Experience with transmural exchange of cardiology related information between 4 hospitals. A pilot study.

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1 Experience with transmural exchange of cardiology related information between 4 hospitals. A pilot study. Project team: J.P. Busman A. Talsma W.A. Dijk E. Meijer J. Frankruijter G. van Kernebeek Arnold Dijk Clinical physicist Thoraxcentrum UMCG Groningen The Netherlands

2 Introduction Background IHE-XDS Aim Setup XDS Groningen region Aim Setup Experience Conclusions

3 Background Diagnostic procedures in Referring Hospitals CAG (Coronary AngioGraphy) Echocardiography Therapeutic Procedures in Intervention Centers PCI (Percutane Coronary Intervention) PVR (Percutane Valve Replacement) CABG (Coronary Artery Bypass Grafting) VR (Valve Replacement)

4 Coronary angiogram Pre PCI Post PCI 4

5 Echocardiogram with Doppler 5

6 Til 1995 Application form From 1995

7 Policy Heart team consultation: cardiologists and cardiothoracic surgeons documentation: CAG s, echo s and reports Outcome: PCI CABG Conservative

8 Groningen region Dokkum UMCG Delfzijl Drachten Martini Winschoten Assen Stadskanaal Emmen

9 Origin of 3000 PCI procedures 2009 umcg B C D E F G H I Centers Images on CD, reports on paper 9

10 Points for improvement Information on CD and paper Administrative rigmarole Slow Error prone Therefore: Electronic exchange of data

11 Electronic data exchange Standards Vendor neutral Widely supported by institutions and industry Potential for other domains like oncology IHE (Integrating the Healthcare Enterprise) Standards DICOM, HL-7 Non-profit Many sponsors (HIMSS, RSNA, ACC, ESC, ) Support by major manufacturers

12 Cardiology domain Integration profiles Echocardiografy workflow profile Heartcatheterisation workflow profile Infrastructure Integration profiles XDS XDS-I Cross Enterprise Document sharing Cross Enterprise Document sharing for Images

13 XDS-profile Profile for trans mural and intramural publishing, registering and retrieving medical records Provides for standards based specifications for the management of these shared documents XDS is content agnostic

14 XDS standards Business standards ebxml, SOAP, MTOM Internet standards HTML, ISO, PDF, JPEG, HTTP(S) Healthcare standards HL7, DICOM, SQL, ASTM

15 XDS actors Document Repository(ies) Document Registry Patient Identity Source Document Source Document Consumer(s)

16 XDS transacties ProvideandRegisterDocumentSet RegisterDocumentSet RegistryStoredQuery RetrieveDocumentSet PatientRegistryRecordAdded PatientRegistryRecordRevised PatientRegistryDuplicatesResolved PatientIdentityFeed

17 XDS basic architecture Actors en Transactions

18 XDS-I architecture Actors en Transactions

19 XDS-I: Publishing a document 1. Provide and register Document set (Key Object Selection (KOS) Document) 2. Register KOS document

20 XDS-I: Request a document 1. Request information 2. Retrieve report 3. Retrieve images through DICOM Q/R or 4. Retrieve images throughwado (http)

21 Other Integration Profiles PIX CT PDQ ATNA PAM BPPC XUA Patient Identifier Cross-referencing Consistent Time Patients Demographic Query Audit Trail and Node Authentication Patient Administration Management Basic Patient Privacy Consents Cross Enterprise User Assertion

22 XDS Groningen Region 1. Developing at home Public domain b.v. (http://ihe.codeplex.com/sourcecontrol/) No XDS-I: lots to develop (complex) 2. Acquire 3 suppliers: Forcare / E.NOVATION Proven experience in Friesland region

23 XDS Groningen region Planning Fase 1 4 clinics (incl. umcg) Fase 1a Images umcg Fase 1b Images umcg Fase 1c Reports umcg Fase 1d Reports umcg Fase 2 expansion towards whole region

24 Components ForIndex ForStore ForConnect ForView ForAudit Registry Repository Document Source Broker: DICOM + HL7 XDS Document Consumer Monitoring (Logging / ATNA)

25 Pilot with: XDS regio Groningen Planning Fase 1 (Images) Nij Smellinghe ZH Drachten Martini ZH Groningen Wilhelmina ZH Assen Start: may 2009 Allotment: july 2009 Implementation: august 2009 End pilot: 1 oktober 2009

26 Installations at the centers Nij Smellinghe ZH Drachten Carestream, Chipsoft EZIS, Philips Martini ZH Groningen Carestream, Chipsoft EZIS, Philips Wilhelmina ZH Assen Carestream, Chipsoft EZIS, Philips UMCG Groningen PACLI, i-soft ZIS, Siemens

27 XDS-I architecture Martini - UMCG ForView ForAudit PACS (Carestream) Martini ZH DICOM Images Meta-data + Document ForIndex (Registry) XDS Meta-data XDS Meta-data PACS (PACLI) UMCG ForConnect (Broker) PIX XDS Meta-data + Document ForStore (Repository) Document HL-7 BSN Chipsoft BSN: Social Security Number

28 XDS Groningen Region Challenges Contracts with hospitals Infrastructure (Demilitarized Zone) Social Security Number Rights: who has access to which documents

29

30 Test Omgeving met DMZ Forecare backend Server Wazkh forview SOAP (tcp) => poort 8443 HL7 (tcp) => poort 2576 ATNA (udp) => Poort 8514 AAN Koppelingen TBV Beelduitwisseling THORAX via XDS SOAP (tcp) <= poort 8443 HL7 (tcp) <= poort 2576 ATNA (udp) <= Poort 8514 G1/ G1/ / /30 Martini Access List in & out ip access-list extended Martini-ziekenhuis-in ip access-list extended Martini-ziekenhuis-out ip route ip route ip route ip route Forecare Server forconnect forview Dbase server Wazkh ForIndexA01 ForAuditA01 Poort 1433 DICOM (tcp) => poort 8104 DICOM (tcp) <= poort 104 Thorax MINI PACS wpzkh neologica dicom burner Thorax PACS Thor_ds4.nt_thorax.umcg.nl ES-ee-1 ISA DMZ Forecare frontend Server wadmz ???.?? forstore forindex foraudit forconnect Zorgnet Friesland Scheper Nortel Checkpoint Access List in & out ip access-list extended Scheper-Ziekenhuis-in ip access-list extended Scheper-Ziekenhuis-out ip route ip route Nij Smellinghe Forecare Server forconnect forview THORAX Domein Access List in & out ip access-list extended???????????-in ip access-list extended???????????-out ip route ip route

31 Burger Service Nummer (Social Security Number) Ideal Patient ID starting 1 june 2009 obligatorily for transmural communication NICTIZ: Draft BSN & DICOM objects Purchase of ForConnect PIX option december 2009

32 Basic Patient Privacy Consent Electronic documenting patient authorization for distributing information Electronic documenting of user bevoegdheden gebruiker Disclosure of information at electronic match.

33 Informed consent

34 Document list

35 Gegevensstroom HC verrichtingen Polikliniek Afdeling Martini WZ Assen Aanvraagformulieren Acceptatie XDS CAG, etc PCI Hartteambespreking Planning MZA + Regie Planborden DICOM Worklist Siemens

36 Configuratie: CARDS Infocop DICOM Worklist Siemens SENSIS PACLI Einde Procedure Planbord Overdracht formulier Poli Plus XDS Registratie t.b.v. declaratie Infocop Voorraadbeheer Martini WZ Assen

37 Remarks / Conclusions XDS and XDS-I function in practice Informed consent too rude BSNr has to be incorporated automatically Bulk transmissions through pre-fetching After positive results pilot Expansion to the whole region Expansion to other domains Expansion to intramural architecture Expansion with home made actors

38 Er is gekozen voor de XDS-standaard omdat deze toekomstvast lijkt te zijn. Veel leveranciers van software in de zorg zijn bezig aan te sluiten op de XDS-standaard. Omdat de XDS-standaard ook het koppelen van een regionale infrastructuur aan een landelijke infrastructuur ondersteunt, heeft het NICTIZ de standaard omarmd als onderdeel van het LSP. Doel van het UMCG met het opzetten van de regionale XDS infrastructuur is om uitwisseling van àlle zorgdocumenten tussen de verschillende ziekenhuizen in de regio mogelijk te maken. Daarbij moet gedacht worden aan digitale DICOM-beelden van andere afdelingen, zoals Radiologie en Nucleaire Geneeskunde, maar ook aan non-dicom-beelden en andere documenten zoals medische verslagen. Omdat dit dus verder zal gaan dan alleen Cardiologie is de centrale ICT-afdeling betrokken bij het project, is de XDS-standaard als ziekenhuisbeleid benoemd en zijn ook andere afdelingen op de hoogte gebracht van de ingeslagen weg. Zo is bijv. de afdeling Radiologie op de hoogte en geïnteresseerd om aan te sluiten na de eerste fase.

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