems. [RAD-1]

Placer Order Management – The Order Placer informs the Order Filler of the initiation or cancellation of an order. The Placer/Filler Order Management transaction will sometimes be referred to as “-New” when a new order is being initiated, or as “-Cancel” when an existing order is canceled. [RAD-2]

Filler Order Management – The Order Filler informs the Order Placer of the initiation, cancellation, or change in the status of an order. The Placer/Filler Order Management transaction will sometimes be referred to as “-New” when a new order is being initiated, or as “-Cancel” when an existing order is canceled. [RAD-3]

Procedure Scheduled – Schedule information is sent from the Department System Scheduler/Order Filler to the Image Manager. [RAD-4]

Query Modality Worklist – Based on a query entered at the Acquisition Modality, a modality worklist is generated listing all the items that satisfy the query. This list of Scheduled Procedure Steps with selected demographic information is returned to the Acquisition Modality [RAD-5].

Modality Procedure Step In Progress – An Acquisition Modality notifies the Performed Procedure Step Manager of the start of a new Procedure Step and the PPS Manager informs the Department System Scheduler/Order Filler and Image Manager. [CARD-1, derived from RAD-6]


TRANSACTIONSTRANSACTIONSModality Procedure Step Completed – An Acquisition Modality notifies the Performed Procedure Step Manager of the completion of a Procedure Step and the PPS Manager informs the Department System Scheduler/Order Filler and Image Manager. [RAD-7]

Modality Images/Evidence Stored – An Acquisition Modality sends acquired or generated images, waveforms, or other evidence documents to the Image Archive. [CARD-2, derived from RAD-8 and RAD-43]

Storage Commitment – A requestor (Acquisition Modality) requests that the Image Manager confirm ownership for the specified DICOM objects (images, waveforms, evidence documents, or any combination thereof) that the requestor stored in the Image Archive, thus allowing the sender to delete those objects now owned by the Image Manager. [CARD-3, derived from RAD-10]

Patient Update – The ADT Patient Registration System informs the Order Placer and the Department System Scheduler/Order Filler of new information for a particular patient. The Department System Scheduler may then further inform the Image Manager. [RAD-12]

Procedure Update – The Department System Scheduler/Order Filler sends the Image Manager updated order or procedure information. [RAD-13]

Query Images – An Image Display queries the Image Archive for a list of entries representing images by patient, study, series, or instance. [RAD-14]

Retrieve Images – An Image Display requests and retrieves a particular image or set of images from the Image Archive. [CARD-4, derived from RAD-16]Maintain Time – Synchronize the local time with the time maintained by the Time Server. [ITI-1]


Case 1 : Patient Registered at ADT and Ordered Case 1 : Patient Registered at ADT and Ordered at the Order Placer at the Order Placer

Clinical Context– Corresponds to traditional Radiology workflow– Order placed in central system– Also deals with case where emergency identifier has been

created– Common identifiers known ahead of time

IHE Context– MPPS in Progress from first modality used to update

worklists for others


Case 2 : Patient Registered at ADT and Ordered Case 2 : Patient Registered at ADT and Ordered at DSS/OF at DSS/OF

Clinical Context– Slight difference to Case 1– Order placed NOT in central system but in department– Department system provides info to Central ordering system – Typical of many institutes, relieves need for HIS terminal in

lab

IHE Context– Filler Order Management (New Order) transaction [RAD-3]

is sent from Department System Scheduler/Order Filler to the Order Placer.


Case 3 : Patient Registered at ADT and ProcedureCase 3 : Patient Registered at ADT and Procedure

Not OrderedNot Ordered – Schedule on MPPS – Schedule on MPPS

Clinical Context– Procedure not ordered at hospital/dept. e.g. due to time-

constraints.– A modality initiates creation of common identifiers on

Departmental system – Allows multiple modalities participating in the case to be

synchronized

IHE Context– DSS/OF creates a Requested Procedure/Scheduled

Procedure Steps in response to the first MPPS-In-Progress – Requested Procedure created without waiting for response

from Order Placer. This improves speed of cross-modality synchronization

TO BE CONTINUED……


Case 4 : Patient Registered at Department System Case 4 : Patient Registered at Department System Scheduler/OF and Procedure OrderedScheduler/OF and Procedure Ordered

Clinical Context– Variation on Case 2 (procedure ordered in Department)– Patient registered NOT in central system but in department– Covers emergency case or when HIS is unavailable – Temporary Patient identifier used, – Manual reconciliation with official HIS ID later is used to update

department records and ordering system

IHE Context– Temp ID is used to schedule procedure steps to modalities as

normal. – Filler Order management is not invoked until after the

reconciliation with official ID occurs. This is trigger to update DSS/OF, Image Manager and Order Placer with official patient, and order numbers


Case 5 : Patient NOT RegisteredCase 5 : Patient NOT Registered

Clinical Context– Combination of Case 3 and Case 4– No information/time to create patient/order identifiers at HIS or

Department system– Patient ID entered at first modality is adopted for other

modalities (as in Case 4)– procedure triggered by first modality shared across other

modalities (as in Case 3)

IHE Context– DSS/OF creates a Requested Procedure/Scheduled

Procedure Steps in response to the first MPPS-In-Progress– Filler Order management is not invoked until after the

reconciliation with official ID occurs. This is trigger to update DSS/OF, Image Manager and Order Placer with official patient, and order numbers


Case 6 : Patient Update During Procedure Case 6 : Patient Update During Procedure

Clinical Context– unidentified patient registered at the ADT system and

brought into the cath lab with temporary patient demographics

– Patient is identified and official ID/demographics sent by HIS while procedure is in progress.

– Some data in the procedure is produced with temporary info and some with official.

– This must be reconciled across the procedure

IHE Context– Modality may continue to transmit data with temporary

identifiers– DSS/OF and Image Manager must continue to automatically

reconcile such incoming data with the official data throughout procedure.


Case 7 : Change RoomsCase 7 : Change Rooms During Procedure During Procedure Clinical Context– Not uncommon – diagnostic interventional, equipment failure,…– procedure is halted in one room, with one set of modality

equipment, and resumed in another room with different equipment– For continuity of clinical data, it is critical that this be treated as a

single Procedure

IHE Context (no comparable case in Radiology TF)– Each modality in the first room will issue a Modality Procedure

Step Completed or Discontinued Note – not required prior to moving, can be done later, but needed to

complete the step at end of procvedure.

– DSS/OF used to can reassign the Requested Procedure to a new room and create Scheduled Procedure Steps for those modalities who use WLM to restart procedure

– IF no re-assignment - new modalities can issue broad (not own AE Title) query to get original SPS and then append an MPPS to that


Case 8 : Cancel Procedure Case 8 : Cancel Procedure

Clinical Context– When cases are cancelled it’s important that information

systems reflect same so that staff are informed and can respond appropriately.

– Case covers procedure cancelled prior to start

IHE Context– DSS/OF notifies the Order Placer system and Image

Manger. – All three systems may maintain information about the

cancelled Order and Requested Procedure for a pre-determined length of time.


Case 3: Patient Registered at ADT and Procedure Not Ordered – Schedule on MPPSCase 3A: Unidentified Patient Registered at ADT and Procedure Not Ordered

Patient Registration [RAD-1]

Register J.Doe

ADT Order Placer

AcquisitionModality

Filler OrderManagement - New [RAD-3]

Department System Scheduler/ Order Filler

Auto-create Procedure

Procedure Scheduled [RAD-4]

Modality Procedure Step Completed [RAD-7]

Modality Procedure Step Completed [RAD-7]

Modality Procedure Step In Progress [CARD-1]

Modality Procedure Step In Progress [CARD-1]

AcquisitionModality n

Query Modality Worklist [RAD-5]

Patient Reconciliation

J.Doe -> J.Smith

Patient Update/Merge [RAD-12]

Patient Update/

Merge [RAD-12]

Perform Acquisition

Perform Acquisition

Filler Order Mgmt - Status Update [RAD-3]

ImageManager/

PPS Manager

Filler Order Mgmt - Status Update [RAD-3]

Case 3 : again….. Case 3 : again…..


Case 3 : Case 3 : Significant TransactionsSignificant Transactions

– MWLM query (not shown) will not return a response for current patient

(from card/wristband)

– Unscheduled Performed Procedure Step created

– DSS/OF recognizes patient and room from data in MPPS-In-Progress

[CARD-1] (i.e. Patient ID and AE Title)

– DSS/OF creates a (generic/specific) Requested Procedure/Scheduled

Procedure Steps for other modalities in room using info above.

Different than Radiology !

– Order Placer and Image Manager informed of new, active procedure.

– Requested Procedure created without waiting for response from Order

Placer. This improves speed of cross-modality synchronization.

– Subsequent MWLM queries [RAD-5] from equipment in this cath lab

will receive the appropriate scheduled procedure steps including the

necessary patient/study identifiers


Case 3 : Case 3 : HighlightsHighlights

Contributions– Multi-modality synchronization supported– Modality-initiated, ad-hoc, cases become “managed”

Time delays between first MPPS and shared SPS are seconds/minutes

Avoids trying to synch multiple studyUID’s later (not addressed)

Different…. not Deviant – Auto create of Requested Procedure contradicts “letter” of IHE-

R – but not “spirit” Goal is to reconcile and unscheduled PPS with a Requested

Procedure


For more info:For more info:

IHE Cardiology Technical Framework version 1.0 for Trial Implementation at:– www.rsna.org/ihe– www.acc.org/quality/ihe.htm

Submit questions and comments to:– http://forums.rsna.org

http://www.rsna.org/ihe

http://www.acc.org/quality/ihe.htm

http://forums.rsna.org/


IHE WorkflowIHE Workflow

Three levels of IHE workflow control:– Order / Requested Procedure / Procedure Step

Workflow management issues for cath– Un-ordered cath exams (emergency)

– Unidentified patients

– Multi-modality coordination

– Diagnostic and interventional procedures

– Change of rooms during procedure

– … and interactions among these issues!


Integration Profile:Integration Profile:A Solution to an Integration ProblemA Solution to an Integration Problem

Actors cooperating

through TransactionsTransactions

to solve a specific problem

↓ Pt. Registration [Rad-1]↓ Patient Update [Rad-12]

Pt. Registration [Rad-1] ↓ Patient Update [Rad-12] ↓

← Placer Order Management [Rad-2]→ Filler Order Management [Rad-3]

ADT

↓ Procedure Scheduled [Rad-4]

↓ Procedure Updated [Rad-13]

↑ Modality PS in Progress [Card-1]↑ Modality PS Completed [Rad-7]

Order PlacerDSS/ Order Filler

↓ Patient Update [Rad-12]