Healthcare information standards (IHE, DICOM, HL7)

• 1. in the management and integration of virtual slides in Pathology Marcial Garca Rojo(1), Carlos Peces(2), Jose Sacristan(2), Gloria Bueno(3) 1) Hospital General de Ciudad Real. Spain 2) Castilla-La Mancha Health Care Services (SESCAM)3) University of Castilla-La Mancha

2. Presentation objective

• We describe our experience in the use of emergingIT standards in Pathology , including the integration of Virtual Slides in Pathology general workflow.

• A regionalproject on digital pathologyis presented

• This digitalization effort has been of specialbenefitfor second opinion (teleconsultation), continuing medical education, and quality assurance in Pathology.

3. Infrastructures development SANITEL:Communication network BACKBONE inter-province communication network 155 Mbps circuits ATM between TO & AB-CR-CU-GU Gigabit Ethernet ring in province capitals STM-1 STM-1 STM-1 STM-1 E3 _ _ TOLEDO _ _ CIUDAD REAL _ _ ALBACETE CUENCA GUADALAJARA Talavera 4. Population-based patient databasesearch engine Images Central database YKONOS.Hospital 1 Hospital 2 Primary care centre 1 Primary care centre 2 5. Standards in Pathology

• Integration in Pathology Information Systems has not yet been achieved.

• Standardization efforts are progressing to provide integration in healthcare information technology (IT) systems, such as:

• CEN TC 251 (pr EN13606): electronic health record

• HL7: messages

• DICOM: images

• IHE initiative ( http://www.ihe.net/ ): How to use standards

• Fist goal is to elaborate a document, thePathology Technical Frameworkthat identifies the workflow, the IHEactors(i.e. functional components, application roles), and shows thetransactionsbetween them.

6. IHE Definition

• IHE is an initiativeby healthcare professionals and industryto improve the way computer systems share healthcare information.

• IHE promotes the coordinated use of established standards such asDICOM and HL7to addressspecific clinical needsin support of optimal patient care.

• Systems developed in accordance with IHEcommunicate with one another better , are easier to implement, and enable care providers touse information more effectively .

7. Sitios web relacionados

• Integrating the Healthcare Enterprise Europe:http://www.ihe-europe.org/

• IHE.net:http://www.ihe.net/ (American College of Cardiology, Healthcare Information and Management Systems Society and the Radiological Society of North America)

• IHE Technical Frameworks:http://www.ihe.net/Technical_Framework/index.cfm

• IHE-UK:http://www.ihe-uk.org/

• IHE-France:http://www.gmsih.fr/tiki-index.php?page=IHE

8. The IHE Process (annually)

• Identify Interoperability Problems

• Specify Integration Profiles

• Test Systems at the Connectathon

• Publish Integration Statements for use in Request For Proposals (RFPs)

9. 2. Specify Integration Profiles

• Experienced healthcare IT professionalsidentify relevant standardsand definehow to apply themto address the problems, documenting them in the form ofIHE integration profiles .

• Examples: Use of HL7 (ADT) to send a request of pathology study from the HIS to PIS, and how to retrieve pathology images using DICOM

10. IHE Pathology. An example of problems to deal with

• Pathology images are in a digital format but often without any organization. Model for integration:IHE

• A model in digital radiology (Scanner and magnetic resonance) DICOM

• DICOM:Digital Imaging and Communications in Medicine , refers to a file header standard.

• DICOM headers can wrap many commonly used image file types, including JPEG and TIFF

• Can we apply DICOM standard in pathology? How this is done with virtual slides?WG26

11. IHE promotes standards: Advantages of DICOM

• Organization: Central repository of medical images for all medical specialties:PACS

• Integration with e-Health Record

• One viewer for all medical images

• Independence of

• • devices manufacturers

• • proprietary file formats

12. Actors in Pathology Information Framework

• Actors:information systems or components of information systems that produce, manage, or act on information associated with operational activities in the enterprise.

• Acquisition Modality Acquires and creates medical images , e.g. a Computed Tomography scanner or Nuclear Medicine camera. A modality may also create otherevidence objectssuch as Grayscale Softcopy Presentation States for the consistent viewing of images orEvidence Documents containing measurements .

• Order Filler Apathology department-based information systemthat provides functions related to the management of orders received from external systems or through the department systems user interface.

• Order Placer Ahospital or enterprise-wide systemthat generates orders for various departments and distributes those orders to the correct department, and manages state changes of those orders.

• Image Archive Provideslong term storageof evidence objects such as images, presentation states, Key Image Notes and Evidence Documents.

• Image Display Offersbrowsing of patients studies . In addition, it may support the retrieval and display of selected evidence objects including sets of images, presentation states, Key Image Notes, and/or Evidence Documents.

13. Transactions in the Pathology Technical Framework

• Transactions: Interactions between actors that transfer the required information through standards-based messages.

• Filler Order Management

• • Contains all the messages required between theOrder Filler(PIS) and theOrder Placer (HIS)for the notification of anew filler order , as well as the creation of theplacer orderthat reflects it.

• • Ensure that each filler order will be represented by a placer order, and will have both a filler order number and a placer order number.

• • It can also be used for order modification or cancellation.

• Modality Worklist Provided

• • Based on a query entered at the Acquisition Modality,

• • Listing all the items that satisfy the query.

• • List of Scheduled Procedure Steps with selected demographic information and information about specimen is returned to the Acquisition Modality.

14. HL7: A common languaje

• Messages between applications:

• MSH|^~&|APA||||20050714150127||ORM^O01|-11407200515012714|R|2.3|PID||1|1||MOD_NOMB^MOD_APE1^MOD_APE2||19410907000000|F|||^^^^||||||||||||||||||||PV1|||^|||^|||||||||||||0|||||||||||||||||||||||||||ORC|XO|-1|05B0000003||CM||||||||||||

• MSH|^~&|APA||||20050714150134||ORU^R01|-11407200515013414|R|2.3|PID||1|1||MOD_NOMB^MOD_APE1^MOD_APE2||19410907000000|F|||^^^^||||||||||||||||||||PV1|||^|||^|||||||||||||0|||||||||||||||||||||||||||ORC|XO|-1|05C0000001||CM|||||0^DESCONOCIDO||10009^GOMEZ , ALICIA|||||OBR|1|-1|05C0000001|^^^^|||20050714145607||0|^^^|F|||20050714000000|^^^^^|10009^GOMEZ , ALICIA^^|||GI^GINECOLOGIA|||20050714145607|||F||0^^^^^^^^^|||||10002^GARCIA^F.^H.^^||||20050714145607|0||^^^^|OBX|1||73^MUESTRA^L^A^|0|CERVIX CT1|^^^^|||0||||||^^^^|^^^|^^^^|OBX|2||^MATERIAL REMITIDO^L^^|1|CITOLOGIAS/ RASPAT CV/ A) CERVIX CT1|^^^^|||0||||||^^^^|^^^|^^^^|OBX|3||^DATOS CLINICOS^L^^|2||^^^^|||0||||||^^^^|^^^|^^^^|OBX|4||^MACRO^L^^|2||^^^^|||0||||||^^^^|^^^|^^^^|OBX|5||^MICRO^L^^|2|A )celulas vaginales normales|^^^^|||0||||||^^^^|^^^|^^^^|OBX|6||^MICRO^L^^|3| |^^^^|||0||||||^^^^|^^^|^^^^|OBX|7||^DIAGNOSTICO^L^^|4|A )CITOLOGIA NORMAL|^^^^|||0||||||^^^^|^^^|^^^^|OBX|8||^DIAGNOSTICO^L^^|5| |^^^^|||0||||||^^^^|^^^|^^^^|OBX|9||T83000^SNOMED^L^^|6|CERVIX|^^^^|||0||||||^^^^|^^^|^^^^|OBX|10||M00120^SNOMED^L^^|7|CITOLOGIA NORMAL|^^^^|||0||||||^^^^|^^^|^^^^|

15. File format problems

• PACS systems manage images which are DICOM-compliant.

• DICOM files are limited in size to 2GB.

• Most DICOM systems cannot manage TIFF files with atiledorganization, and/or TIFF files with JPEG or JPEG2000compression .

• For these reasons it is generally not possible to import Aperio SVS files directly into PACS.

16. Our project: Serendipia

• Serendipity: The faculty of making fortunate discoveries by accident .

• Knowledge transferenceopportunities are common, but the key driver in order that transference to take place (encouraging serendipity) are:

• • The need of the receptor organisation

• • Perspective by donor and receptor

• • Adequate resources in order transference to happen

• However,concordancebetween donor and receptor is not easy and often, serendipity is a key factor in success.

• Organizations must improveSerendipia probabilities , offering adequate resources and structures.

• (British National Space Centre. 2004)

17. Telepathology HOSPITAL A HOSPITAL B Sender Second opinion 18. SERENDIPIA Projectspecific objectives

• Pathology Information System (LIS)

• Image management (including virtual slides)

• Increasing automation in Pathology laboratory

• Object identification: Code bar, RFID

• Specific workstation for pathologists (high resolution: reports, washable: gross/autopsies)

• Data entering (user interface)

• Viewing images and text data

• Communication interactive tools

• Information searches

• Knowledge management

19. Pathology workflow 20. Standards: IHE. Actors & Transactions 21. SESCAM integration design Gross station Autopsy room Micro photo AppserverJ2EE DICOM viewer Virtual slide scanner Virtual slide server Virtual slide viewer Virtual slide repository Path report managing (LIS) 22. Storage needs

• Hospital clinical workload :

• • Number of specimens per year: 5,000 to 40,000.

• • # slides per case: 5

• • Not every case is digitized. Initially, only those requiring collaborative work or when they are of high scientific or teaching interest.

• • Range of size per slide: 0.5 4 GB

• • Medium size (40x), using JPEG2000 compression: 1 Gigabyte ->100 times an X-ray film .

23. Storage needs per hospital

• On line storage for 4 years (1 stphase):

• • Albacete Hosp.(800 beds) : 40 Terabytes.

• • • Almansa(100 beds) :8 Terabytes.

• • • Villarrobledo(100 beds) : 8 Terabytes.

• • Alczar de San Juan(400 beds) : 32 Terabytes.

• • • Tomelloso(100 beds) :8 Terabytes.

24. Architecture: Components

• Pathology Information System ( Novopath )

• PACS 5.6 ( Udiat ): JPGEG2000 links

• Web application J2EE ( Satec )

• Image Server software and viewer ( Aurora )

• Virtual slide ( Aperio )

• User management: LDAP, Kerberos

• Balancing web access by hardware, clustering

• Integrations by HL7 messaging, no intermediary file

25. Architecture Reference Hospital J2EE/Aurora SIAP BACKUP PACS/APERIO Tapes library Storage server Application server/Web Linux RH 4.0/iAS Servidor de BBDD Linux RH 4.0Oracle Cluster 2Gb 2Gb BD SERVICES ServerLDAP Solaris 9 ServerBackup Linux RH PACS server W2003 SQL Server 2005 iAS/WEB EnvironmentEnvironment Environment SIAP Environment 26. Virtual slides

• Virtual microscopy:Aperio ScanScope

• XT: 120-slides / CS: 5 slides

• Speed: (15 X 15 mm):