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David S. Mendelson, M.D. Chief of Clinical Informatics The Mount Sinai Medical Center

Integrating the Healthcare Enterprise RSNA/NIBIB Image Sharing: An IHE profile tailored to Consumer Control. David S. Mendelson, M.D. Chief of Clinical Informatics The Mount Sinai Medical Center Co-chair IHE Board. Meaningful Use Objectives.

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David S. Mendelson, M.D. Chief of Clinical Informatics The Mount Sinai Medical Center

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  1. Integrating the Healthcare EnterpriseRSNA/NIBIB Image Sharing:An IHE profile tailored to Consumer Control David S. Mendelson, M.D. Chief of Clinical Informatics The Mount Sinai Medical Center Co-chair IHE Board

  2. Meaningful Use Objectives • Improving Quality, Safety, Efficiency & Reducing Health Disparities • Engage Patients and Families in Their Care • Improve Care Coordination • Ensure Adequate Privacy and Security Protections for Personal Health Information

  3. IHE • XDS profile was built around the concept of an affinity domain • Legal relationships at the enterprise level • How can the consumer fit into this model • Use the same actors and transactions

  4. Image sharing- Why? • Benefit of historical exam during interpretation • Rapidly growing cost of healthcare especially growing utilization of imaging • Overutilization • Prevent duplicate exam because a recent exam is inaccessible • Radiation exposure • Quality • Expedites clinical care through easy availability of imaging examination

  5. 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 • Policy

  6. 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 • Policy

  7. Our Product – Information! • Imaging Exam • Order • Direct patient history • Prior exams • Report • Demographics • Referring Clinician • Reporting Team • Indication • Narrative • Procedure • Impression • Structured report

  8. 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 • Policy

  9. Radiology Physician Patient 2nd Radiology Patient Consulting Physician Clinical Trial

  10. Who? • Primary Clinician • Often has existing access • Not always • Consulting Physician • Ambulatory Imaging Center – Hospital • Either direction • Second Hospital or enterprise • Patient or relative • Research • De-identified

  11. 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 • Policy

  12. Film • Are you old enough to remember film? • Still exists • Clinical offices

  13. Film • Today – generally regarded as the least desirable media • Expensive Medium • Limited latitude • Expensive to handle • Sharing • Copying expensive, time consuming, bulky • Accessibility • Import - scanning

  14. The “CD”- “better than sliced bread” or “be careful what you ask for – you may get it” • Portable • Compact • Can hold thousands of images • Inexpensive ($0.50 or less) • What’s wrong here?

  15. The New Film Library

  16. CDs- Problems • Different data formats • Non-Dicom • Different viewers • End-user confusion • Defective Discs • Disc must be in your possession • Patient Identity • Wrong Patient on Disc • Time consuming • Clinician’s are confused • They share their confusion with their Radiologist

  17. Difficult Discs-Wrong Patient/Information • Mayo Clinic • Unreadable Disc – 0.6% • Wrong- 0.2% • Mount Sinai- estimates • 5% cannot be imported • Rare wrong patient

  18. Patient Identity • Patient has a MRN at importing institution • Patient does not have a MRN at importing institution • MRN is in the DICOM header

  19. Our Colleagues Help!

  20. Importing an Exam- the process • Identify the patient locally • Confirm the images belong to the patient • Determine the name the imported exam • Convert into DICOM format • Scan film • Read disc • ? Dicom • Read from buffer • Import and perform reconciliation • Into PACS? • Into RIS? • Into a parallel system? • EMR • Is it for interpretation? • Is it to be billed?

  21. Importing an Exam – a variant • Establish a standard viewing environment for clinicians for outside exams. • Allow them to designate exams for import from this environment • Import into local PACS

  22. Issues for exam import • Accuracy of the foreign information • Compatibility • Legal? • Responsibility ??? • Changes to the exam or report after import • How does one become aware?

  23. CD- Opportunities to improve • Importing a disc provides the opportunity to correct • Robust import solutions -commercial • Standard import interface • Reconciliation process • Trained personnel • Standards • DICOM • PDI extensions (IHE- Portable Documents for Imaging) • BIR- (IHE- Basic Image Review) • Minimum requirement for review

  24. Mechanisms of Sharing- Reports • Mail • RIS • FAX • E-Mail • PACS • VPN • Internet • EMR-Patient Portal • PHR

  25. When to release a Report vs. Image? • The patient is entitled • Legal • Practical • Is the patient prepared for the information in the report? • Immediate use to clinician • May be meaningless to most patients other than a curiosity

  26. Network/Internet base sharing • Replace the CD (SneakerNet) with the Internet • Convenience vs. Security • New opportunities • Shared Image processing • Efficiencies

  27. Network/Internet base sharing • Proprietary applications • Usually used within an enterprise or a limited domain with legal agreements • Health Information Exchange (HIE) • Multiple enterprises with a set of legal agreements • Often have selected their own standards- not truly open standards based • Sustainability

  28. Network/Internet • Security/Privacy-Confidentiality • HIPAA • Security/ Privacy-Confidentiality • HIPAA • This is the networked version of the CD • More convenient • Same issues need to be addressed

  29. Network/Internet • 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

  30. 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

  31. Methods • Point to Point • E-mail • Cloud Computing • HIE (Health Information Exchange) • These are not mutually exclusive- there is overlap

  32. Point to Point • A limited number of entities establish direct connections • Usually requires a direct formal relationship (legal) • Can be successful to address very specific interoperability problems • Doesn’t scale

  33. HIE • Requires legal relationships between participants • Requires patient identity management • Enables a greater number of entities to participate • May be scalable • HIE to HIE • Consent issues • Commonly all or nothing rather than episode or event based • Patients may wish to only expose limited pieces of data

  34. Sharing Healthcare Information in the Cloud Primary Doctor Hospital Specialist Imaging Center Hospital Patient Patient Surrogate

  35. Cloud Computing • WHO • Enterprise • HIE • Consumer • WHAT • Services • Transactions • Archive

  36. IHE-XDS (Cross-Enterprise Document Sharing) • XDS.a • XDS- I.a • XDS.b • ?? XDS-I.b • a vs. b • Related to web standards and transactions

  37. XDS

  38. XDS-I

  39. Canada Health Infoway

  40. NIBIB/RSNA Image Sharing Project A Standards Based Solution

  41. Goals of Contract • NIBIB contract • Bootstrap an IHE based network • 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

  42. NIBIB contract summary • Consumer Control • Employ IHE solutions whenever possible • IHE generally has not focused on consumer driven solutions but rather on institutional and enterprise workflow • 5 Academic Institutions • Mayo Clinic • Mount Sinai Medical Center • University of California San Francisco • University of Chicago • University of Maryland • Establish a clearinghouse • Engage PHRs • 300,000 patients over 2 years

  43. 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

  44. Software architecture

  45. Project design assumptions • Security is paramount • Restrictive policy • PHI is never unsecured • Consumer controls the flow of information by placing it in the PHR • Diminishes the need for BAAs between enterprises • Imaging Site to Clearinghouse • Clearinghouse to PHR

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