EMR Integration: Embedding Diagnostic and Enterprise Images

Transcription

1 @IntegratorBrad EMR Integration: Embedding Diagnostic and Enterprise Images Brad Genereaux Product Manager, Agfa HealthCare Co-chair, DICOM WG-27 Web Technologies Co-chair, HL7 Imaging Integration / DICOM WG-20

2 Faculty/Presenter Disclosure Faculty: N/A Relationships with commercial interests: Product Manager, Agfa HealthCare Grants/Research Support: N/A Speakers Bureau/Honoraria: N/A Consulting Fees: N/A Other: Co-chair, DICOM WG-27 Web Technologies Co-chair, HL7 Imaging Integration / DICOM WG-20

3 Education Goals By the end of this presentation, attendees should be able to: Identify the value of imaging inside the electronic medical record (EMR) Understand the general steps to achieving imaging integration in the EMR Identify areas of concern and strategies of mitigation of risks in imaging integration in the EMR

4 What do I mean by EMR? Electronic Medical Record (EMR) Electronic Health Record (EHR) electronic version of a patient s medical history Types of EMRs : Hospital Physician Office Specialist Patient Today s focus

5 EMRs at the Centre of Electronic Care Medical Data In To the EMR Via Devices To Those That Need It Admissions PC in Office Family Doctor Radiologist Disease Info Shared Workstation ER Physician Specialist Prescriptions Tablet Nurse Technician Lab Work EMR Clerk Coder Consent Forms Phone Surgeon Transcription -ist Questionnaires Wallaroo Resident Fellow IMAGES! Home PC Researcher Department Chiefs

6 What do I mean by imaging? 1 Diagnostic Imaging Obtained to elicit a differential diagnosis or confirm a clinical suspicion Procedural Imaging Obtained before, during, and after surgical and percutaneous invasive procedures Evidence Imaging Captured primarily for documentation of a patient s current state Image-Based Clinical Reports i.e., image-enriched textual reports where thumbnail image depictions of lesions identified 1.

7 What do I mean by Image Enabling? Supporting the EMR with seamless access to images, in context to the patient, and meeting the clinician s goals and needs of patient care DIAGNOSIS: Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sed consectetur aliquet ipsum eget tempor. OBJECTIVE: Vivamus non feugiat nulla, ac auctor turpis. Donec luctus magna nec nisi ornare, a interdum magna egestas. Etiam vel posuere quam, non sodales enim. Interdum et malesuada fames ac ante ipsum primis in faucibus. Proin nisl velit, euismod in tellus vitae, feugiat aliquet ligula. Fusce ipsum urna, laoreet suscipit quam nec, tempus gravida felis. Cras tempus eget elit hendrerit egestas. Vestibulum orci odio, tempus ac dictum vitae, sagittis et lectus. ASSESSMENT: Proin et eleifend leo, non efficitur nibh. Morbi lorem diam, vehicula quis posuere eget, lacinia non mi. DIAGNOSIS: Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sed consectetur aliquet ipsum eget tempor. OBJECTIVE: Vivamus non feugiat nulla, ac auctor turpis. Donec luctus magna nec nisi ornare, a interdum magna egestas. Etiam vel posuere quam, non sodales enim. Interdum et malesuada fames ac ante ipsum primis in faucibus. Proin nisl velit, euismod in tellus vitae, feugiat aliquet ligula. Fusce ipsum urna, laoreet suscipit quam nec, tempus gravida felis. Cras tempus eget elit hendrerit egestas. Vestibulum orci odio, tempus ac dictum vitae, sagittis et lectus. ASSESSMENT: Proin et eleifend leo, non efficitur nibh. Morbi lorem diam, vehicula quis posuere eget, lacinia non mi.

8 Studies Demonstrate Effectiveness of Embedding Images While written descriptions of lesions and infectious processes may be detailed, the visual presentation of these conditions is much more accurate and effective for diagnosis and treatment. Imaging: New Electronic Tool For Clinicians, 2003 (Susan I. Reynolds)

9 If I Can t Find It, It Does Not Exist If imaging studies are not readily available, patients may need to be re-imaged 3 Increased patient risk (radiation, hospital-borne infections) Increased cost to the patient / healthcare system (unnecessary exams) Increased patient and caregiver discomfort and anxiety Increased delay for the patient (while re-imaging takes place) Increased delay for other patients (while re-imaging takes place) Or need for increased unnecessary capacity 3.

10 Let s integrate images in the EMR Where do we begin?

11 EMR Integration Checklist Set your goals and use cases for embedding images Understand the level of maturity of the systems involved Engage the right people resources from each stakeholder group Include the right hardware and software configurations Create execution plan detailing milestones and go/no-go criteria Include sufficient testing of both core and edge use cases

12 Goals and Use Cases Who is the consumer? Referring physicians in an office setting Surgeons and nurses prepping for surgery Clerks processing patient transfers from elsewhere / regional repository Patients themselves All of the above? What do they need? Access instantly (when their visit is planned) Access as fast as possible (when it is something ad-hoc) Casual review when images are available for review All of the above?

13 Understand your Governance Model System ownership Who owns the EMR systems? Who owns the imaging systems? Who owns the secondary systems (i.e., network, authentication)? Image stewardship Who owns the images? How long do you keep images for? Understand politics in your organization Service expectations Do you have Service Level Agreements? (uptime / performance guarantees) Both with your vendors and also your constituents How does one call for help if there is a service or a QA issue?

14 Value-Add Workflows Empower clinicians to create their own clinical content with an enterprise capture solution Understand the difference between order-based imaging and encounterbased imaging Embed order creation workflows in connected RIS scenarios Allow collaboration on imaging to happen From data to sharing context to sharing workflows Extend your critical results framework to include imaging results (and image-enable those)

15 EMR Integration Levels of Maturity No context Full context Level 0 Level 1 Level 2 Level 2.5 No connection from EMR to image viewer Manual launch of image viewer Manual search for patient Manual display request Push URLs to EMR to launch image viewer Popped-out launch of image viewer Push Acc#s to EMR to embed image viewer Embedded image viewer maintains context Discover available studies for given patient Embedded image viewer in EMR Patient identifier based

16 Know the Players of Imaging Integration Hospital IT Hospital IT Staff Integration specialist Project manager Hardware systems analyst Network analyst Clinical analyst Clinician champions Image Viewer Vendor Staff Integration specialist Project manager Workflow analyst Sales Imagingenabled EMR EMR Vendor Staff Integration specialist Project manager Clinical analyst Sales

17 Know the Stakeholder Roles Hospital IT Hospital IT Documents clinical use cases Plan a concrete scope of work Configure their systems in accordance to specifications Coordinate the vendors activities Provide access to supporting systems Imaging Viewer Vendor Provide the imagingbased APIs necessary to integrate Perform necessary configurations to support integration Help troubleshoot issues Imagingenabled EMR EMR Vendor Provide methods to connect to imaging-based APIs Perform necessary configurations to support integration Help troubleshoot issues

18 Use the right hardware / software for the job Ensure the necessary hardware is in place Servers and storage Network and security infrastructure (routers, firewalls) Ensure the necessary software is in place Obviously EMR and imaging software and associated databases Security infrastructure (LDAP, reverse proxies,..) Ensure sufficient licenses Ensure that you have a valid and functional test environment

19 EMR, Imaging, and Networks Can range from simple to very complex LAN User EMR Images Same Network EMR User Internet Firewall LAN Images VPN outside the Network EMR User Internet Firewall DMZ Portal / Proxy Firewall LAN Images Proxied access to Data Don t forget about network encryption (HTTPS) User Internet Firewall DMZ Portal / Proxy Firewall LAN EMR LAN Firewall Internet Firewall LAN Images Access to Foreign Images

20 Authentication (Knowing who the user is) Active Directory for enterprise authentication Access to your computer and Windows services Kerberos for single sign-on services EMRs typically provide their own user accounts Investigate methods on how to provide user context in these scenarios Consider strong password policies Avoid using client-launched fixed service account integrations i.e., EMR launches Active Directory LAN User EMR Images

21 Authorization (knowing what users can access) Understand your organization s data policy Respect patient privacy regulations (PIPEDA, HIPAA) Data authorization models typically fall under EMR jurisdiction I.e., some models include Provide everyone access and rely on professional conduct User EMR Images Patient access opt-in (specifically allow users to a particular record) or opt-out (control access to VIP patients) Time of day access (connected to a user s schedule management) Break the glass when access is disallowed but it is an emergency situation (subject to audit scrutiny) Authorization also controls what the user can do i.e., amend and sign-off on diagnostic reports, add their own markup, view final and/or preliminary reports LAN VIP Patient

22 Standards in EMR Integration HL7 HL7 V2 Used in some workflows to communicate availability of studies via ORM (order) / ORU (result) messages FHIR is coming DICOM / DICOMweb DICOMweb Rendered images by WADO-RS or WADO-URI Great for thumbnails / study preview IHE IID (Embedding zerofootprint viewer) EUA, XUA, IUA (Authentication) ATNA (Auditing) WIC (Image Capture) XDS-I (sharing)

23 Consideration : Patient and Study Identity Once multi-site, patient and study identity become challenging Patient and accession number collisions Use patient identity issuer fields and consider the use of MPIs where necessary Also an issue when content is imported (from CDs) However, this is made less relevant in the imaging-integrated EMR, as the study should already be reconciled by the time it is available Procedure terminology consolidation becomes important, especially in multi-site scenarios

24 Execution and test plans You know your systems, your data, your people, your workflow There is no one-size-fits-all plan Work with your vendors and leverage their templates

25 Let s do this! Set your goals and use cases for embedding images Understand the level of maturity of the systems involved Engage the right people resources from each stakeholder group Include the right hardware and software configurations Create execution plan detailing milestones and go/no-go criteria Include sufficient testing of both core and edge use cases Go-live!

26 Any

27 Bibliography 1. Roth, Christopher J., Lannum, Louis M., Persons, Kenneth R. 31 May A Foundation for Enterprise Imaging: HIMSS-SIIM Collaborative White Paper. Journal of Digital Imaging, pp 1-9. Retrieved from 2. Susan I. Reynolds, RN BSN M.Ed Imaging: New Electronic Tool For Clinicians. AMIA Annu Symp Proc Retrieved from 3. Vest JR, Kaushal R, Silver MD, Hentel K, Kern LM: Health information exchange and the frequency of repeat medical imaging. Am J Manag Care 20(11 Spec No. 17):eSP16 esp24, Retrieved from Images used from A Foundation for Enterprise Imaging: HIMSS-SIIM Collaborative White Paper (by Roth, Christopher J., Lannum, Louis M., Persons, Kenneth R.) from under the terms of the Creative Commons Attribution 4.0 International License ( Selected images were used.