Managing Clinical Imaging in EMRs. Guillermo Elizondo, MD, PhD Department of Radiology University Hospital, UANL Monterrey, NL Mexico

Transcription

1 Managing Clinical Imaging in EMRs Guillermo Elizondo, MD, PhD Department of Radiology University Hospital, UANL Monterrey, NL Mexico

2 I ask Congress to move forward on a comprehensive health care agenda improved informahon technology to prevent medical errors and needless costs George W. Bush, State of the Union, 2005

3 DiagnosHc Radiology Re- Defined: The use of various imaging tools to examine the body in order to guide pahent treatment

4 Imaging Tools: CT Scanning (CAT Scan) MRI (Magne:c Resonance Imaging) Ultrasound Angiography & IntervenHonal X- ray & Fluoroscopy Mammography & etc. Ultrasound CT Scanning MRI

5 Systems/ApplicaHons VOCABULARY/ ACRONYMS HIS EMR Hospital Information System Electronic Medical Record system RIS* Radiology Information System PACS* Picture Archiving & Communication Systems Medical Imaging Modality = equipment (xray machine, MRI, etc)

6 VOCABULARY/ OrganizaHons ACRONYMS (cont) HL7 DICOM NEMA ACR Health Level 7: an ANSI-accredited Standards Developing Organization Digital Imaging & Communications in Medicine std National Electronics Manufacturers Association (electronics stds body) American College of Radiologists IHE Integrating the Health Enterprise Consortium of interested parties HIMSS Healthcare Information & Management Systems Society

7 Information Management Using PACS All Recent Exams Are PreFetched Automatically When Exam is Scheduled Seconds Later, A Remote Specialist Can Read Study Referring Physician Receives Results Via Web Within Hours Chaotic Previous Exam Is Somewhere In Here All Information, Anywhere, Any Time Productivity (Exams/Day) Results Of PACS Implementations 66%+ reduction in reporting time 80%+ reduction in film usage 30%+ reduction in FTEs Report Turnaround Time (Hrs) % 66% 216 Mean Std. Dev Before After Before Tremendous Benefits From Workflow Optimization After

8 Radiology is an applied IT field Diagnosis? Digital Image: A Dx Puzzle & Fax Results

9 Radiology: InformaHon Steps The Radiologist Works HERE!

10 DiagnosHc Radiology PACS: Picture Archival & CommunicaHon System DICOM: A Digital CommunicaHon Standard between DiagnosHc ModaliHes & PACS IHE: IntegraHng the Healthcare Enterprise Radiology is an applied IT field

11 PACS & DiagnosHc Radiology PACS: Picture Archival & CommunicaHon System Provides a means to move, display and store images generated by radiology or other hospital depts. Radiology product : The interpretahon of an image InterpretaHons MUST be Hmely!

12 PACS Evolution Current Generation 1990s Web MR/CT, etc. DB RIS 1980s Advanced Apps Modality Archive Modality archiving simple storage systems Individual modality based systems No workflow CR Department Workflow Multi-modality systems Focus on workflow Simple RIS integration using interfaces/brokers Limited enterprise workflow No IT integration Diagnostic WS Integrated RIS/PACS WS Enterprise Workflow Enterprise solution hospitals, clinics Integrated RIS/PACS workstation Web based connectivity with referring physicians Standalone advanced clinical apps Standalone Workstation Enterprise Image Management

13 RIS (Radiology InformaHon Systems) Designed to store, manipulate, and retrieve informahon for planning, organizing, direchng, and controlling administrahve achvihes associated with the provision and uhlizahon of radiology services and facilihes. Common system components include scheduling, dictahon, dictahon report distribuhon h`p://

14 Integrated RIS-PACS Access to Powerpoint, , Netscape, etc. PACS Worklist Detailed patient demographics Patient EMR Patient Reports On-line requisition

15 PACS Market Evolution Replacement Market Research Pioneers Early Adopters Mass Adoption Solutions Offered Single Modality Applications Departmental PACS Enterprise RIS/PACS Multi-Modality Viewing Apps Departmental RIS/PACS Standards ACR-NEMA 2.0 DICOM + HL7 ACR-NEMA DICOM 3.0 IHE Technology Enablers Mainframe Computers 9-track tapes Optical Storage Media TCP/IP adoption Affordable UNIX workstations Hi-Res Displays Optical Storage Jukeboxes Voice Recognition NAS / SAN HSM Systems Storage H/W $

16 The Evolution of Imaging IT Market Segments Optical Imaging Replacement Mass Adoption Research Pioneers Early Adopters Cardiology PACS Market Research Pioneers Early Adopters Replacement Mass Adoption Radiology PACS Market Research Pioneers Early Adopters Replacement Mass Adoption

17 Change of Paradigm Historical Radiologist Workflow Clerks/Tech match up films to be read with patient s master jacket Films with masters are delivered to Radiologist Rad hangs films on view box Is there previous in master Rad hangs previous for review Rad enters MRN into RIS, finds patient, reviews results 1 No 1 Rad bar codes Rad bar codes requisition into into dictation system Rad dictates patient name, order, and accession number in dictation system, and dictates report Rad places films back into daily folder and signs bag Rad places signed daily with patient master jacket aside for pickup by clerical staff. Radiologist Workflow with RIS/PACS Rad opens unread worklist on PACS in dictate mode and opens first exam to be read Relevant prior studies automatically display Dictation automatically initiated. Order information from the RIS automatically sent to dictation system. Rad clicks on clinical history icon to review patient s reports and results from HIS/RIS 1 1 Patient and order level information sent from PACS to RIS with no patient search required Rad dictates report, and clicks next study Next study is loaded. Dictation is initiated, and previous exam is marked dictated in PACS

18 Hard and Sob Savings Reduced film, chemical and folder cost Reduce off- site storage cost Reduced cost of processor maintenance Reduced retakes No repeat studies due to lost exams Hard savings SoA savings More efficient use of personne Technologists, radiologists, others More efficient use of equipment Reduced space requirements Reduced Liability Improved exam tracking

19 Integra<ng the Healthcare Enterprise Sponsored by: the Healthcare Informa<on and Management System Society

20 What is IHE about? IHE is an inihahve promohng and supporhng the integrahon of systems in the healthcare enterprise. Goal: Improve the efficiency and effechveness of clinical prachce by: Improved InformaHon Flow Advanced MulH- System FuncHons

21 Why is IHE needed?

22 Who is IHE? ParHcipants: Professional SocieHes Healthcare InformaHon and Management Systems Society (HIMSS) Radiological Society of North America (RSNA) Vendors (over 30 companies) Standards Group Commi`ee Members RSNA and HIMSS sponsor IHE to provide a neutral forum for working on the Big Picture

23 What Does IHE Accomplish? Integrated Systems - > exchanging informahon Your system receives relevant informahon PaHent Demographics Order InformaHon Related Clinical Data >>> More efficient workflow, reduced errors, more intelligent equipment Your system distributes relevant informahon Clinical Data measurements, tests, monitoring >>> More valuable if it s available anywhere, anyhme >>> More valuable when combined with other data (No single device has all the answers)

24 acquisi'on completed images printed 24

25 Key Image Notes Profile Note1 For referring physician: This image shows the renal rupture. Note2 For referring physician: This image has the hematoma. Note1 for refering physician This image shows the renal rupture. Note2 for refering physician This image has the hematoma. Study & Key Image Notes Note1 for refering physician This image shows the renal rupture. Note2 for refering physician This image has the hematoma. 25

26 Referring Physician Emergency Department Remote Clinics Radiology Department Images and Reports Electronic Medical Record Other Departments: - Oncology - Surgery - Neurology - Pediatrics - etc. 26

27 HL7 Mission ANSI standard for electronically defining & exchanging clinical & administrahve data in the healthcare industry. Transfer protocol Events/triggers Message Types, data PaHent ID (ADT) Charges Orders Results Fields are based on posihon in the record Format is agreed upon, but data content varies among vendors

28 DICOM : Founders: NaHonal Electrical Manufacturers Assoc. (NEMA) American College of Radiology (ACR) Mission - - oriented toward equipment Standard for the vendor- independent exchange of medical images and related informahon

29 DICOM (cont) Contains Transfer protocol Data structures for medical imaging modalihes (equipment) & network services for clinical applicahons (eg image transmission, archive access, prinhng, workflow support) Fields are based on tags Data content absolutely consistent this is an electronics equipment std Header for idenhfying info Binary bits/pixels for images

30 Departmental PACS diagnoshc tools Collateral content 3D, Fusion, CAD Clinical and Surgical extensions Enterprise Worklist Departmental management & reporhng tools EMR IntegraHon Voice RecogniHon Structured ReporHng: eg OB, ER discrepancy & crihcal results reporhng

31 The Pathology Cockpit current focus Worklist & Case History Gross / Low Res. Image Analysis Digital Slides A B A This is an example text bocks for the gross image shown above. This text is so small that it is unlikey that anyone can read it. Can you? I really doubt it. This is an example text bocks for the gross image shown above. This text is so small that it is unlikey that anyone can read it. Can you? I really doubt it. Source: Aperio Technologies B Report

32 Pathology Next stage Advanced diagnoshc tools 3D, Fusion, CAD MuH- spectral imaging Test sub- rouhnes (histology, etc.) Enterprise Worklist Departmental management & reporhng tools EMR IntegraHon Voice RecogniHon Structured ReporHng CriHcal findings / ER?? Departmental ProducHvity ReporHng

33 Synergies with DiagnosHc Imaging Leverage image management infrastructure Cost and experhse synergies will speed adophon Rou<ne access will likely create clinical use cases which will drive the adop<on The extent to which these use cases impact outcomes will impact market accelerahon Access needs vary Pathologists want access to diagnoshc image data Radiologists have interest in access to summary data and no interest in WSI access

34 PACS needs to store more than Radiology images! Histopathology Cytology Blood films Voice RIS Endoscopy HIS Broker PACS Internal TransacHons EPR Colposcopy ECGs Medical photographs Opthalmology EEGs Videos Dermatology

35 PACS Parts / Environment Reports DICOM Archive RIS HL- 7 messages HL- 7 Interface DICOM MWL DICOM Server images images Workflow Engine Web Server images images images Work stahons DictaHon system images modalihes printer

36 HIS/ RIS Broker EMR gateway Database Server Image Server (RAID) Long Term/ Near line Archive Networks DigiHzer

37 Components of PACS AcquisiHon Gateways Non- DICOM modality gateway DICOM Print Server Media Server ReporHng Server Monitor QC Server Web Server WorkstaHons

38 PACS Components EMR gateway Enterprise Archive DICOM Modality Non-DICOM Modality Through Acq. gateway Gateway or Frame Grabber Image Server (RAID) Diagnostic Workstations (DICOM) Clinical Workstations (DICOM) W/S QA Server Diagnostic Workstation Film Digitizer Web Server Data Base Server Computed Radiography or DR CR/ DR QA Workstation Broker for RIS/HIS Media Server LTS Archive SAN/NAS

39 PACS layout 1

40 PACS layout 2

41 PACS layout 3

42 PACS layout 4

43 PACS Central Architecture DICOM Modality Diagnostic Workstations (DICOM) Non-DICOM Modality Gateway or Frame Grabber Image Server (RAID) Clinical Workstations (DICOM) Diagnostic Workstation Film Digitizer Web Server Computed Radiography or DR CR/ DR QA Workstation Data Base Server Archive RIS

44 Central Architecture Image Server and Database Manager is the HEART Any image, any where, any Hme Unique central copy Easy update of data Requires high performance servers PotenHal single point of failure at server Bandwidth demanding

45 PACS Distributed Architecture DICOM Modality Non-DICOM Modality Gateway or Frame Grabber Diagnostic Workstations (DICOM) Clinical Workstations (DICOM) Web Server CR QA Workstation Film Digitizer Data Base Server Diagnostic Workstation Computed Radiography Archive RIS

46 Distributed Architecture Exams are routed from modality to selected workstahons Complex rouhng algorithms based on department / user preference Difficult to support concurrent review of images Less destruchve for failure at database server

47 AcquisiHon (DICOM) Gateway

48 Role of AcquisiHon gateway Compression/ decompression and security Check the images for integrity Convert to PACS format (header, byte- order, matrix size) Queue for images (priority) to database server (background) Share the workload and no point of failure for mulhple AcquisiHon gateway

49 Database Server and Image Server

50 Database Server (PACS controller) The Heart of the system IntegraHon cross point between HIS/RIS and PACS (status update) Create and manages pahent folders Manage reading worklists and user profiles Manage data transfer within the system Support data mining and teaching folders

51 Image Server (RAID) Online (rapid access) exam storage and distribuhon device Support simultaneous exam input and output transfer operahons Up to Three months of storage capacity Scalable capacity

52 WorkstaHons Four Primary Categories - Advanced Analysis: - Used by specialists for advanced diagnosis - 3D, volume rendering - DiagnosHc: - For primary diagnosis; located in reading rooms; high- end 2K monitors - Clinical: - Used by clinicians and staff to consult; ICU / ER applicahons; less costly than diagnoshc; 1K monitors - At Home Review: - low- end; PC based; cost- effechve; review applicahon; lossy compressed for faster transmit

53 Broker HIS/RIS and PACS interface

54 Hospital InformaHon System Support clinical and medical pahent care achvihes in the hospital Administer the hospital s daily business transachons like finance, payroll etc Evaluate hospital performances and costs and make long- term forecast

55 Radiology InformaHon Systems Similar to HIS but of smaller scale Interfaces to PACS based on HL7 Department administrahve management - Scheduling and Film tracking - Resource management and reporhng - Monitor pahent status Link to Hospital InformaHon System (HIS) - Billing and Master Record Link to Clinical Management System (CMS) - Prefetch for Clinical visit - epr integrahon

56 Radiology IT Environment Technology Components Functions RIS PAC Database Short Term Storage Archive Diagnostic and Clinical Workstations Web RIS Orders, Scheduling Film Library Management Charge Capture and Billing Reporting Modalities Image capture QA and Image Processing Ultrasound CR CT or MR Advanced Clinical Apps PACS Acquisition Diagnostic reading stations Clinical review and Web distribution Archiving Advanced Applications Clinical Applications 3D Volume Rendering PACS Provides A Platform For Digital Workflow Solution For Radiology

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