xds (cross-enterprise document sharing)
TRANSCRIPT
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
Sharing Healthcare Information in the Cloud
Hospital
Imaging Center
Primary Doctor
Consultant
Patient Patient
Surrogate
2nd Radiologist
2nd Hospital
Clinical Trial
Cloud Computing
WHO
Enterprise PACS EMR
HIE Provider Consumer
WHAT
Services Archive
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.”
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
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 E-mail
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
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.”
PHR- Image Enabled
Consumer Control
Simplifies Consent
Full Longitudinal Record
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
Information and Image Exchange- Internet Historical Images anywhere, anytime, as
needed
Patient consent models
bandwidth
EMR integration- bidirectional
Regulatory
Image quality
Dose
Peer review
IHE-XDS (Cross-Enterprise Document Sharing)
XDS-I.b
Canada Health Infoway
A Standards Based Solution
NIBIB/RSNA Image Sharing Project
2009-2012
2012-2016
NIBIB/RSNA Image Sharing Project
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
A Standards Based Solution
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 2nd 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 2nd factor question
Develop web based viewers Download full DICOM data set
Misc Consumers
Radiology Dept
Image Enabled PHR- DELL
Report
Patient PHR view- lifeIMAGE
Patient and Dr. PHR view
Patient account permits sharing
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?
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
RSNA Image Share- Initial Patient experience
Patients enrolled in production environment- 3000
April 1, 2013
Approximately 1/3 have closed the loop and used the PHR
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
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
Version 3.0
Incorporates Clinical trials
RSNA CTP
Revised Site to Site using CTP pipelines
In testing
Expected Release – late 2012
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…..
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
Edge Server modifications
Flexible send time
Email address for logon
PHI issue
Vendor implementation
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
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
Cloud Sharing- a Transition
Proprietary Cloud Services
Standards Based Cloud Services
Resources
http://www.rsna.org/Image_Share.aspx