Pacs, hospitalIs, radiology information sytems

Pacs

1. DICOM, PACS, HL7 & HIE

2. INTRODUCTION Radiology is adopting digital imaging very rapidly. Estimates of the present level of digitally acquired images ranges up to 90%. These digital images come from every area of medical imagibg , including nuclear medicine, UTZ, radiography, flurosocpy , CT and MRI.

3. INTRODUCTION Screen film radiographs can be digitized with the use of CR & DR and be transported with the use of various system that incorporates with the Computer Heath Sytem of a certain Facilities (e.g. RIS, HIS &ETC.). The use of PACS with an integration of the different standards set by DICOM, IHE & HL7, these systems made a gradual advantages on digital imaging that improves the quality of care in the modern health care system.

4. PICTURE ARCHIVING COMMUNICATION SYSTEM (PACS) P icture archiving and communication system (PACS) is a medical imaging technology which provides economical storage a nd convenient access to medical images from multiple modalities . PACS when fully implemented , allows not only the acquisition but also the interpretation and storage of each medical image in digital form without resorting to film. The projected efficiencies of time and cost are enormous

5. PICTURE ARCHIVING COMMUNICATION SYSTEM (PACS)

6. PACS MAIN USES Hard copy replacement : no more papers and printing radiology films. Digital images and text are used (soft copy) Remote access : Teleradio l ogy. Telemedicine. Access from home Electronic image integration platform : HIS, RIS, EMR Radiology Workflow Management

7. PICTURE ARCHIVING COMMUNICATION SYSTEM (PACS) PACS improves image interpretation, processing viewing, storage and recall. There are four Principle components of PACS: Digital Image Acquisition - DONE IN CR & DR. The Display System Network Storage System

8. The Display Sytem The display system is composed of m onitors that has a function to optimally view the acquired digital images after processing. Monitors used where: C athode Ray Tubes (CRT's) L iquid Crystal Display (LCD) .

9. The Display Sytem C athode Ray Tubes (CRT's) The first type of monitor that was used to view the digital images .

10. The Display Sytem L iquid Crystal Display (LCD) Widely used monitors, usually, 2 or more LCD monitors are connected with the PACS that is used to view the patients information and projections acquired.

11. COMPARISON of CRT and LCD

12. Resoulution is one of the specifications that must be reviewed inorder to see the minute detail of the organ that is being imaged. - Resolution is usually affected by how much mega pixel does the digital images had . e.g viewing mammograms need at least 5 megapixel.. The Display Sytem

13. Quality assurance - Gamma correction or often simply gamma, is a nonlinear operation used to encode and decode luminance in video or still image systems. The Display Sytem

14. Gamma C orrection The Display Sytem

15. Networks The Network of a PACS is comprised of: Client and servers Routers, switches Storage devices .

16. Networks T ypes LAN (Local area Netwrok ): e.g Inside hospital network VPN (Virtual private network): For teleradiology or telemedicine services and support.

17. Network The speed of data transfer of each individual data information such as patient information and image data depends on the bandwidth. Bandwidth describes the maximum data transfer rate of a network or Internet connection. Bandwidth , depends on medium (line) of data transfer. Fiberoptic C ables L eased line

18. Network The integrity of the datas that was stored in the different computer system can be at risk, that's why in every system there are installed Network Security. Network security is any activity designed to protect the usability and integrity of your network and data. It includes both hardware and software technologies It targets a variety of threats It stops them from entering or spreading on your network Effective network security manages access to the network

19. Storage System To store the datas and information that was acquired to the patient before, during and after a diagnostic procedure storage system is require. It may be short term or long term storage depending on the storage type that is being used. Contingency storage is also implemented inorder to retrieve/recall the different datas that was suddenly/mistakenly deleted or if the main storage device is full.

20. Storage System Storage types spinning disks ( eg , hard drive) magnetic tape ( eg , audio cassettes), optical media ( eg , compact discs and digital video discs), and solid-state ( eg , USB [universal serial bus] flash memory cards) Most PACS use combinations of these .

21. Storage System Redundancy refers to storage of multiple copies of imaging data. It is implemented to identify the patients information to the different systems of different departments of an infirmary. A redundant array of inexpensive disks (RAID) is the most frequently-used redundancy system in PACS storage

22. Storage System R edundant A rray of I nexpensive D isks (RAID)

23. PACS S upporting S oftwares Speech Recognition Digital Teaching Files . e.g The Medical Imaging Resource Center (MIRC) Image Processing: e.g CAD, 3d visualization, dual energy subtraction. Asynchronous Communication Tools. Emails, instant messaging, SMS

24. Besides PACS Radiology Information System (RIS) : for scheduling patients, storing reports, and patient tracking; Hospital information system,(HIS) , which keeps track of patient demographic data and locations. Electronic Medical Record (EMR) : to organize all medical data from an entire enterprise.

25. Digital Imaging and Communication In Medicine (DICOM). is a standard for handling, storing, printing, and transmitting information in medical imaging. It includes a file format definition and a network communications protocol.

26. What is the Goal of DICOM? - The goals of DICOM are to achieve compatibility and to improve workflow efficiency between imaging systems and other information systems in healthcare environments worldwide.

27. Order entry Document review Scheduling Modality assignment Radiographer and Radiologist assignment Room assignment Radiology reports Receiving orders from HIS Inventory radiology system KPI Scheduling Image archive (store) Image distribution. Image visualization Image analysis. CT MRI ENDOSCOPY ECG HIS/EMR RIS PACS DICOM DICOM DICOM DICOM DICOM HL7 HL7

28. HL7 An Introduction

29. Health Level 7 or HL7 Health Level Seven or HL7 refers to a set of international standards for transfer of clinical and administrative data between software applications used by various healthcare providers. These standards focus on the application layer, which is "layer 7" in the O peration S ystem I nterconnection (OSI) model.

30. Open System Interconnection Model (OSI) - Is a conceptual model that characterizes and standardizes the communication functions of a telecommunication or computing system without regard to its underlying structure and technolog y

31. OSI MODEL

32. Brief History of HL7 Founded as an international standards development organization in 1987 to promote communication between hospital data systems Stated a goal of creating a platform independent method of moving data between different systems Developed grammar for messaging and standardized vocabulary

33. HL7 is an international standards development organization (SDO) that was established to enable interoperability of health care information. Initially it focused on interoperability among information systems within large hospitals. Later, the organization began focusing on interoperability among systems in disparate organizations, including public health.

34. Early initiatives of the organization included developing grammar for messaging and a standardized vocabulary It is not the only standard that is used for transmitting health related data. Others include : NCPDP (National Council for Prescription Drug Programs) for ordering medications EM TEP (OASIS Emergency Management Tracking of Emergency Patients) for tracking health information for patients in transport

35. While both NCPDP and EM TEP are specialized standards, they can be mapped to HL7 concepts.

36. HL7 Versions HL7 version 2.x messaging HL7 version 3 messaging HL7 Clinical Document Architecture (CDA) HL7 Fast Healthcare Interoperability Resources (FHIR)

37. Because HL7 continually evolves with use and experience, multiple HL7 versions now exist as you can see by this list. This presentation focuses on version 2 messaging only. CDA and FHIR are presented in another EHR Toolkit presentation.

38. The HL7 organization released version 2 messaging decades ago. This version is still being updated and improved and is widely implemented in the U.S. In addition to the current Meaningful Use requirements around version 2 messaging, version 2.x supports unsolicited updates such as new information sent to be added to a case report. Version 2.x also supports query and response—for example, an EHR system requesting and receiving an immunization history from a registry . HL7 Version 3 messaging has been implemented widely internationally, but not in the U.S.

39. CDA is widely adopted in the U.S. and is in use with Consolidated-Clinical Document Architecture (C-CDA ) A key distinction between HL7 messages and HL7 CDA documents is that messages are packets of data sent from one system to another, generally for incorporation into the receiving system. In comparison, documents are basically electronic versions of physical documents . Public health largely relies on version 2.x messages, although CDA has been piloted in some areas, including reporting for cancer, fetal birth and deaths . FHIR (pronounced “fire”) is just emerging, but appears to be easily implemented and may be the wave of the future. It can support Version 2, Version 3, and CDA paradigms .

40. Messaging Business Process Transport Layer Prepare data for transport Parse data received Process Data 4) Prepare Response Parse Response Process Response HL7 HL7 HL7 HL7 HL7 is critical but not enough by itself. trigger Sender Receiver

41. HL7 Standards Version 2.x Messaging Standard – an interoperability specification for health and medical transactions Version 3 Messaging Standard – an interoperability specification for health and medical transactions Clinical Document Architecture  (CDA) – an exchange model for clinical documents, based on HL7 Version 3 Continuity of Care Document  (CCD) – a US specification for the exchange of medical summaries, based on CDA. Structured Product Labeling  (SPL) – the published information that accompanies a medicine, based on HL7 Version 3 Clinical Context Object Workgroup  (CCOW) – an interoperability specification for the visual integration of user applications

42. DICOM and Integrating the Healthcare Enterprise:

43. IHE Mission IHE is a regulating body that has an initiative promoting and supporting the integration of systems in the healthcare enterprise . **Systems means HIS, RIS, modalities, PACS, review stations, printers, etc.

44. IHE Integration Goals Improve the efficiency and effectiveness of clinical practice: Improve Workflow Improve Information Accuracy Improve Information Availability Enable Cross-System Functionality

45. IHE Integration Profiles B A Proven Standards Adoption Process IHE Integration Profiles : Detailled selection of standards and options each solving a specific integration problem A growing set of effective provider/vendor agreed solutions Vendors can implement with ROI Providers can deploy with stability ** RFP – REQUEST FOR PROPOSAL Standards Easy to Integrate Product s IHE Integration Profile A IHE Demonstration IHE Connectathon Product With IHE User Site RFP IHE Technical Framework

46. IHE Integration profiles Access to Radiology Information Basic Security Consistent Presentation of Images Evidence Documents Key Image Notes Simple Image and Numeric Reports - Presentation of Grouped Procedures Post-Processing Workflow Reporting Workflow Charge Posting Patient Informa-tion Reconci-liation , Scheduled Workflow

47. IHE IT Infrastructure 5 Integration Profiles Enterprise User Authentication Provide users a single name and centralized authentication process across all systems Enterprise User Authentication Provide users a single name and centralized authentication process across all systems Retrieve Information for Display Access a patient’s clinical information and documents in a format ready to be presented to the requesting user Retrieve Information for Display Access a patient’s clinical information and documents in a format ready to be presented to the requesting user Patient Identifier Cross-referencing for MPI Map patient identifiers across independent identification domains Patient Identifier Cross-referencing for MPI Map patient identifiers across independent identification domains Synchronize multiple applications on a desktop to the same patient Patient Synchronized Applications Synchronize multiple applications on a desktop to the same patient Patient Synchronized Applications Consistent Time Coordinate time across networked systems Consistent Time Coordinate time across networked systems

48. IHE & DICOM / HL7 Standards are vital (HL7, DICOM, ICD) They provide tools & technologies But Standards alone are insufficient They are open to interpretation There is room for optional variations They avoid specifying how to apply them to particular real world scenarios **What’s wrong with DICOM? Nothing but misinterpretation and ambiguity

49. IHE Stimulated adoption of DICOM features By 1998, DICOM Storage and Query Retrieve SOP Classes have been implemented and actively used by dozens of vendors However, some features were interpreted differently (scout lines, query keys) IHE established common interpretation

50. Use of DICOM in Workflow Management DICOM Modality Work List ( MWL ) and Modality Performed Procedure Lists ( MPPS ) were defined but not well implemented because their use without correlation with overall information flow in Radiology Department was limited IHE defined use cases and established mechanisms to use these DICOM SOP Classes via Scheduled Workflow Integration Profiles

51. IHE researched DICOM data model Patient Imaging Serv. Req. (Order) Requested Procedure Scheduled Procedure Step 1:n 1:n 0:n Scheduling Image Study Series Series Image Image Image Image 1:n 1:n 1:n Work Products Study Mgt Performed Procedure Step Work Tracking n:m

52. IHE Integration Profiles based on DICOM Most IHE Radiology Integration Profiles are based on one or more DICOM SOP Classes IHE spearheaded implementations of several recently defined DICOM capabilities spending time and effort to build practical implementation framework for them

53. IHE Profiles vs. DICOM SOPs Consistent Presentation of Images Simple Image and Numeric Report Key Image Note Grayscale Presentation State Structured Reporting Key Object Selection Document

54. IHE Profiles vs. DICOM SOPs Post-Processing Workflow and Reporting Workflow Evidence Documents General Purpose Worklist and PPS Mammo CAD, Chest CAD, etc.

55. IHE initiated development of DICOM features IHE actively influenced development of DICOM: Correction proposals for better consistency of MWL/MPPS Development of Key Object Selection Documents Development of common audit messaging

56. Operational influences DICOM influenced development process of IHE Technical Framework: Supplements, Correction Proposals DICOM adopted IHE approach to definitions of use cases: Actors, transactions…

57. Summary The development of DICOM has influenced the development of IHE Technical Framework, and in turn, was influenced by user needs that are advocated for by the framework developers. Cooperative effort of two bodies have proved very effective and will continue in the future, allowing for further advancement of DICOM and its acceptance in user and vendor communities.