Presented by Eugene Igras
UPDATE
Adoption of standards to share diagnostic imaging information
in the pan-Canadian EHR
DICOM Standards Committee – December 4, 2008
2008 Canada Health Infoway Inc.
2
Agenda
• Sharing DI data in the pan-Canadian EHR context
• Adoption of standards in the DI Domain
• Issues to be addressed
• 2008 Events
• Conclusion
2008 Canada Health Infoway Inc.
3
Infoway Diagnostic Imaging Program• Vision
Foster and accelerate the development and adoption of DI solutions to assist healthcare providers in acquisition, collection, storage, management, distribution and viewing patient radiology reports and images (any study, any time, any where) regardless of where the DI tests were conducted and/or the reports transcribed.
• Strategy
Build on existing standard-based PACS / RIS capabilities
Use IHE XDS/XDS-I Integration Profiles to:
Implement Registry & Data Repository (or multiple Repositories)
Enable interoperability with the EHR components, including:• Clinical Viewer• Health Information Access Layer (privacy & security, consent
management)• Registries (Client, Provider, Site and Terminology)
Ensure privacy and security of DI information
2008 Canada Health Infoway Inc.
4
• Improve Access to Services Provide timely access to DI information irrespective of where the images were
acquired and/or the report transcribed
Provide access to a longitudinal record of patient DI history
Improve timeliness and continuity of care
Enable real-time collaboration and clinical consultations
Improve training opportunities
• Improve Productivity & Contain Costs Increase patient throughput, reduce patient transfers and wait times
Provide capabilities for Radiologists to share workload across the region
Reduce DI exams by reducing avoidable retakes
• Improve Quality of Care Improve quality of DI information (accuracy, completeness, consistency)
Reduce radiation exposure
Reduce medical errors
Value Proposition
2008 Canada Health Infoway Inc.
5
Common Approach
Adherence to Infoway DI Program vision Leverage existing RIS and PACS as operational film-less solutions Consolidation of DI data into DI Repository (DI-r) or multiple Repositories Seamless sharing of DI data among authorized users
Provide access to a longitudinal record of patient DI history
Conformance & Compliance to Standards Architecture: EHRS Blueprint v2 Privacy & Security: Jurisdictional privacy protection legislation
Privacy & Security Requirements & ArchitectureISO/IEC 17799
Content & Messaging: HL7 v2.x and v3, CDA, DICOM Terminology: SNOMED CT & other terminology standards IHE Integration Profiles: XDS/XDS-I - to support DI data sharing
PIX/PDQ – to support patient identity/CR with HL7 v3
ATNA – to support securityOther IHE Radiology and IT Profiles
Electronic Business & Internet Standards
2008 Canada Health Infoway Inc.
6
Standards used in DI Domain An array of standards address DI Requirements in Canada
Internet StandardsHTML/XML, HTTP,
PDF, JPEG, MIME, UTF-8 …
Electronic BusinessStandards
ebXML, Web Services
HealthcareContent, Messaging, Terminology
HL7/CDA, DICOM, SNOMED CTLOINC, ICD-10-CA…
EHRS Blueprint v2Privacy & SecurityPrivacy Legislation
IHE Integration ProfilesXDS/XDS-I,
PIX/PDQ, ATNA…
2008 Canada Health Infoway Inc.
7
Scope of the XDS Affinity Domain in the EHR Context
JURISDICTIONAL INFOSTRUCTUREAncillary Data & ServicesRegistries Data
& ServicesEHR Data & Services Data
Warehouse
OutbreakMgmt
PHSReporting
SharedHealth
Record
DrugInformation
DiagnosticImaging
LaboratoryHealth
Information
ClientRegistry
ProviderRegistry
LocationRegistry
TerminologyRegistry
POINT OF SERVICE
Hospital, LTC,CCC, EPR
PhysicianOffice EMR
EHR Viewer
Physician/Provider
BusinessRules
EHRIndex
MessageStructures
NormalizationRules
Security Mgmt
Privacy DataConfig
Services
Physician/Provider
Physician/Provider
Lab System(LIS)
Lab Clinician
RadiologyCenter
PACS/RIS
Radiologist
PharmacySystem
Pharmacist
Public HealthServices
Public Health
Provider
Longitudinal Record Services
HIAL Communication BusCommon Services
2008 Canada Health Infoway Inc.
8
• Leverage and implement IHE integration profiles DI domain
• Co-authored XDS-I content supplement• Funded development of XDS-I MESA tool set• Declared XDS/XDS-I as a pan-Canadian Standard (“Stable for
Use”)• Implement XDS/XDS-I in current DI projects across Canada
Client Registry• Authored a change proposal to IHE PIX/PDQ to support HL7 v3
messaging EHR Infostructure
• Completed a review of IHE ITI integration profiles for consideration as pan-Canadian standards
• Coordinate with IHE to avoid duplication Leverage IHE technical committees to develop new profiles and/or
propose changes to existing profiles e.g. support for v3 messaging Leverage MESA tools for conformance testing Provide resources to IHE International through IHE Canada
Infoway and IHE
2008 Canada Health Infoway Inc.
9
DI Projects Across Canada • Most provinces in Canada
Have deployed digital DI modalities and PACS/RIS solutions
Have completed architecture for DI Repository (or multiple Repositories) integrated with the EHR
Plan to deploy interoperable EHR / DI solutions
All DI Solutions
Span multiple health regions, hundreds of hospitals, and DI clinics
Integrate multi-vendor PACS / RIS environment
Are designed to handle
• Multiple patient identification domains and EMPI services
• Multiple security domains
• Millions of exams per year (e.g., Alberta: over 4.5 million)
Provide services to thousands of users (e.g. Alberta: over 15,000)
2008 Canada Health Infoway Inc.
10XDS – Actors and Transactions
Provide & Register Document Set
• Submits document sets• Creates and submits documents
description (metadata)
• Stores documents & metadata• Creates & maintains document URI (Uniform Resource Identifier)• Forwards metadata for registration• Supports document retrieval
Register Document Set
Patient Identity Feed
• Stores and maintains metadata• Creates and maintains links to documents• Supports document search (query)• Enforces policies at the time of registration
• Feeds identity of known patients to Document Registry
Query Registry
Retrieve Document
• Initiates search (query)
• Initiates retrieval of documents
DocumentRegistry
DocumentConsumer
DocumentRepository
DocumentSource
Patient Identity Source
2008 Canada Health Infoway Inc.
11XDS-I – Actors and Transactions
• Receives, stores & maintains metadata• Creates and maintains document index• Supports document search (query)• Enforces policies for registration
DocumentRegistry
DocumentRepositoryImaging
DocumentSource
Provide & Register Document Set
Patient Identity Source
• Feeds identity of known patients to Document Registry
• Initiates search and retrieval of documents
Register Document Set
Retrieve Document
Patient Identity Feed
DocumentConsumer
ImagingDocumentConsumer
WADO Retrieve
Retrieve ImagesRetrieve Presentation StatesRetrieve ReportsRetrieve Key Imaging NoteRetrieve Evidence Documents
• Initiates retrieval of DICOM objects referenced within the manifest
• Creates text / PDF report and/or imaging manifest documents
• Submits document sets with document description (metadata)
• Supports retrieval of DICOM objects
• Stores documents and metadata• Enhances metadata with document
URIs to enable retrieval• Forwards the enhanced metadata for
registration• Supports document retrieval
Query Registry
2008 Canada Health Infoway Inc.
12Real-world Systems vs. XDS-I Actors
DocumentRegistry
DocumentRepositoryImaging
DocumentSource
Patient Identity Source
DocumentConsumer
ImagingDocumentConsumer
PACS
Mod
Mod
DI Repository (DI-R)• Stores and maintains a lifetime record of relevant DI data including
• Images and reports
• Key image notes, image processing results & overlay information
• Presentation states and other evidence documents
• Serves as shared operational PACS for greenfield sites
• Supports 2-3 Million exams per year
• Delivers DI data to consumer over a network
• Facilitates seamless sharing of DI information
• Maintains quality and integrity of data
DI-R
PACS
Mod
Mod
Mod
RISMod
Mod
2008 Canada Health Infoway Inc.
13Real-world Systems vs. XDS-I Actors
PACS
Mod
Mod
DI-R PACS
Mod
Mod
Mod
EMR
Viewer
DocumentRegistry
DocumentRepositoryImaging
DocumentSource
Patient Identity Source
DocumentConsumer
ImagingDocumentConsumer
RIS Mod
2008 Canada Health Infoway Inc.
1414
• How to ensure interoperability of XDS-based systems with other solutions that handle discrete data (e.g., Lab, Drug)? How does an XDS Registry for DI evolve into and/or co-exist with other
indexing scheme?
How to ensure other XDS/XDS-I consumers (e.g., EMR) adopt Document Consumer actor capabilities to access DI content?
• How to provide document sharing capabilities across multiple affinity domains?
• How to ensure data quality attributes (e.g., accuracy, completeness, integrity) are maintained/preserved in a data sharing environment?
• How to provide a uniform clinical terminology given a multitude of terminology schemes and vocabularies?
• How does a jurisdiction approach XDS Affinity Domain policies for consumers that are “associated “with the Affinity Domain (GP, Specialist) but not “in” the Affinity Domain?
Issues To Be Addressed (1)
2008 Canada Health Infoway Inc.
15
Issues To Be Addressed (2)
• Synchronization of shared radiology studies Radiology study split
Radiology study attribute changes
Deletion of a study component (e.g. radiology image)
• Standardized representation of DI study in the XDS Affinity Domain A single manifest
Multiple manifests
• Standardized use of XDS Affinity Domain attributes and metadata
• Division of responsibilities between PACS and DI-r
• Data synchronization between local PACS systems and DI-r
• Linking of documents from multiple repositories and support for consultation workflows including creation of new objects
2008 Canada Health Infoway Inc.
16
Terminology & Classification Systems Current & Future State
AcquisitionModalities
POS Information Systems
Storage & Retrieval• DI-rs• Doc Repositories
Document Sharing• Document Registry
HIAL
CT MRIX-Ray
US
PACS HISRIS EMR /Viewer
Content & Format• Images – DICOM• Discrete DataTerminology/Codes• DICOM (SNOMED RT, LOINC)• ICD-9/10• HL7 v2.x
Current State
Content & Format• Images - DICOM• Reports - DICOM SR, Text, PDF• Discrete DataTerminology/Codes• DICOM (SNOMED RT, LOINC)• ICD-10/10CA• CCI• HL7 v2.x and v3
Content & Format• Images & Manifests - DICOM• Reports - DICOM SR, HL7 CDA R2Terminology/Codes• Implementation-specific
Future State
Content & Format• Registry entries - ebXMLTerminology/Codes• To be standardized
Content & Format• Images & Manifests - DICOM• Reports - DICOM SR, HL7 CDA R2Terminology/Codes • Adopted / Adapted / developed• Harmonized with pan-Canadian
Terminology
Content & Format• Images - DICOM• Reports - DICOM SR, Text, PDF• Discrete DataTerminology/Codes• DICOM (SNOMED CT, LOINC)• ICD-10CA, ICD-PSC• HL7 v3
Content & Format• Images – DICOM• Discrete DataTerminology/Codes• DICOM (SNOMED CT, LOINC)• ICD-10-CA• HL7 v3
Normalization
2008 Canada Health Infoway Inc.
17
Terminology Standardization: Candidate Data Entities
Patient Provider and Delivery Site
• Procedure Requestor, Facility• Request Recipient, Service
Delivery Site Request
• Request Priority Indicator• Clinical Reason for Request• Request Status• Consent Details
Procedure• Modality• Anatomical Site, Position,
Laterality, View Aspect• Contrast Medium• Specimen Details• Preparation Instructions• Procedure Performance Details• Procedure Substitution Details
Clinical Status• Clinical Synopsis• Problem/Diagnosis• Observation• Adverse Reaction• Alert• Severity (of problem, diagnosis
or allergic reaction) DI Study
• Study & Series Details
• Image Instances Report
• Authorship, Review, Approval• Interpretation, Findings, Comments• Evidence
Source: Diagnostic Imaging Data Specification; http://www.nehta.gov.au
2008 Canada Health Infoway Inc.
18
XDS-I Metadata Attributes - Sample
Metadata Attribute / Source Metadata Attribute/ Source
Document Author Attributes Patient Attributes
authorSpecialty / Source system patientId / Imaging Document Source
authorInstitution / Source system sourcePatientId / Source system
authorPerson / Imaging Document Source sourcePatientInfo / Source system
authorRole / Imaging Document Source Service Attributes
authorRoleDisplayName / practiceSettingCode / Imaging Document Source
Document Submission Set Attributes practiceSettingCodeDisplayName /
classCode / Imaging Document Source serviceStartFime, serviceStopTime / Source system
confidentialityCode / Source system typeCode, typeCodeDisplayName / Source system
creationTime / Source system XDS Submission Set Attributes
formatCode / Imaging Document Source authorDepartment, authorInstitution, authorPerson
parentDocumentRelationship /Source system contentTypeCode, contentTypeCodeDisplayName
parentDocumentId / Source system patientId
mimeType / Imaging Document Source sourceId
submissionTime / Source system
uniqueId
2008 Canada Health Infoway Inc.
19
• Integrates information Eliminates fragmentation of data captured and recorded in stand-alone systems through
integration of data across organizations and systems Improves quality of DI information (accuracy, completeness, consistency) Addresses patient privacy and data security in a comprehensive and consistent manner
• Improves Access Provides timely access (anywhere, anytime) to DI information irrespective of where the
images were acquired and the reports transcribed Provides access to a longitudinal record of patient DI history Improves timeliness and continuity of care Enables collaboration among care providers Improves training opportunity
• Improves Productivity Increases patient throughput, reduces patient transfers and wait times Provides capabilities for Radiologists to share workload across the Affinity Domain Reduces DI exams by reducing avoidable retakes
• Improves Quality of Care Reduces radiation exposure Reduces medical errors
XDS-I Value Proposition
2008 Canada Health Infoway Inc.
20
2008 Events
• Infoway Partnership Conferences April 2008 (Toronto)
October 2008 (Montréal)
Standards Collaborative Working Groups SCWG 1 - Population Care SCWG 2 - Individual Care SCWG 3 - Managing the Healthcare System SCWG 4 - Medication Management SCWG 5 - Labs & Diagnostics SCWG 6 - Infostructure & Architecture SCWG 7 - Non-clinical Registries SCWG 8 - Privacy & IT Security Services SCWG 9 – Clinical Terminology
• Project team meetings
2008 Canada Health Infoway Inc.
21
Conclusion
• IHE XDS-I is aligned with the pan-Canadian EHR architecture and accepted as the right approach to achieving seamless sharing of DI documents within the EHR Declared a pan-Canadian Standard “stable for use” All Provinces recognize the value of consolidating DI data in domain
repositories DI projects across Canada adopt XDS-I
• There are still outstanding issues to be addressed by: Infoway invested DI projects Infoway Standards Collaborative (Standards Collaborative Working
Groups) IHE Canada / IHE Vendor community
2008 Canada Health Infoway Inc.
22
Infoway Standards Collaborative
Contact: Grant Gillis ([email protected])
Infoway Solution Architecture Group
Contact: Eugene Igras ([email protected])
Thank you!