Cardiology Workflow & Display Requirements

ACCA IHE Workshop 2007

Bob Baumgartner, BSN, MBA McKesson Corporation IHE-Cardiology Planning Committee Administrative Co-Chair
September, 2005

What IHE Delivers

Agenda
Cardiology Workflows General
Cath Workflow
Echo Workflow Stress Workflow

Content Display Requirements

Stress Echo Stress

Cardiology Workflows
Cardiology:
the study of the

heart

its action
and diseases

The Problem
This is an example of a cardiology workflow. Any questions! Workflow is the linchpin to data integrity
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General Workflow
Pt. Registration [RAD-1] Patient Update [RAD-12] ADT Pt. Registration [RAD-1] Patient Update [RAD-12] Order Placer DSS/ Order Filler Placer Order Management [RAD-2] Filler Order Management [RAD-3] Procedure Scheduled [RAD-4] Patient Update [RAD-12] Procedure Updated [RAD-13] Instance Availability Notification [RAD-49] Evidence Creator Image Display

Modality PS in Progress [CARD-1] Modality PS Completed [RAD-7]

Modality PS in Progress [CARD-1] Modality PS Completed [RAD-7] Storage Commitment [CARD-3]

Performed Procedure Step Manager

Modality Image/Evidence Stored [CARD-2]

Query Images [RAD-14] Retrieve Images/Evidence [CARD-4]

Image Manager Modality PS in Progress [CARD-1] Modality PS Completed [RAD-7] Storage Commitment [CARD-3] Modality PS in Progress [CARD-1] Modality PS Completed [RAD-7] Query Modality Worklist [RAD-5]

Image Archive

Modality Image/Evidence Stored [CARD-2]

Acquisition Modality

Agenda
Cardiology Workflows General
Cath Workflow Echo Workflow Stress Workflow

Content Display Requirements

Stress Echo Stress

Cath Lab
6 7 5 8 9 10 11 3 4

2 1

Multiple re-entry of Patient ID Error prone Results fragmented across systems Results inconsistently time-tagged
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Administrative Process Flow

ADT Register/ Admit Patient Patient Registration [Rad-1] Order Placer Department System Scheduler/ Order Filler Image Manager Acquisition Modality

Create Order Placer Order Mgmt New [Rad-2] Schedule Procedure Procedure Scheduled [Rad-4] Start Procedure Query Modality Worklist [Rad-5]

Select Patient

Procedure Performance Process Flow

Order Placer Department System Scheduler/ Order Filler Image Manager/ Image Archive Acquisition Modality Acquisition Modality n

Modality Procedure Modality Procedure Step In Progress Step In Progress [Card-1] [Card-1]
Update Schedule

Query Modality Worklist [Rad-5] Modality Procedure Step In Progress [Card-1] Modality Procedure Step In Progress [Card-1] Modality Images/ Evidence Stored [Card-2]

Perform Acquisition Perform Acquisition

Modality Images/Evidence Stored [Card-2] Modality Procedure Modality Procedure Step Completed Step Completed [Rad-7] [Rad-7] Order Status Update [Rad-3] Storage Commitment [Card-3]

Use Cases
Case C1:

Patient Registered at ADT and Procedure Ordered at the Order Placer Case C2: Patient Registered at ADT and Procedure Ordered at DSS/OF Case C3: Patient Registered at ADT and Procedure Not Ordered Case C4: Patient Registered at DSS/OF and Procedure Ordered Case C5: Patient Not Registered Case C6: Patient Updated During Procedure Case C7: Change Rooms During Procedure Case C8: Cancel Procedure Case C9: Post-Procedure Evidence Creation Case C10: EP Ablation / Implantation Lab
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Case C1: Patient Registered at ADT and Procedure Ordered at the Order Placer
Clinical Context
Corresponds to traditional Radiology workflow Order placed in central system Also deals with case where emergency

identifier has been created Common identifiers known ahead of time IHE Context
MPPS in Progress from first modality used to

update worklists for others

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Case C2: Patient Registered at ADT and Procedure Ordered at DSS/OF

Clinical Context
Slight difference to Case 1 Order placed NOT in central system but in department Department system provides info to Central ordering

system Typical of many institutes, relieves need for HIS terminal in lab

IHE Context
Filler Order Management (New Order) transaction [RAD-3]

is sent from Department System Scheduler/Order Filler to the Order Placer.

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Case C3: Patient Registered at ADT and Procedure Not Ordered

Clinical Context
Slight difference to Case 2 Procedural information is NOT entered at the departmental

system The first modality must initiate the process of creating common procedure identifiers (usually hemo) The common procedure identifiers are created by the departmental system based on the information available from the first modality Can generate a generic cath procedure if no coded procedural type is available

IHE Context
Upon receiving the first MPPS the DSS/OF will auto generate a

Requested Procedure and its associated Scheduled Procedure Steps utilizing the Study UID provided in the first MPPS. All other modalities use the Query Modality Worklist transaction.

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Case C4: Patient Registered at DSS/OF and Procedure Ordered

Clinical Context
This case accommodates the emergency case where there is

not enough time to register the patient on ADT system A temporary patient identifier is created at the department level The order placer is notified only after the patient is registered and manually reconciled on the department system

IHE Context
The DSS/OF assigns a temporary Patient ID with a temporary

name and schedules the required procedures The DSS/OF does not send the Filler Order Management (New Order) transaction to the Order Placer until the patient is registered on the ADT system and reconciliation occurs on the DSS/OF.
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Case C5: Patient Not Registered

Clinical Context
This is the Emergent Case where the patient information is not

known or there is not enough time to enter the information A temporary ID is assigned by the department and entered at the first modality and forwards that information to the departmental system to be shared with the other modalities Like in C4 information is sent to the Order Placer post patient registration and reconciliation on the departmental system

IHE Context
Patient ID and name are selected based upon locally (usually

department) base rules The first modality will send an MPPS with the appropriate information to the DSS/OF which will in turn generate the appropriate requested procedure(s) using the Study UID assigned by the first modality
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Case C6: Patient Updated During Procedure

Clinical Context
An unidentified patient may have been registered at the ADT and

brought into the cath lab with the temporary ID During the procedure the patient information is updated on the ADT which sends the patient update information This can results is some of the information been associated with the temp ID and the rest with the permanent ID The case defines how the reconciliation occurs.

IHE Context
The modality may have requested information from the DSS/OF

prior the patient update The Image Manager needs to update the items stored to Image Archive as well as any subsequent items received.
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Case C7: Change Rooms During Procedure

Clinical Context This is the case when the patient is moved due to any of the following reasons:
The change from a diagnostic to interventional procedure
The need to use the current room for another patient Equipment failure

NOTE: This case does not cover the scenario where a patient is moved to the holding area from a procedure room. IHE Context
Each modality will issue a MPS (Completed or Discontinued) The DSS/OF will reassign the requested procedure to the new

room In the event the DSS/OF does not reassign, each modality in the new room would use the broad Modality Worklist Query This insures consistency of the Study UID for all information
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Case 7: Change Rooms During Procedure

Department System Scheduler/ Order Filler Image Manager Acquisition Modality Room 1 Acquisition Modality n Room 1 Acquisition Modality Room 2 Acquisition Modality n Room 2

Query Modality Worklist [Rad-5] Modality Procedure Step In Progress [Card-1] Update Schedule Query Modality Worklist [Rad-5] Modality Procedure Step In Progress [Card-1] Modality Procedure Step In Progress [Card-1] Modality Procedure Step In Progress [Card-1]

Perform Acquisition

Perform Acquisition

Modality Procedure Step Discontinued [Rad-7]

Modality Procedure Step Discontinued [Rad-7]

Reassign Procedure

Query Modality Worklist [Rad-5] Modality Procedure Step In Progress [Card-1] Modality Procedure Step In Progress [Card-1]

Perform Acquisition

Update Schedule Query Modality Worklist [Rad-5] Modality Procedure Step In Progress [Card-1] Modality Procedure Step In Progress [Card-1]

Perform Acquisition

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Case C8: Cancel Procedure

Clinical Context
This case allows for the information systems to keep track of

cancelled procedures allowing the cath lab staff to appropriately respond to queries regarding that patient.

IHE Context
When the procedure is cancelled within the department the

DSS/OF notifies the Order Placer system and Image Manager The length of time this procedural information is maintained is determined by local policy.

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Case C9: Post-Procedure Evidence Creation

Clinical Context
Allows for imaging and other procedural data to be analyzed

post-procedure using specialized software (e.g., QCA, QLV, derived images) This case does NOT apply to core lab analysis for clinical trials or outcome analysis

IHE Context
This analysis must be performed on a station that groups the

Image Display and Evidence Creator Actors The Evidence Creator notifies the IM/IA and DSS/OF of the activity via the MPPS In Progress and Complete transactions The Evidence Creator stores its evidence to the IM/IA via the Storage Commit Transaction.
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Case C10: EP Ablation / Implantation Lab

Clinical Context
Allows for the wide array of specialized equipment used in the

EP lab Provides demographic and time synchronization

IHE Context
Initial implementation is an extension of the CATH profile Support for use cases C1 C9 Emergency use cases C3 and C5 are highly unusual in the EP

lab.

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Agenda
Cardiology Workflows General
Cath Workflow

Echo Workflow Stress Workflow

Content Display Requirements

Stress Echo Stress

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Use Cases
Case E1: Patient Registered at ADT and Procedure Ordered Case E2: Intermittently Connected Modality

Case E3: Intermittently Connected Modality with Ad Hoc Procedure, Patient Registered, Scheduled Procedure
Case E4: Intermittently Connected Modality with Ad Hoc Procedure, Patient Registered, Unscheduled Procedure Case E5: Intermittently Connected Modality with Ad Hoc Procedure, Patient Unregistered, Unscheduled Procedure Case E6: Stress Echo Staged Protocol Case E7: Echo Measurements Evidence Creation
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Case E1: Patient Registered at ADT and Procedure Ordered

Clinical Context Corresponds to traditional Radiology workflow Order placed in central system Also deals with case where emergency identifier has been created Common identifiers known ahead of time IHE Context The Scheduled Procedure Steps are obtained by the modality through Query Modality Worklist, the acquisition is performed and statused thought Modality Performed Procedure Step.

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Case E2: Intermittently Connected Modality

Clinical Context
Allows for the mobile workflow typical of TTE and TEE Assumes the modality is only intermittently connected to the

network Also covers the case of the modality being turned off

IHE Context
Process flow identical to Case E1 Must be paired with an Image Manager/Image Archive that

also supports Intermittent Connectivity MPPS are stored and sent when connection established Image Manage must queue N-Event Report messages for storage commitment
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Case E3: ICM with Ad Hoc Procedure, Patient Registered, Scheduled Procedure
Clinical Context
This extends Case E2 to allow for a scheduled procedure

but the modality cant query the worklist since it is not connected to the network

IHE Context
The modality will treat this as unscheduled procedure
The patient ID and demographics must be manually entered The modality must create the Study Instance UID Manual matching process at DSS/OF to reconcile the

scheduled and performed procedure information Post match the DSS/OF will reconcile with the Image Manager to correct for the Study Instance UID
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Case E4: ICM with Ad Hoc Procedure, Patient Registered, Unscheduled Procedure
Clinical Context
This is the drive by echo or Stat echo performed without an

order placed in the system

IHE Context
This case is identical to other unscheduled procedure cases

Modality creates the Study Instance UID

When connected the modality will send a MPPS in Progress DSS/OF will generate an exception for reconciliation Patient demographic reconciliation should occur

automatically based on patient ID The Image Manager will use the Patient Update transaction to update the demographics
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Case E5: ICM with Ad Hoc Procedure, Patient Unregistered, Unscheduled Procedure
Clinical Context
This case is similar to Case E4 except the patient is not yet

registered. (Emergency Admit)

IHE Context
Temporary Name and ID entered into the modality

DSS/OF will generate an exception

Manual match of the temporary ID with the Patient

Registration information Patient Update sent to the Image Manager

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Case E6: Stress Echo Staged Protocol

Clinical Context
Allows for appropriate identification of Stages and Views

during a stress echo

IHE Context
Similar to Case E1

Type of stress protocol is specified in the Scheduled

Protocol Code Sequence or Scheduled Step Description Within the perform acquisition activity there are several stages but typically considered the same procedure step A status of Discontinued can indicate technical failure to reach the end point of the exam.

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Case E7: Echo Measurements Evidence Creation Clinical Context

Measurements are normally obtained during the

acquisition on the modality. This case supports the ability to obtain additional measurements on the clinical workstation post acquisition and update the study data.

IHE Context
This case is similar to Cath C9 The actor participates in both the ECHO and ED

profiles Generation of a DICOM SR with reference to original

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Agenda
Cardiology Workflows General
Cath Workflow
Echo Workflow

Stress Workflow

Content Display Requirements

Stress Echo Stress

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Stress Testing
Image Intensivemultiple samples of 12 lead ECG during the protocol Summary report usually one page in length Physician will do comparisons to previous studies

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Stress Options
Stress Echo
Began in the early mid 1990s Observation of wall motion and ejection fractions with the

heart under stress High specificity for correlating ischemia to functional abnormalities Can be done with exercise but mainly chemical

Nuclear Stress
Most often combined with exercise or chemical stress testing Use of radioisotope to detect presence and resolution of

ischemic regions of the heart Scan immediately post Scan 4 hours to 1 day later Resolution of ischemic area determines viability of muscle

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Stress Workflow Diagram

Pt. Registration [RAD-1] Patient Update [RAD-12] ADT Pt. Registration [RAD-1] Patient Update [RAD-12] Order Placer DSS/ Order Filler Placer Order Management [RAD-2] Filler Order Management [RAD-3] Procedure Scheduled [RAD-4] Patient Update [RAD-12] Procedure Updated [RAD-13] Instance Availability Notification [RAD-49] Evidence Creator Image Display Report Creator

Modality PS in Progress [CARD-1] Modality PS Completed [RAD-7]

Modality PS in Progress [CARD-1] Modality PS Completed [RAD-7] Storage Commitment [CARD-3]

Performed Procedure Step Manager

Modality Image/Evidence Stored [CARD-2]

Query Images [RAD-14] Retrieve Images/Evidence [CARD-4]

Image Manager Modality PS in Progress [CARD-1] Modality PS Completed [RAD-7] Storage Commitment [CARD-3] Modality PS in Progress [CARD-1] Modality PS Completed [RAD-7] Query Modality Worklist [RAD-5]

Image Archive

Modality Image/Evidence Stored [CARD-2]

Acquisition Modality

Report Creator

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Stress Workflow Actors and Options

Actor
Acquisition Modality

Option Name
Patient Based Worklist Query Broad Worklist Query PPS Exception Management Stress ECG Stress Echo Nuclear Medicine (see note 3)

Optionality
O R (see note 1) O R (see note 2) R (see note 2) R (see note 2) O R R R R O R R R

Vol & Section

RAD-TF 2: 4.5 RAD-TF 2: 4.5 RAD-TF 2: 4.7 CARD-TF 2: 4.2 CARD-TF 2: 4.2 RAD-TF 2: 4.8 RAD-TF 2: 4.7 CARD-TF 2: 4.3 CARD-TF 2: 4.2 CARD-TF 2: 4.2 RAD-TF 2: 4.8 RAD-TF 3: 4.49 CARD-TF 2: 4.4 CARD-TF 2: 4.2 RAD-TF 2: 4.16

Image Manager/ Image Archive

PPS Exception Management Intermittently Connected Modality Stress ECG Echocardiography Nuclear Medicine (see note 3) Availability of PPS-Referenced Instances

Image Display

Stress ECG Stress Echo Cardiac NM (see notes 3, 4)

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Use Cases
Case S1: Cardiac Stress Test, ECG Only
Limited use with lower sensitivities and specificities

Screening tool only

Case S2: Cardiac Stress Test with Imaging

More common use case

Echocardiography requires Consistent Time to combine clinical data from Stress Monitor and Echo Modality

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Agenda
Cardiology Workflows General
Cath Workflow
Echo Workflow Stress Workflow

Content Display Requirements

Stress Echo Stress

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Stage and Views

Stress Echo Option Stage Number & View Number Stage Code Sequence & View Code Sequence
Coding Scheme Designator (0008,0102) SRT SRT Code Value (0008,0100) Code Meaning (0008,0104)

Views
Apical two chamber

Apical four chamber

Apical long axis

Parasternal long axis

Parasternal short axis Parasternal short axis at the aortic valve level Parasternal short axis at the level of the mitral chords Parasternal short axis at the Mitral Valve level Parasternal short axis at the Papillary Muscle level

P5-01201 P5-01202

Image acquisition at baseline Pre-stress image acquisition

Right Ventricular Inflow Tract View Right Ventricular Outflow Tract View Subcostal long axis Subcostal short axis Suprasternal long axis Suprasternal short axis

SRT
SRT SRT

P5-01203
P5-01204 P5-01205

Mid-stress image acquisition

Peak-stress image acquisition Image acquisition during recovery

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Benefit: Stress Echo Viewing Consistency

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Agenda
Cardiology Workflows General
Cath Workflow
Echo Workflow Stress Workflow

Content Display Requirements

Stress Echo

Stress

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Stress: Protocol and Stage Procedure

Protocol Stages
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Stress: Protocol and Stage

Procedure : Exercise Stress

Protocol: Bruce
Stages:
Standard Bruce has 7 stages

Stage 1: 1.7 mph @ 10 % grade Stage 7: 6.0 mph @ 22 % grade

Important Note: A procedure can be considered complete irrespective of the protocol being complete!
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Attribute Summary
Concept Requested Procedure Modality Worklist Requested Procedure Code Sequence (0032,1064) Scheduled Protocol Code Sequence (0040,0008) Echo Procedure Code Sequence (0008,1032) Performed Protocol Code Sequence (0040,0260) CID 12001* ECG Procedure Code Sequence (0008,1032) Performed Protocol Code Sequence (0040,0260) CID 3261 NM Procedure Code Sequence (0008,1032) Performed Protocol Code Sequence (0040,0260) CID 3261**

Protocol

Protocol Stage Number

Acquisition Context Sequence (0040,0555) >(109055, DCM, Protocol Stage)

Patient State

Stage Number (0008,2122) Stage Code Sequence (0040,000A) CID 12002*

Acquisition Context Sequence (0040,0555) >(109054, DCM, Patient State) CID 3262

Acquisition Context Sequence (0040,0555) >(109054, DCM, Patient State) CID 3101

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