Acknowledgements
• IHE-RO Symposium @ ASTRO 2006
Integrating the Healthcare
Enterprise
- Radiation Oncology -
– Mike Vannier
– Jay Cooper
– Keith LaPlain
• IHE-RO Technical Committee
– iherotech@aapm.org
Bruce Curran, M.S., M.E.
• IHE 2007 Workshop
Department of Radiation Oncology
University of Michigan
Ann Arbor, MI
– http://www.ihe.net
Disclosures
Outline
• DICOM in Radiation Therapy
• Co-chair, IHE-RO Technical Committee
– Funding from ASTRO for participation
• Vice-Chair, DICOM Working Group 7
– Funding from AAPM for participation
– Brief History
– Scope
– Why it doesn’t work
• IHE
– Brief History
– Structure and Current Activities
• IHE-RO
1
AAPM / RTOG
• “A Standard Format for Digital Image Exchange”
• Modified by NCI Particle Intercomparison
Contract
• Used by NCI High Energy Photon External Beam
Contract
• Modified further by NCI Electron External
Beam Contract
• Adopted and Significant Extended by RTOG
QA Center
• Started as ACR-NEMA
–
–
–
–
Committee formed in 1983
1985 - ACR-NEMA V1.0
1988 - ACR-NEMA V2.0
V1.0 & v2.0 image transfer based on point-to-point
medium.
– Version 3, renamed DICOM 3. Used network for image
transfer.
DICOM 3 History
•
•
•
•
•
1990 - The name was changed to separate
the standard from the originating body
1991 - Release of Parts 1 and 8 of DICOM
1992 - RSNA demonstration, Part 8
1993 - DICOM Parts 1-9 approved, RSNA
demonstration of ALL parts
1994 - Part 10: Media Storage and File
Format
1995 - Parts 11,12, and 13 plus Supplements
Part 2 Conformance
Part 4 Service Class Specifications
Part 1 Overview
•
DICOM 3 Structure
Part 3 Information Object Definitions
Part 6 Data Dictionary
Part 5 Data Structure & Encoding
Part 7 Message
Exchange
Part 8
Network
Part 9
Point-toPoint
Part 10 Storage Media
& File Format
Part 11 Media Storage
Appl. Profiles
• Originally Developed as AAPM Report #10
DICOM 3 History
Part 12 Physical
Media Formats
2
Healthcare Standards
Insurance
Insurance
General
General
Practitioners
Practitioners
Hospital
e.g. EDIfact
HIS
HIS
Wards
Wards
L i te Box
MAGN
ETOM
HL7
Cardiology
Cardiology
Pharmacy
Pharmacy
Treatment
Treatment
(RT)
(RT)
Pathology
Pathology
Storage, Query/Retrieve,
Study Component
Print Management
e.g. EDIfact
Laboratory
Laboratory
DICOM Application Domain
Query/Retrieve
Results Management
ICU
ICU
Radiology
Radiology
OR
OR
Surgery
Surgery
Media Exchange
Query/Retrieve, Patient &
Study Management
DICOM
Teleradiology
to clinics
Information Management System
Radiation Therapy: Imaging +
• Need for more that just Images
Departmental Data Flows
CT
MR
R&V / Archive
MAGN
ETOM
– Field descriptions
– Prescription / Fractionation
• Information objects “evolve”
– At simulation, only basic setup
information
– After planning, fields, doses, …
– Verification data
Portal Imaging
L i te Box
MAGN
ETOM
DB
Image
Image,
Setup
Image
All
Image
SS, Plan,
Image
SS, Plan,
Dose
Image
Image, SS,
Plan
L i te Box
Simulator
CT Sim
Plan
L i te Box
RTP
Linac
3
DICOM RT
• Proposed at RSNA, 1994
– Working Group started in 1995 as NEMA RT Section
TG
– First objects approved in 1998
• Added several objects for Radiation Therapy
–
–
–
–
–
RT Dose
RT Structure Set
RT Image
RT Plan
RT Treatment Record(s)
• Since DICOM 3.1, just another part of DICOM
DICOM Conformance Statement
DICOM “Testing”
• DICOM Part 2 specifies the structure of a
conformance statement
• DICOM does not specify a test suite or a
compliance verification mechanism
• All DICOM implementations must be
supported by a properly constructed
conformance statement
Hmmmmmm
• Implementation Model which describes the
Application Entities in the implementation
• Detailed specification of each Application Entity
– SOP Classes supported
– policies for initiation and acceptance of associations
•
•
•
•
•
Presentation Contexts
SOP options
Supported communications protocols
Specializations
Configuration
DICOM
The New Yorker, 7/2007
4
The Problems
DICOM Conformance Statement
• Allow a user to determine which optional
components of the DICOM Standard are
supported by a particular implementation, and
what extensions or specializations an
implementation adds.
• By comparing the Conformance Statements
from two implementations, a knowledgeable
user should be able to determine whether or not
interoperability is possible.
• DICOM-RT Objects Evolve
– Numerous ‘Optional’ Fields
– Different Interpretations
– ‘Stale’ Data
• Security
– HIPPA has heightened awareness of the
need to protect data
– Network Protection / Isolation
DICOM
• No formal testing structure
– Left to the user to examine
manufacturer Conformance Statements
to verify compatibility
– Knowledge necessary to truly verify
compatibility is arcane, not easy to
acquire or keep current
– Much more difficult for DICOM RT
Extensions compared to images
What is IHE?
• Standards-based,
• Global Initiative
generating
• Real-world Implementations
in patient care
“Defining, testing, and implementing
standards-based interoperability for
EHR’s”
5
Why IHE?
IHE brings reality to workflow
• 1970’s—Mainframe Era--$100,000 per
interface
• 1990’s—HL7 2.x--$10,000 per interface
• 2000’s—IHE Implementation Profiles—
Cheaper than a new phone line!
How? IHE Eliminates Options
found in Published Standards
IHE Organizational Structure
Who is IHE?
Multi-Domain & Multi-National
Multi-Domain
Multi
Multi
Multi-National
• IHE is a joint initiative among:
–
–
–
–
–
–
–
–
American College of Cardiology (ACC)
Radiological Society of North America (RSNA)
Healthcare Information Management Systems Society (HIMSS)
GMSIH, HPRIM, JAHIS (laboratory)
American Society of Ophthalmology
American College of Physicians (ACP)
American College of Clinical Engineering (ACCE)
And many more….
• Began in 1997 in Radiology (RSNA) and IT (HIMSS)
• International effort: IHE- Europe and IHE-Asia
• Additional sponsors for Cardiology including ASE, ESC,
ASNC, SCA&I, HRS and more
IHE (International) Strategic Development Committee
Sponsor
Co-Chairs
supervises
reports
Global
IHE North
America
IHE Domain-related
Planning and
Technical Committees
IHE Europe
IHE Asia/Oceania
Regional &
National
Deployment
Global Development:
Radiology,
IT Infrastructure,
Cardiology,
Lab, etc.
Delegates
Interoperability
contribute
Participants
6
IHE 2006 – Nine Active Domains
Over 100 vendors involved worldworld-wide, 5 Technical Frameworks
37 Integration Profiles, Testing at Connectathons
Demonstrations at major conferences worldworld-wide
15 Active national chapters on 4 continents
IHE StandardsStandards-Based
Standards-Based Integration Solutions
Professional Societies Sponsorship
Healthcare Providers & Software Developers
Electronic Health Record
Healthcare IT Standards
General IT Standards
HL7, DICOM, etc.
Radiology
14 Integration Profiles
IHE
Process
4 Integration Profiles
IHE
IT Infrastructure
Laboratory
5 Integration Profiles
Patient Care
Coordination
1 Integration Profile
1 3 In t e g r a t i o n P r o f i le s
Future
Domains
Patient Care
Devices
Pathology
Eye Care
Oncology
Interoperable Healthcare IT
Solution Specifications
Interoperable Healthcare IT
IHE Integration
Profile Specifications
Solution
Interoperable Healthcare IT
IHE Integration
Profi
le Specifications
Solution
Interoperable Healthcare IT
IHE Integration
Profile Specifications
Solution
IHE Integration Profile
IHE Integration Profiles
Scheduled Workflow
P
a
t
i
e
n
t
I
n
f
o
r
m
a
t
i
o
n
Proven Standards Adoption Process
Product IHE Integration
Statement
Charge
Posting
IHE Connect-a-thon
Results
-
R
e
c
o
n
c
i
l
i
a
t
i
o
n
Internet, ISO, etc.
Cardiology
Presentation
of Grouped
Procedures
PostProcessing
Workflow
IHE
Technical
Framework
Reporting
Workflow
Standards
Consistent
Presentation
of Images
Evidence
Documents
Key Image
Notes
Access to Radiology Information
Basic Security
Simple
Image and
Numeric
Reports
IHE
IHE
Integration
Integration
Profiles B
Profile A
Product
With IHE
IHE
ConnectConnect-a-thon
IHE Integration Profiles at the heart of IHE :
IHE
Demonstration
Easy to
Integrate
Products
User Site
RFP
– Detailed selection of standards and options each solving a specific
integration problem
– A growing set of effective provider/software-developer agreed solutions
– Vendors can implement with ROI
7
IHE Technical Frameworks
Department System
Scheduler/
Order Fi ller
Order
P lacer
ADT
Image
Manager/
PP S Manager
Acquisition
Modality
Regist er J.Doe
Patient
Registration [RAD-1]
Placer Order
Management–
New [RAD-2]
One or the
other methods
of creating an
order is used
Filler Order
Management New [RAD-3]
Schedule
Procedure
Procedure
Scheduled [RAD-4]
Query Modality Worklist [RAD-5]
Fill er Order
Mgmt - Status
Update [RAD-3]
Patient Reconcili ation
J.Doe ->
J.Smith
ADT
Pt. Registration [RAD-1 ] ↓
Patient Update [RAD-12] ↓
DSS/ Order Filler
Patient Update/
Merge [RAD-12]
↓ Pt. Registration [RAD-1]
↓ Patient Update [RAD-12]
← Placer Order Management [RAD-2]
→ Filler Order Management [RAD-3]
↑ M odality PS in Progres s [CARD-1]
↑ M odality PS Completed [RAD-7]
Fill er Order
Mgmt - Status
Update [RAD-3]
Modalit y Procedure
Step In Progress
[CARD-1]
Modality P rocedure
Step Completed
[RAD-7]
Modality Procedure
Step In P rogress
[CARD-1]
Perform
Acquisition
Modalit y Procedure
S tep Compl eted
[RAD-7]
Pat ient Update/
Merge [RAD-12]
Order Placer
↓ Procedure Scheduled [RAD-4]
↓ Patient Update [RAD-12]
↓ Procedure Updated [RAD-13]
↑ Instance Availab ility Notification [RAD-49]
Evidence
Creator
← Modality PS in Progress [CARD-1]
← Modality PS Completed [RAD-7]
Detailed standards implementation
guides
Performed
Procedu re
Step Manager
Storage ↓
Co mmitment
[CARD-3]
Image Display
↓Modality Image/Evidence
Stored [CARD-2]
Image
Manager
↓ Query Images [RAD-14]
↓ Retrieve Images/Evidence [CARD-4]
Image
Archive
→ M od ality PS in Progress [CARD-1]
→ M od ality PS Completed [RAD-7]
Storage
Co mmitment ↑
[CARD-3]
↑Modality Image/Evidence
Stored [CARD-2]
← Modality PS in Progress [CARD-1]
← Modality PS Completed [RAD-7]
← Query Modality Worklist [RAD-5]
Acquisitio n
Modality
IHE Connectathon, January 2006
•300+ participants, 120+ systems
•60+ systems developers
•Four Domains: Cardiology, IT Infrastructure,
Patient Care Coordination, Radiology
•2800+ monitored test cases
IHE Connectathon
• Open invitation to the Software
Developer Community
• Advance testing tools (MESA) applied
• Compliance Testing organized and
supervised by the sponsors of IHE
• Thousands of cross-system tests
performed
• Product Integration Statements
validated
Request for Proposals (RFPs)
• Much easier to specify and agree to an IHE
Integration Profile than detailed technical specs:
– “Device must support IHE Scheduled Workflow
Integration Profile, and vendor must supply an
IHE Integration Statement.”
• Software Developer response:
8
• Results
–
–
–
–
–
–
–
Over 3000 attendees visited the HIMSS RHIO Showcase
37 vendors demonstrated 48 systems
700 attendees created and tracked their own health record
63 educational sessions were presented
5 International delegations
3 VIP tours
16 clinical scenarios were demonstrated
IHE-RO
• DICOM WG-7 (April, 2004)
– Introduction to IHE
– Discussion on how Radiation Oncology could
participate
• NEMA Radiation Therapy Section
– At AAPM 2004, discussed need to improve
interoperability in RT
• ASTRO
–
–
–
–
Board of Directors Proposal, June 2004
Kick-off, ASTRO Annual Meeting, 2004
First Meeting of IHE-RO PC & TC @ RSNA, 2004
Joint Effort led by ASTRO with AAPM, NEMA, and others
• IHE-RO Technical Committee
– First Meeting, January, 2005 w/ DICOM WG-7
IHE-RO
INTEGRATING THE HEALTHCARE ENTERPRISE (IHE) –
RADIATION ONCOLOGY (RO)
Participants in IHE-RO
Advanced Technology Consortium
(ATC)
American Association of Physicists
in Medicine (AAPM)
American College of Radiology
(ACR)
American Society for Therapeutic
Radiology and Oncology (ASTRO)
Association of Radiation
Oncologists of India (AROI)
Canadian Association of Radiation
Oncologists (CARO)
Chinese Society of Radiation
Oncologists (CSRO)
CMS
Egyptian Cancer Society – Radiation
Oncology
Elekta
International Atomic Energy
Agency (IAEA)
Impac
Japanese Society for
Therapeutic Radiology and
Oncology (JASTRO)
Miranda Solutions
National Cancer Institute
(NCI)
National Electrical
Manufacturers Association
(NEMA)
Nucletron
Philips
Tomotherapy
Radiological Society of North
America (RSNA)
Siemens
Varian
European Society for Therapeutic
Radiology and Oncology (ESTRO)
9
IHE-RO
Exactly How Does IHE-RO Function?
INTEGRATING THE HEALTHCARE ENTERPRISE (IHE) –
RADIATION ONCOLOGY (RO)
Participants in IHE-RO
International Atomic Energy
Agency (IAEA)
Advanced Technology Consortium
Impac
(ATC)
Japanese Society for
American Association of Physicists
Therapeutic Radiology and
in Medicine (AAPM)
Oncology (JASTRO)
American College of Radiology
Miranda Solutions
(ACR)
National Cancer Institute
American Society for Therapeutic
(NCI)
Radiology and Oncology (ASTRO)
National Electrical
Association of Radiation
Manufacturers Association
Oncologists of India (AROI)
(NEMA)
Canadian Association of Radiation
Nucletron
Oncologists (CARO)
Chinese Society of Radiation
Philips
Oncologists (CSRO)
Tomotherapy
CMS
Radiological Society of North
Egyptian Cancer Society – Radiation
Oncology
America (RSNA)
Siemens
Elekta
• Planning Committee
• Technical Committee
– Identifies information
– Identifies and
systems or components
implements standards
of information systems
for interactions between
that produce, manage,
actors that communicate
or act on information
the required information
associated with clinical
through standards-based
and operational
messages.
activities that require
integration.
The PC and TC work together to
Prioritize Efforts, Propose Solutions,
and Eventually Demonstrate Connectivity
Varian
European Society for Therapeutic
Radiology and Oncology (ESTRO)
- what did he just say?
IHE-RO Basic Interoperability
IHE-RO Actors
2005-2007 Integration Profile
Contouring
System
Imaging Study
Simulation
System
Rad Onc
IMS
Planning
Workstation
• Proposals circulating between
Planning Committee and Technical
Committee
– Many applications combine actors
Planning Application
DICOM
Image
Archive
RT Plan G
RT SSet
Treatment
Verification
RT Dose
Treatment
Delivery
RT
Archive
Patient Registrar
Multi-Media Registration
Contouring
Reference Point Generation
Prescription Entry
Beam Placer / Shaper
Dose Calculator
Plan Evaluator
Fractionator
Reference Image Creator
RT SSet RT Plan
RT Dose Reference
Images
10
IHE-RO CT Simulation Application
IHE-RO Treatment Planning Application
Contouring &
Beam Editor Application
Image
Archive
Multi-Media Registration
Contouring
Reference Point Generator
Beam Shaper / Placer
Prescription Entry
Reference Image Creator
DICOM
RT SSet
Planning Application
Image
Archive
RT Plan G
RT SSet
RT Dose
RT Plan G
RT
Archive
Reference Images
IHE-RO Treatment Delivery
DICOM
RT
Archive
Patient Registrar
Multi-Media Registration
Contouring
Reference Point Generation
Prescription Entry
Beam Placer / Shaper
Dose Calculator
Plan Evaluator
Fractionator
Reference Image Creator
RT SSet RT Plan
RT Dose Reference Images
IHE-RO Technical Frameworks
11
Actors
•
•
•
•
•
Archive
Contourer
Geometric Planner
Dosimetric Planner
Dose Displayer
Informal Connectathon 2006
IHE-RO Connectathon 2006
Participants
• Phillips
• Siemens
• Nucletron
• Varian
• Elekta
• Brainlab
• Tomotherapy
• CMS
• IMPAC
Evaluators
• Bruce Curran (U Mich)
• Walter Bosch (Wash U ATC)
• Chuck Pelizzari (U Chicago)
• Philip Devlin (Harvard)
Supporters
• Keith La Plain (Varian)
• Stuart Swerdloff (IMPAC)
• Robyn Watson (ASTRO)
• Jamie Gale (ASTRO)
• Mike Sullivan (ASTRO)
• Amy Kapinus (ASTRO)
• Stephen Vastagh (NEMA)
Informal Connectathon 2006
•25+ participants, 9 Vendors, 10+ systems
•95+ monitored test cases
12
What’s Next?
•
•
•
•
•
•
•
•
Compositing Dose
Residual Dose Optimization
Multimodality Image Registration
On-line Image Review (reference image vs.
delivery image)
Off-line Image Review (reference image vs.
delivery image)
Scheduling Treatment Delivery and
Verify/Record
Query/Retrieve
Configuration Management
Profile Roadmap
• Initial Implementation (2005-2007)
– RO General Integration Profile
•
•
•
•
•
CT Image Retrieval / Storage
Image Set Contouring
Geometric Plan Definition
Dosimetric Plan Definition
3D Dose Matrix Viewer
– Reduce Multiplicity of Implementation Paths
– Test Tools Contract in place
– Connectathon Scheduled (8/25/2007)
• 2008 Profiles
– RO Multimodality Registration
– Treatment Delivery Workflow
Selected for 2008
IHE-RO 2006 Connectathon
13