Healthcare information standards (IHE, DICOM, HL7)

Healthcare information standards (IHE,

DICOM, HL7)

http://serendipia.hgcr.sescam.jccm.es/

in the management and integration of virtual

slides in Pathology Marcial García Rojo(1), Carlos Peces(2),

Jose Sacristan(2), Gloria Bueno(3)1) Hospital General de Ciudad Real. Spain2) Castilla-La Mancha Health Care Services

(SESCAM) 3) University of Castilla-La Mancha

Servicio de Salud de Castilla-La Mancha 2

Presentation objective

We describe our experience in the use of emerging IT standards in Pathology, including the integration of Virtual Slides in Pathology general workflow. A regional project on digital pathology is presentedThis digitalization effort has been of special benefit for second opinion (teleconsultation), continuing medical education, and quality assurance in Pathology.


STM-1

STM-1

STM-1

STM-1

E3

__

TOLEDO

__

CIUDAD REAL

__

ALBACETE

CUENCA

GUADALAJARA

Talavera

Infrastructures developmentSANITEL: Communication network

BACKBONE inter-province communication network

155 Mbps circuits

ATM between TO &

AB-CR-CU-GU

Gigabit Ethernet ring in province capitals


Hospital 1

Hospital 2

Population-based patient database search engine

Images Central database

Primary care centre 1

Primary care centre 2

YKONOS.


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 recordHL7: messages DICOM: imagesIHE initiative (http://www.ihe.net/): How to use standards

Fist goal is to elaborate a document, the Pathology Technical Framework that identifies the workflow, the IHE actors (i.e. functional components, application roles), and shows the transactions between them.


IHE Definition

IHE is an initiative by healthcare professionals and industry to improve the way computer systems share healthcare information.

IHE promotes the coordinated use of established standards such as DICOM and HL7 to address specific clinical needs in support of optimal patient care.

Systems developed in accordance with IHE communicate with one another better, are easier to implement, and enable care providers to use information more effectively.


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


The IHE Process (annually)

1. Identify Interoperability Problems

2. Specify Integration Profiles3. Test Systems at the

Connectathon4. Publish Integration

Statements for use in Request For Proposals (RFPs)


2. Specify Integration Profiles

Experienced healthcare IT professionals identify relevant standards and define how to apply them to address the problems, documenting them in the form of IHE 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


IHE Pathology. An example of problems to deal with

Pathology images are in a digital format but often without any organization. Model for integration: IHEA model in digital radiology (Scanner and magnetic resonance) DICOMDICOM: 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 TIFFCan we apply DICOM standard in pathology? How this is done with virtual slides? WG26


IHE promotes standards:Advantages of DICOM

Organization: Central repository of medical images for all medical specialties: PACSIntegration with e-Health RecordOne viewer for all medical imagesIndependence of

devices manufacturersproprietary file formats


Actors in Pathology Information FrameworkActors: 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 other evidence objects such as Grayscale Softcopy Presentation States for the consistent viewing of images or Evidence Documents containing measurements.

Order Filler – A pathology department-based information system that provides functions related to the management of orders received from external systems or through the department system’s user interface.

Order Placer – A hospital or enterprise-wide system that generates orders for various departments and distributes those orders to the correct department, and manages state changes of those orders.

Image Archive – Provides long term storage of evidence objects such as images, presentation states, Key Image Notes and Evidence Documents.

Image Display – Offers browsing 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.


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 the Order Filler (PIS) and

the Order Placer (HIS) for the notification of a new filler order, as well as the creation of the placer order that 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.


HL7: A common languajeMessages 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||||||^^^^|^^^|^^^^|


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 a tiled organization, and/or TIFF files with JPEG or JPEG2000 compression. For these reasons it is generally not possible to import Aperio SVS files directly into PACS.


Our project:Serendipia

Serendipity: The faculty of making fortunate discoveries by accident.

Knowledge transference opportunities 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, concordance between donor and receptor is not easy and often, serendipity is a key factor in success.

Organizations must improve Serendipia probabilities, offering adequate resources and structures.

(British National Space Centre. 2004)


Telepathology

HOSPITAL A HOSPITAL B

Sender Second opinion

Servicio de Salud de Castilla-La Mancha 04/10/23 18

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

SERENDIPIA Project specific objectives


Pathology workflow


Standards: IHE. Actors & Transactions


SESCAM integration design

Gross station

Autopsy room

Micro photo

App server J2EE

DICOM viewer

Virtual slide

scanner

Virtual slide

server

Virtual slide

viewer

Virtual slide

repository

Path report

managing (LIS)


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.


Storage needs per hospital

On line storage for 4 years (1st phase):• Albacete Hosp. (800 beds): 40 Terabytes.

• Almansa (100 beds): 8 Terabytes.

• Villarrobledo (100 beds): 8 Terabytes.

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

• Tomelloso (100 beds): 8 Terabytes.


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


Architecture Reference Hospital

J2EE/Aurora

SIAP

BACKUP

PACS/APERIOTapes library

Storage server

Application server/WebLinux RH 4.0/iAS

Servidor de BBDDLinux RH 4.0

Oracle

Cluster

2Gb2Gb

BD

SERVICES

Server LDAP

Solaris 9

Server Backup

Linux RH

PACS serverW2003

SQL Server 2005

iAS/WEB

Environment

Environment

EnvironmentSIAP

Environment


Virtual slides

Virtual microscopy: Aperio ScanScopeXT: 120-slides / CS: 5 slidesSpeed: (15 X 15 mm): <2 min/slide, 20x (frozen s)Resolution: 40x: 0.25 μm/pixelSpectrum™ Plus: Multiuser & muti-siteImage analysis (Quantification IHQ)Files:JPEG2000 (original files are single file (TIFF/SVS), or a directory with multiple files (CWS-Composite WebSlide)


Object identification

DocumentsContainersCassettesSlides

Bar codeDirect print: Leica/Sakura(2D: datamatrix)Label (resistant) with bar code:

Radiofrequency (RFID): tissue blocks and slides


RFID: Identifying with radiofrequency

Low/high frequency. Passive/activelabel (“tag”)Reader

Only RFIDBoth (RFID & bar code)Mobile devicesSingle protocol / multi-protocol

Pending: Better standardizationExample: identification of slides by scanner


Specific workstations

Reading (high res.) wkst and teleconsultation

Autopsy and gross room: Washable keyboards, mouse and screen.

4 Mpixels30”(75.62 cm)

Pitch: 0.250 mmSize:

2560 x 1600Brightness:

200(Dicom)/ 370 (max) cd/m2

3 Mpixels20.8” (52.8 cm)Pitch: 0.207 mmSize: 2048 x 1536 Brightness: 500(Dicom)/ 800 (max) cd/m2


Small hospital

Code bar reading containers / slides

Gross station

Wash. Keyb. mouse

Label printer

Photomicroscopy

Scanner(<5 slides)

Storage (8 TB)

Telepathology portal

Serendipia Project in summary

Reference Hospital

Code bar reading container /cassettes/slides

Autopsy room

Reading wkst

Videoconferencing

Voice recognition

Scanner >50 slides

Storage (40 TB)


Support centre

Centralizing malfunctions or breakdowns notifications and technical consultations.

Permanent, 7x24, 365 days a year availability.

On line information about incidences and notifications.

Two software engineers for support team.

Corrective, evolutionary & Preventive maintenance.

Staff training plan


CONCLUSIONS•Eight public hospitals have been included in the initial phase, including integration with enterprise health record. Cost: 3,5 million euros.

•Improving and automating critical processes

•Faster and more reliable diagnoses (frozen sect.)

•Foster intra- and interdepartamental consultation

•Remote consultation and distant collaborative work will attenuate the shortage of pathologists.

•Better follow-up of the diagnostic process

•Introducing image processing and analysing tools


9th European Congress on Telepathology

http://www.seapcongresos.com/telepathology2008/


IHE & DICOM. Collaborate with standardization bodies!

Christel Le [email protected]

Marcial García [email protected]