Integrating The Healthcare Enterprise Research Articles

The challenge of integrating the healthcare enterprise

Clinical engineers face technical challenges and opportunities in healthcare technology as results of changing focus in healthcare and the computerization and interconnection of medical devices and systems. Combined, these trends will increasingly move us away from the traditional "bricks and mortar" hospitals and physician's offices and move us toward their virtual successors. Ultimately, diagnosis and treatment will take place at an earlier stage. A major challenge to achieving this goal has been the diversity of current healthcare technologies and the paucity of technical standards for exchanging useful information between different medical devices. The consequence is a technical "Tower of Babel", where these disparate devices lack a common means of communication. The answer to this challenge is an initiative known as Integrating the Healthcare Enterprise (IHE). IHE brought together healthcare information and medical imaging systems industry members "to agree upon, document, and demonstrate standards-based methods of sharing information in support of optimal patient care". By developing integration profiles that detail core processes such as scheduled workflow, image presentation, information access, record retrieval, reporting, and charge posting and adopting existing standards. IHE defines guidelines that medical device manufacturers can follow to ensure their device will interface and effectively communicate with a device from another manufacturer. IHE holds promise to transform the existing technical "Tower of Babel" into sets of integration profiles that will facilitate interoperability of medical devices. The success of IHE will lead to technological integration and thereby meet one of the most critical challenges as healthcare systems move to the next level.

DICOM router: An open source toolbox for communication and correction of DICOM objects 1

Today, the exchange of medical images and clinical information is well defined by the digital imaging and communications in medicine (DICOM) and Health Level Seven (ie, HL7) standards. The interoperability among information systems is specified by the integration profiles of IHE (Integrating the Healthcare Enterprise). However, older imaging modalities frequently do not correctly support these interfaces and integration profiles, and some use cases are not yet specified by IHE. Therefore, corrections of DICOM objects are necessary to establish conformity. The aim of this project was to develop a toolbox that can automatically perform these recurrent corrections of the DICOM objects. The toolbox is composed of three main components: 1) a receiver to receive DICOM objects, 2) a processing pipeline to correct each object, and 3) one or more senders to forward each corrected object to predefined addressees. The toolbox is implemented under Java as an open source project. The processing pipeline is realized by means of plug ins. One of the plug ins can be programmed by the user via an external eXtensible Stylesheet Language (ie, XSL) file. Using this plug in, DICOM objects can also be converted into eXtensible Markup Language (ie, XML) documents or other data formats. DICOM storage services, DICOM CD-ROMs, and the local file system are defined as input and output channel. The toolbox is used clinically for different application areas. These are the automatic correction of DICOM objects from non-IHE-conforming modalities, the import of DICOM CD-ROMs into the picture archiving and communication system and the pseudo naming of DICOM images. The toolbox has been accepted by users in a clinical setting. Because of the open programming interfaces, the functionality can easily be adapted to future applications.

World Trend of Integrating the Healthcare Enterprise (IHE) and Demonstration in CyberRad 2005

World Trend of Integrating the Healthcare Enterprise (IHE) and Demonstration in CyberRad 2005

Introduction to IHE

Integrating the Health Care Enterprise (IHE) is an initiative from the Radiological Society of North America (RSNA) and Healthcare Information and Management Systems Society (HIMSS) to provide a test bed, demonstration and specification of how standards such as DICOM and HL7 can be used to provide an integrated environment. The definition of integration profiles is critical to this specification.

Implementing a full-feature PACS solution in accordance with the IHE technical framework: the CHILI approach 1

Rationale and objectives During the last 4 years, Integrating the Healthcare Enterprise (IHE) has worked in establishing a reliable integrated environment for medical imaging devices and other clinical information systems by using existing industry standards such as Digital Imaging and Communication in Medicine (DICOM) and Health Level Seven (HL7). Because IHE is organized and driven by professional organizations representing both buyers and vendors, it was able to define a common language for the various health care parties who are involved in the integration process. Thus IHE offers a rigorously organized technical framework that provides a comprehensive guide for a coordinated implementation of information standards. Materials and methods A multistage plan for incorporating the IHE elements while scaling up general-purpose workstations with teleradiology functionalities to a full-feature picture archiving and communication system (PACS) solution was created. To introduce a pragmatic example, the plan approach was applied to the CHILI workstations (CHILI, Heidelberg, Germany). To implement the proposed plan in making various legacy systems comply with IHE, the effects of available resources and market needs on the plan are discussed. Most implementation challenges and problems were overcome using generic design approaches and well-designed DICOM utilities. Results On completion of the first stage, the PACS viewer and reporting workstations were IHE-compliant. In addition, the plan facilitates the conformance process while maintaining the planned software development cycle. Conclusion Based on these positive results and the practical experience acquired during the first stage, further stages will be completed to provide the system with the required plug-and-play interoperability among systems from different vendors.

Extending the IHE initiative to Europe: experiences

The IHE (Integrating the Healthcare Enterprise) initiative has recently developed into a multinational effort that addresses the specific needs of healthcare systems in North America, many European countries as well as Japan. The introduction of IHE in Europe is a particular challenge because the structure of the healthcare sector deviates significantly from country to country, with different legislation, language, medical and organisational procedures and hospital information systems (HIS)/RIS systems that are typically tailored towards a specific national market. Experiences in Europe show that IHE cannot simply be copied, but has to be adapted to the specificities of national healthcare systems. However, these are only of minor nature compared to the overall complexity of the transactions involved.

IHEによる新たな標準化へのアプローチ(IHE : 医療連携のための情報統合化プロジェクト)

IHEによる新たな標準化へのアプローチ(IHE : 医療連携のための情報統合化プロジェクト)

Using the IHE scheduled work flow integration profile to drive modality efficiency.

The IHE (Integrating the Healthcare Enterprise) Scheduled Work Flow integration profile describes a communication and work flow environment that provides benefits for radiology departments who want to standardize system software. The IHE technical framework defines this environment by specifying the systems involved and the messages exchanged by those systems. The Modality Worklist is a key component of the Scheduled Work Flow integration profile that allows an operator at each modality in the department to retrieve a list of scheduled procedure steps to perform and to automate the process of entering the correct patient identification information in all the images created with the modality. The IHE technical framework defines two transactions used by the modality to tell the Image Manager and Order Filler what was performed and how many images were acquired: the Modality Procedure Step in Progress and Modality Procedure Step Completed. Users who specify the Scheduled Work Flow integration profile will benefit immediately by achieving a certain baseline of functionality. However, users will derive further benefits of increased operational efficiency through negotiation with the providers of software solutions. The integration profile defines features that are optional; users should evaluate these features and request those that are determined to be beneficial.

Introduction to Paper by Sridhar B. Seshadri, MSEE, MBA, et al, “Prototype Medical Image Management System (MIMS) at the University of Pennsylvania: Software Design Considerations”

IT IS ILLUMINATING and perhaps a little humbling to review a paper written over 15 years ago and compare it to the state-of-the-art in PACS today. Clearly, there have been astounding improvements in the core technology: increased processing power, higher communications bandwidth, cost-effective storage capacity, and superb display technologies. However, the authors’ view (in 1987) that the industry (vendors and customers) needs to focus more on software and systems issues still rings true. Standardization of hardware and software components has come a long way with the digital imaging and communications in medicine (DICOM) and Integrating the Healthcare Enterprise (IHE) standards; without these yeoman efforts, PACS would still be in the dark ages. Also, PACS appears to have “graduated” from being a departmental solution to becoming more and more integrated into the mainstream clinical information systems from information technology providers. Despite these great achievements, I think the industry needs to invest more thought and effort into unleashing the power of PACS with revolutionary workflow and process-change around the technology that will help users realize greater benefits. Interestingly, Louis Gerstner Jr., in an interview about his new book, Who Says Elephants Can’t Dance? says (about the computer industry) “. . . the process of integrating this technology and achieving the benefit is unbelievably painful for companies. The industry has been all about faster, faster, more function, more function. . . .” It appears, at least in this regard, that PACS shares the challenges of the rest of the computer industry!

Introduction to Paper by Ronald L. Arenson, M.D., et al, ?The Digital Imaging Workstation?

MANY OF THE ISSUES highlighted in our 1990 manuscript are still true today. But monitors are brighter and more stable and now are offered in flat-panel formats. Workstations are most often PC-based and less expensive. Perhaps the biggest difference is the vast increase in network performance, dramatically reducing the need for prefetching from remote storage and selection of images for downloading to the workstation. The availability of much less expensive random-access storage also has changed the entire concept of archives. One of the most important advances relates to the introduction of Web-based image presentation, providing inexpensive, easy-to-support access to the picture archiving and communications system (PACS) outside of the main department and its dedicated workstations. The implementation of Integrating the Healthcare Enterprise (IHE) by numerous vendors will accelerate the full integration and utilization of PACS in the medical center–wide enterprise.

Introduction to the Paper by Eliot Siegel and Bruce Reiner, ?Work Flow Redesign: The Key to Success When Using PACS?

AS AN EARLY PICTURE ARCHIVING AND COMMUNICATION SYSTEM (PACS) adopter, I am often asked about “the most important lesson that I’ve learned about filmless radiology.” Although we have learned many things during the past decade, the most important lesson has undoubtedly been that the purchase of a PACS provides an opportunity to re-engineer and streamline the inefficient manual workflow found in most conventional imaging departments. In my experience, many imaging departments have used PACS as an electronic substitute for film, completely emulating all aspects of a conventional department. Such departments continue to push individual studies from a specific acquisition device (such as a CT scanner) to a specific workstation in a manner similar to hanging films from that modality on a specific film alternator. They continue to enter patient information either electronically or on paper multiple times on multiple information systems in a manner analogous to paper and index cards, rather than having these systems communicate with each other. It is therefore not surprising that there have been mixed results with regard to the impact of PACS on departmental productivity and cost savings. It has been my experience that departments that have concentrated on redesign of workflow using integrated systems that communicate with each other have been able to achieve the greatest gains in savings and efficiency. In 1991, when we purchased our PACS for the Baltimore VA Medical Center, we were required to create custom interfaces for each of these information systems in order to achieve interoperability. Today, customers can take advantage of the Integrating the Healthcare Enterprise (IHE) effort to minimize the need to reinvent this wheel and to optimize departmental and/or hospital workflow for imaging. This paper discusses our analysis which compared our workflow processes before and after implementation of an enterprise-wide PACS.

IHE (Integrating the Healthcare Enterprise): a new approach for the improvement of digital communication in healthcare

Parallel to the introduction of diagnosis related groups (DRGs) for the reimbursement of hospitals, a marked reduction of financial means within the healthcare system is taking place. Healthcare enterprise information systems will play an increasing role to accommodate the new working conditions by developing reliable and efficient workflow solutions. Interfacing the systems currently in use can meet considerable obstacles. By offering high connectivity, IHE (Integrating the Healthcare Enterprise), which was initiated by concerted actions of users and vendors, ensures improved health care delivery and, furthermore, assists in acquiring new information systems in the future. IHE is not a standard but makes extensive use of existing international standards, such as HL7 and DICOM. National IHE demonstrations confirmed the power of this approach and presented its mission to large groups of users and vendors. The concept continues to grow and for the first time provides groups of various interests cooperative solutions to the problems encountered in collecting and distributing information.

PACS, ICRS and IHE: making sense of electronic healthcare records

Complex modern healthcare delivery depends on appropriate access to currently relevant data, which implies interoperability of computer systems at a national scale.There is a growing expectation that relevant records will be multimedia records that include or reference images, waveforms and other large information objects as stored in PACS.The Integrating the Healthcare Enterprise (IHE) initiative has implemented a methodology to enable users and suppliers in the medical imaging domain to work together to implement interoperable systems using subsets of existing standards.IHE provisions can form the basis for an important part of the patient record stored in electronic form.

Clinical implementation of the IHE presentation of grouped procedures integration profile in a multivendor environment--workflow modification and barriers to implementation.

The implementation of presentation of grouped procedures (PGP) integration profile, as described in the Integrating the Healthcare Enterprise (IHE) Technical Framework, on computed tomography (CT) and magnetic resonance (MR) scanners as well as the picture archiving communication system (PACS) addresses the problem faced by many institutions in which there are multiple-requested procedures performed in one acquisition. It is a solution that, just like the initial implementation of PACS, requires substantial modification to workflow. Implementation of PGP not only speeds access to relevant images for the requested procedure, it reduces network traffic and is less demanding on workstation hardware because of the smaller data sets transmitted. These workflow issues show that PGP implementation is not complete when the vendors install the necessary hardware and software modifications. This report discusses the workflow modifications and the barriers to implementing the PGP solution.

Global initiative strives to link health care information systems.

274 July/August 2002 It is hard to imagine worldwide agreement on ways to link information systems while we struggle with local systems that can't communicate. However, this vision is coming closer to reality as a result of a joint initiative sponsored by the Healthcare Information and Management Systems Society (HIMSS) and the Radiological Society of North America (RSNA). The Integrating the Healthcare Enterprise (IHE) initiative promotes coordinated use of established communications standards such as HL7 and DICOM to address specific integration needs. Not even the most advanced institutions have begun to realize the full potential of computer systems to reduce medical errors, improve the efficiency of care providers, and enhance the overall quality of clinical care. To do so, health care demands a framework for information sharing that meets the needs of care providers as well as patients—and gains acceptance among the companies that build the systems they rely on. Standards provide the foundation for such a framework, but alone do not solve the problem. In any standard there may be gaps, options, and room for conflicting interpretations. No standard could map perfectly to the complex and ever-changing information domain of a health care enterprise. Filling the gap between standards and systems implementation has, until now, required expensive, site-specific interface development to integrate even standards-compliant systems. To close that gap, a process for building a detailed framework for the implementation of standards is needed. IHE provides that process. Clinicians, administrators, and other health care professionals are frustrated by computer systems that don't effectively share information. They envision a day when vital information can be passed seamlessly from system to system within and across departments and made available as needed at the point of care. The IHE initiative aims to make this vision a reality. IHE integration profiles organize the integration capabilities needed to address specific patient care needs. Integration profiles offer a convenient way for vendors and users to reference the functionality defined in the IHE Technical Framework without having to restate all of the detail. They describe clinical information and workflow needs and specify the functional units (actors), and transactions required to address them. Volunteer members of HIMSS and RSNA, including radiologists and other clinicians, health care executives, and information technology experts, play a key role in guiding the development of IHE and determining priorities for integration. Vendor representatives also collaborate in the process, which is making progress toward removing the obstacles to integration and optimal patient care. During the third year of the initiative, which commenced at the HIMSS Annual Conference and Exhibition this February in Atlanta, 33 companies representing 68 systems completed the testing process “Envision a day when vital information can be passed seamlessly from system to system within and across departments and made available as needed at the point of care.”

Upgrading legacy systems for the Integrating the Healthcare Enterprise (IHE) initiative.

As technology vendors have adopted standardized communication protocols, including Digital Imaging and Communications in Medicine (DICOM) and Health Level 7 (HL7), interconnectivity between various devices has been simplified. The recent Integrating the Healthcare Enterprise (IHE) initiative will further promote the use of standards for interconnectivity. Until these standards are universally accepted, we must live in a transitional world where some components will communicate without any modification, while others require upgrades to allow them to meet the new standards. In designing and implementing the network at University of California Los Angeles (UCLA) Medical Center, some integration problems were found that are common to the industry. Creating departmental workflow with only a limited number of acquisition devices supporting the DICOM worklist was the initial problem addressed. Although many manufacturers provide this function for their new scanners, upgrading existing equipment is often cost-prohibitive. To ensure the quality of the demographic information in the image data and the workflow of the system, third-party worklist components were required to upgrade the legacy acquisition devices. These worklist components provided a standards-compliant facade on top of the legacy equipment, allowing seamless integration with the remainder of the network. To support the distribution of worklist information and the feedback of procedure status, a bidirectional HL7/DICOM protocol bridge was required. Although many radiology information system (RIS) manufacturers will be providing native DICOM capabilities in future product releases, the majority of current RIS installations have no DICOM functionality. Similar to the legacy scanners, the HL7/DICOM bridge provided a DICOM-compliant facade to the non-DICOM RIS. The additional use of web-based technology for worklist display further extended flexibility of this facade. We have demonstrated standards-compliant facade technology allowing legacy components to operate seamlessly in an IHE environment at a fraction of the cost of upgrading to new equipment.