IMAGE SHARING. Review and Update Its Time Has Arrived!

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1 IMAGE SHARING Review and Update Its Time Has Arrived! David S. Mendelson, M.D. Professor of Radiology Senior Associate - Clinical Informatics The Mount Sinai Medical Center Co-chair IHE International Board

2 Sharing Healthcare Information in the Cloud Hospital Clinical Trial 2 nd Radiologist Primary Doctor Imaging Center Consultant 2 nd Hospital Patient Patient Surrogate

3 Cloud Computing WHO WHAT Enterprise PACS EMR HIE Provider Consumer Services Archive

4 NIST definition-cloud Computing Cloud computing is a model for enabling ubiquitous, convenient, on-demand network access to a shared pool of configurable computing resources (e.g., networks, servers, storage, applications, and services) that can be rapidly provisioned and released with minimal management effort or service provider interaction.

5 Network/Internet base sharing This is the networked version of the CD (SneakerNet) More convenient Same issues need to be addressed Convenience vs. Security & Confidentiality HIPAA New opportunities Shared Image processing Efficiencies Proprietary vs. Standards based

6 Network/Internet - Methods VPN/Enterprise Portal Clinical Staff Patient Temporary credentials Enterprise- multi-sites; proprietary solution Multiple PACS and RIS feed one central archive All credentialed can view that archive Point to Point networks HIE Standards based or proprietary sharing network IHE model Patient Centric model / PHR NHIN Direct Secure

7 NHIN- NHIN Direct National Health Information Network (NHIN) NHIN Direct secure point-to-point electronic messages between health care participants Documented understanding enabling trust among participants, such as the Data Use and Reciprocal Support Agreement (DURSA). Health Internet Service Provider (HISP)- an entity that enables the secure exchange between parties

8 NHIN Direct The Direct Project has identified the use of SMTP as its primary mechanism for delivering healthcare content from a sender to a receiver. This choice supports the environments which have minimal capabilities in terms of using Web Services and generating detailed metadata.

9 PHR- Image Enabled Consumer Control Simplifies Consent Full Longitudinal Record

10 Challenges to exchange Who pays for an exchange infrastructure What is the persistence of the information in the exchange Are images different from other forms of healthcare data? Easy secure access is good for the patient Does it endanger the provider?- Is this an impediment? Economic adjustments and evolution are likely to occur Balance of cost control vs. Quality Reduction in Radiation exposure Not all patients agree

11 Information and Image Exchange- Internet Historical Images anywhere, anytime, as needed Patient consent models bandwidth EMR integration- bidirectional Regulatory Image quality Dose Peer review

12 IHE-XDS (Cross-Enterprise Document Sharing)

13 XDS-I.b

14 Canada Health Infoway

15 NIBIB/RSNA Image Sharing Project A Standards Based Solution

16 NIBIB/RSNA Image Sharing Project A Standards Based Solution Consumer controls the flow of information Patient Engagement Diminishes the need for BAAs between enterprises Imaging Site to Clearinghouse Clearinghouse to PHR Bootstrap an IHE based network IHE generally has not focused on consumer driven solutions but rather on institutional and enterprise workflow Primary emphasis is Consumer Control through PHRs Can be extended to other forms of sharing HIE Security and Confidentiality are drivers Replacement / Alternative to CD 5 Academic Institutions Develop a solution for all Radiology Sites Establish a clearinghouse Engage PHRs

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18 Image Sharing/Elements of Solution Edge Server Register a patient Listens to a Radiology Information System (RIS)- looking for a complete exam Retrieves Image set from PACS and Report from RIS Send both to clearinghouse PHI hidden; an RSNA ID and 2 nd factor security token are used to identify the patient Clearinghouse (XDS-I) functions as a secure router Transiently hold encrypted patient data PHR Consumer controls upload and future access Must have RSNA ID available and know answer to 2 nd factor question Develop web based viewers Download full DICOM data set Misc Consumers

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26 Image Enabled PHR- DELL

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30 Report

31 Patient PHR view- lifeimage

32 Patient and Dr. PHR view

33 Patient account permits sharing

34 Advantages of Approach Push model No Query of PACS from outside the firewall Full DICOM data set is available Web viewers Download and Import to PACS Report is available Historical exams can be sent simultaneously Consumer controls flow of information Affords the patient the ability to select what information to share Is this good?

35 RSNA Image Share- Current State 4 Academic sites are live Mount Sinai, UCSF, University of Maryland, Mayo Clinic Last sites are navigating local issues and hope to be live within a few months 2 Community practices are implementing

36 RSNA Image Share- Initial Patient experience Patients enrolled in production environment April 1, 2013 Approximately 1/3 have closed the loop and used the PHR

37 Patient Responses Love it! It s about time This is great My doctor was really pleased to have access to my images Problems Couldn t access my images Got my images- but difficult My doctor couldn t see my images

38 Image Share- Current State Extension to 15 other clinical sites and 8 research sites is under active planning 2 community practices are currently implementing Current version 2.1 Includes Site to Site if patient wishes to bypass PHR Use cases-trauma, Consultation Version 3 in testing Adds clinical trials on same network by integrating CTP Improved Site to Site

39 Version 3.0 Incorporates Clinical trials RSNA CTP Revised Site to Site using CTP pipelines In testing Expected Release late 2012

40 Next steps - New NIBIB (NIH) contract New Funding awarded by NIH for 2 years + 2 option years Expansion of network Vendor Adoption of Edge Server (Open Source) Vendor migration to XDS for all services New use cases Leverage XDS infrastructure/ network PHR HIE XDR Edge Server as a platform QA, Comparative Effectiveness, CDS..

41 Future Directions Refine Workflow Initial workflow is to replace a CD Exam updates Download DICOM data and archive in a local PACS EHR Integration Edge server as a platform Radiation Monitoring Peer Review Quality Metrics

42 Edge Server modifications Flexible send time address for logon PHI issue Vendor implementation

43 Issues that govern sharing Imaging Exams What is our product? Who are our customers? What are the mechanisms of sharing? What are the impediments? Technology Not a large hurdle Policy Security and local rules remain challenging

44 Conclusions We live in a heterogeneous world needing multiple solutions CDs and portable media have both advantages and drawbacks Compliance with standards helps We are transitioning to network/internet solutions Security and confidentiality are even more difficult ONC and State policies will foster these solutions Solutions are evolving Proprietary solutions are often easier to implement Solutions based on open standards will provide the patient with greater flexibility Interoperability will require an adjustment to the way we all think of healthcare data

45 Cloud Sharing- a Transition Proprietary Cloud Services Standards Based Cloud Services

46 Resources