INTEGRATING HEALTHCARE ENTERPRISE
IMAGE SHARING NETWORK SOLUTION
IMAGE SHARING NETWORK SOLUTION
IHE: Integrating the Healthcare Enterprise
A standards-setting organization; Integrates standards such as DICOM, HL7 to provide solutions for real-world needs.
RSNA: Radiological Society of North America
An international society of Radiologists who promote advances in the field of Radiology and provide Software Solutions to support Electronic Health Records including Imaging of all modalities.
NIBIB: National Institute of Biomedical Imaging and Bioengineering
An innovating arm of the Department of Health and Human Services dedicated to advancing research and technologies to improve and innovate healthcare. Plays an important role in advancing Imaging with different modalities and promoting early detection.
DICOM: Digital Imaging and Communication in Medicine
An Internationally recognized standard to transmit, store, retrieve, print, process and display medical imaging information. Standards fully incorporated in image-acquisition devices, PACS, and workstations throughout healthcare infrastructure.
PACS: Picture Archiving & Communications System technology
Utilizes DICOM standards for storage & retrieval of images.
HL7: Health Level Seven, a standards-developing body
Provides standards for the exchange, integration, and sharing and retrieval of electronic health information. ANSI Accredited – founded in 1987.
RIS: Radiology Information System
Integrates workflows in Radiology from initial order through to billing and sharing of exams within the radiology department. Utilizes HL7 and DICOM standards for integration of various devices.
EMPI: Enterprise Master Patient Index.
Database of patient records maintained across the healthcare organization, it maintains a consistent and unique patient identifier by merging and linking patient records. Provides a rich querying mechanism.
PIX: Patient Identifier Cross Referencing.
IHE Actor uses services provided by the EMPI. PIX API including Query API is defined by IHE.
Healthcare professionals have a need to store and access relevant medical documents for any patient under care. Document creation and submission, query & retrieval functions, and secure access must span the healthcare enterprise to provide timely care in the most efficient manner.
Patient exams that include imaging of varying types of modalities and diagnostic reports ultimately belong to the patient, and only the patient has the right to share this information with other caregiving facilities. Strict HIPAA compliance requires that any PHR must always be treated with utmost security and never leave the designated secure areas.
In Radiology, the process begins when an order for an exam is placed by a physician. As part of this process, a local patient-identifier is generated for the order. However, for the lifetime of the patient, there is a global, unique patient identifier that spans the healthcare enterprise. Any Electronic Medical Record must then be tracked and accessible via this global patient ID.
An EMPI or Enterprise Master Patient Index system that is deployed across the healthcare organization helps maintain a consistent and accurate view of a patient’s identity. This database identifies the patient by use of a Global Unique Patient Identifier and accesses the patient record. The patient record contains patient demographics such as date-of-birth, place-of-birth, current address, and numerous other fields. Any variances or multiple records result in the merging or linking of extant records. Tolerance for error is close to zero and is a huge challenge in maintaining integrity across the healthcare enterprise.
IHE (Integrating Healthcare Enterprise) specifications pull together many industry standards such as DICOM, DICOMWeb, MTOM/XOM and more to provide a technical framework (TF) for integrating healthcare systems. This technical-framework specifies IHE-Actors and their Transactions which, when combined together, define a specific integration profile. IHE Profiles can cover various aspects of Healthcare Integration are specified in the following documents:
The Radiology specific profiles are provided in the specifications listed below. The radiology profiles are based on the general specifications but provide additional protocols and fields that apply to Radiology. These sets of specifications also detail the RSNA Image Sharing Network requirements.
There are numerous subfields of Radiology that are specified in IHE and IHE-RAD specifications, but the rest of this post mainly focuses on describing Integration Profiles required for the implementation of an Image Sharing Network.
The reference graph below shows a combination of actors and the SOAP transaction used to carry out the workflow.
There is a distinct Client / Server relationship where the ISN provides services that allow the clients to perform the following:
Within the ISN, various actors implement integration profiles in order to
Fig.1 ISN Reference Model
Sponsored by a grant from NIBIB, RSNA, Mayo Clinic, and research facilities associated with universities were given a charter to build a patient-centric image sharing network (ISN). This network is designed to automate and improve Radiology workflows by facilitating storage of patient documents to the cloud.
Rather than provide a copy of the exam on a CD, the patient can now choose to receive the exam electronically. This has significant implications, such as
lifeIMAGE, a startup company based in Newton, MA, provided the ISN solution to RSNA based workflows. lifeIMAGE was part of the original research group that pioneered the end to end solution strictly based on IHE & IHE-RAD specifications.
The engineering team from BigR.io participated in the ISN Architecture evolution, its implementation, and subsequently validation and interoperability testing at Collectathons where vendors are required to perform live tests against other vendors in order to show full conformance. BigR.io, in collaboration with lifeIMAGE resources, demonstrated pure excellence in showing conformance and also assisted other teams to meet their objectives.
BigR.io’s knowledge in navigating a plethora of standards, such as DICOM and HL7, and its ability to innovate has proven to be a great asset towards providing a sound and robust solution.
The remainder of this post briefly provides the architecture and workflow details, specifically the RSNA Workflow.
The ISN Reference Model as shown in Fig.1 comprises three major functions:
The edge server Function is an application that integrates with RIS and PACS and is deployed on-premise in a healthcare facility. Participating healthcare enterprises are designated an Affinity Domain. The ISN Service itself is multi-tenant and is capable of supporting multiple Affinity Domains.
The workflow begins when an order is entered in the RIS. At this time, a local patient identifier is generated and registered with the PIX-Manager. The PIX associates the patient identifier to a global patient-identifier, and a new global patient identifier is created if one is not found.
On completion of the exam, the edge server constructs an XDR-i-based Provide & Register SOAP Request and sends the submission request to the lifeIMAGE Registry. The request can include the following:
Note that XDR-i does not require the Image Manifest (KOS) as this is built by the XDR-Imaging Recipient component in the Clearinghouse.
The Clearinghouse is a hosted service. Any number of Healthcare Enterprises may subscribe to this service to conduct their desired workflows.
The service is made up of various IHE-specified Actors and these Actors implement the IHE/RAD specific Integration Profiles. Actors & their transactions are as follows:
1. XDR.Imaging Document Recipient (IDR)
2. XDS Imaging Document Source (IDS)
3. XDS Repository
4. XDS Registry
5. PIX manager
PHR is an Edge Application that allows the end-users such as clinicians to access documents such as diagnostic reports and images submitted for a given patient.
In the RSNA Workflow, the patient is given an access key to access their exam electronically. To perform these actions the following Actors are implemented in the PHR:
1. Document Consumer function
2. Imaging Document Consumer function
Integrating Healthcare Enterprise is actively working to bring necessary modernization and efficiencies to the healthcare industry. The patient-centric workflow to share diagnostic exams is just one example of the integration profiles. There is a fair amount of innovation that lies ahead of us to modernize and make healthcare enterprises IT Infrastructure secure, robust, and efficient.
Sushil is a Principal Architect at BigR.io. He leads a team of engineers from lifeIMAGE and BigR.io to deliver a robust, conforming solution for ISN.
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