The Operating Room and the need for an
IT Infrastructure and Standards
IGT Workshop
Rockville, MD, 20th September 2006
Heinz U. Lemke, PhD
Research Professor of Radiology
University of Southern California, Los Angeles, USA
Senior Advisor for Research Strategies
Innovation Center Computer Assisted Surgery
University of Leipzig, Germany
Content
1. Motivation, interfaces, workflow and standards
2. Interfacing examples
3. Patient model-guided therapy and DICOM in
Surgery
Interventional Cockpit/SAS modules
IT Model-Centric World View
Data Exch.
Repository
Therapy Imaging and Model Management System (TIMMS)
Images
and
signals
Modelling
tools
IO Imaging
and
Biosensors
Modelling
Computing
tools
Simulation
WF and
K+D
tools
Kernel for
WF and K+D
Management
Engine
Control
© H.U. Lemke, August 2006
Rep.
tools
Visualisation
Rep. Manager
Devices/
Mechatr.
tools
Validation
tools
Intervention
Validation
Therapy Imaging and Model Management System (TIMMS)
ICT infrastructure (based on DICOM-X) for data, image, model and tool communication for patient model-guided therapy
Data and
information
Models
(Simulated
Objects)
WF`s, EBM,
”cases”
Models and
intervention
records
Workplace in a cardiac surgery OR with several monitors that can be seen
from various positions.
Standards for Medical Technology
n
Source: K. Radermacher, RWTH Aachen
10 IHE Integration Profiles
Scheduled Workflow
Admit, order, schedule, acquire images, notify of completed steps
Patient
Consistent
Access to
Information
Presentation of
Radiology
Postprocessing
Reconciliation
ImagesBasic Security
Information
Work Flow
Unknown
patients and
unscheduled
orders
Hardcopy and
softcopy
grayscale and
presentation state
Schedule, perform,
notify image processing
& CAD steps
Consistent
access to
images and
reports
Audid Trail Consolidation
Presentation
of
& Node Authentication
Grouped Procedures
Subset a single acquisition
Key Image
Notes
ExchangePosting
flagging
Charge
significant images
Simple Image and
Numeric Reports
Exchange simple
reports with image
Collection
of billable
links and,
optionally,
procedure
details
measurements
Scheduled Workflow Profile
report
report
Registration
report
Report
Repository
HISpatient
Diagnostic
Workstation
information
PACS
Film
Lightbox
images
retrieved
Orders Placed
examination orders
RIS
Orders Filled
procedure
scheduled
Image Manager
Prefetch any relevant
& Archive
prior studies
Acquisition
modality
images
Modality
worklist
stored
acquisition
completed
acquisition
images
in-progress
completed
printed
Modality
Film
Folder
Film
WG 24 “DICOM in Surgery“
Project Groups
•
•
•
•
•
•
•
•
•
•
•
PG1
PG2
PG3
PG4
PG5
PG6
PG7
PG8
PG9
PG10
PG11
WF/MI Neurosurgery
WF/MI ENT and CMF Surgery
WF/MI Orthopaedic Surgery
WF/MI Cardiovascular Surgery
WF/MI Thoraco-abdominal Surgery
WF/MI Interventional Radiology
WF/MI Anaesthesia
S-PACS Functions
WFMS Tools
Image Processing and Display
Ultrasound in Surgery
Partial and condensed workflow of “Resection of Tonsillar Carcinoma”
Start of
operating
phase
Disinfection
of the neck
Classificatio
n with TNM
Aseptic
dressing
Suturation
Resection of
tumor and
staging
Marking on
forearm
skin
Lymph
Node
Biopsy
Transfer to
pathology
Start of
operating
phase
(surgery)
Induction of
narcosis
Disinfection
of abdominal
skin
Disinfection
of skin
Prepare for
contralateral
neck
dissection
Neck
dissection
Bilateral
neck dis
complet
e
Aseptic
dressing
Aseptic
dressing
Remove skin
graft
Remove skin
graft
Team waits for
skin graft from
abdominal wall
no
Suturation
yes
Result
Processing of
instantaneous
section
Suturation
using OPmicroscope
Transplantation
of skin graft
onto forearm
Skin graft into
resection situ
Vessel
anastomosis
End of neck
dissection
End of operative
phase (surgery)
End of
narcosis and
transfer
End of
operative
phase
DICOM Workgroup 24
Workflow for Ablation Procedure
DICOM Workgroup 24
DICOM Workgroup 24
Pre-procedure Planning
Functional Categories
1. Basic Imaging
(Image-centric)
a. Pre-procedure evaluation
i. Review of previous imaging studies
b. Post-Procedure
i. Review of the performed Interventional Procedure
ii. Follow-up to evaluate the outcome of the procedure
2. Real-Time Imaging
(Image-centric)
a. Intra-procedural Imaging
3. Pre-Procedural and Intra-Procedural image manipulation
(Model-centric)
a. In the case of tumor biopsy or ablation:
i. Localization – evaluation of location and characteristics of pathology
ii. Targeting – plan and determine access and trajectory of needles/probes
iii. Image guidance – final plans and measurements for probe placement
iv. Navigation
v. Monitoring
4. Physiologic Monitoring
(Model-centric)
Table 1
IOD
Related IOD
Functional
Categories
COMPUTED RADIOGRAPHY IMAGE
1
COMPUTED TOMOGRAPHY IMAGE
1,2 3
ENHANCED COMPUTED
TOMOGRAPHY
MAGNETIC RESONANCE IMAGE
1,2 3
1,2 3
ENHANCED MR
1,2 3
MR Spectroscopy
1,2 3
NUCLEAR MEDICINE IMAGE
ULTRASOUND IMAGE
1,2 3
ULTRASOUND MULTIFRAME IMAGE
1,2 3
Ultrasound (IVUS)
2,3
DIGITAL X-RAY IMAGE
1
Overlay Plane Module
POSITRON EMISSION TOMOGRAPHY
IMAGE
3
1
STANDALONE PET CURVE
1
ENHANCED XA [X-RAY ANGIOGRAPHIC]
IMAGE
2,3
ENHANCED XRF [X-RAY RF] IMAGE
2,3
Content
1. Motivation, interfaces, workflow and standards
2. Interfacing examples
3. Patient model-guided therapy and DICOM in
Surgery
SOMIT Project: Minimal Invasive
Orthopaedic Surgery
Project timing:
2005 – 2010
Partner institutions:
25
Grant volume:
12,5 Mio €
Source: K. Radermacher, RWTH Aachen
Integrated Workstation
– Integrated and consistent
user interface
– Context specific dialogue
and coordinated system
access
– Modular design with
standardised interfaces
Source: K. Radermacher, RWTH Aachen
State of the Art
Source: K. Radermacher, RWTH Aachen
OrthoMIT,
Concept of an Integrated Workstation
• Modular Design („Plug and Play“)
• Open standard and inclusion of present standards
(DICOM, HL7, future S-DICOM)
• Different integrations levels
• Usability of devices integrated as well as standalone
• Communication between devices (bus system,…)
• Workflow-management
• Integration of standard conforming modules without
renewed safety tests (MPG, etc.)
Source: K. Radermacher, RWTH Aachen
Integration of Planning, Imaging,
Navigation and Treatment
Postoperative
Monitoring, e.g.. MRI
Preoperative
Planning
Intraoperative Imaging
and Navigation
Source: C. Bulitta, SIEMENS
OR IT
Integration
OR Integration:
Dräger
Siemens
Storz
Technology-Integration:
OR-Cockpit / OR-Anaesthesia
Touchscreen
Flatscreen
Themes, e.g. :
• Visualisation
• Device-Control
• Context
Information
• RFID triggert
Events
Frontend-Integration
SIEMENS
Integration-server
Pre-/intraop. Imaging
Link H-IT
Applications
(Endonavigation)
TherapyPlanning
KARL STORZ
Dräger
Backend - Integration
• Application specifice Data- and EventSynchronisation (Workflow-controlled)
Source: C. Bulitta, SIEMENS
Concept of levels
1) Consolidation of frontendexchange or integration on
screenlevel
2) Data exchange via existing
interfaces and ESB
integration via inubit IS.
3) Connecting to external
systems (HIS etc.).
4) Frontend integration via
portlets (patient-oriented/
case oriented optimised
visualisation).
Source: C. Bulitta, SIEMENS
Frontend-3
Frontend-2
(anesthesia
cockpit)
(surgery
Frontend-4
cockpit)
(image
viewer)
Enterprise Service Bus
web-service
enabled
HIS
System 1
System 2
conncector
System 3
System N
Frontend-1
(KVM switch/RDP)
Source: C. Bulitta, SIEMENS
Content
1. Motivation, interfaces, workflow and standards
2. Interfacing examples
3. Patient model-guided therapy and DICOM in
Surgery
Diagnostic Image-Centric World View
PACS
DICOM
DICOM
Archive
Modalities
(X-ray,
CT, US, MR,
SPECT, PET)
Images
Identification
(name, SS #,
exam code,
date, …)
Acquisition
Parameters
(CAD etc.)
Integrated Patient Care
Modalities
(X-ray,CT, US,
MR,SPECT,
PET,OI)
Biosensors
(physiology,
metabolism,
serum, tissue, …)
Data bases
(Atlas,
P2P repositories,
data grids, ...)
Omics
EMR
EBM
Workflow
IHE
Integration
and Diagnosis
(Data fusion,
CAD, …)
Mechatronics
(Navigation,
ablation, …)
Modelling and
Intervention
(Simulation,
decision support,
validation, …)
Future-PACS based on DICOM-X
Image-Centric
World View
Model-Centric
World View
H. U. Lemke, CARS 2006
Interventional Cockpit/SAS modules
IT Model-Centric World View
Data Exch.
Repository
Therapy Imaging and Model Management System (TIMMS)
Images
and
signals
Modelling
tools
IO Imaging
and
Biosensors
Modelling
Computing
tools
Simulation
WF and
K+D
tools
Kernel for
WF and K+D
Management
Engine
Control
© H.U. Lemke, August 2006
Rep.
tools
Visualisation
Rep. Manager
Devices/
Mechatr.
tools
Validation
tools
Intervention
Validation
Therapy Imaging and Model Management System (TIMMS)
ICT infrastructure (based on DICOM-X) for data, image, model and tool communication for patient model-guided therapy
Data and
information
Models
(Simulated
Objects)
WF`s, EBM,
”cases”
Models and
intervention
records
DICOM RT Modules
PS 3.3-2006 Annex A, Composite IOD
•
•
•
•
•
•
•
RT Dose
ROI Contour
Structure Set
RT General Treatment Record
RT General Plan
RT Tolerance Tables
RT Brachy Application Setups
• …
Generic and patient specific
modelling tools
•
•
•
•
•
•
•
•
Geometric modelling
Prosthesis modelling
Properties of cells and tissue
Segmentation and reconstruction
Biomechanics and damage
Tissue growth
Tissue shift
Properties of biomaterials
Modelling
tools
Generic and patient specific
modelling tools
• Atlas-based anatomic modelling
• FEM of medical devices and anatomic tissue
• Collision response strategies for constraint
deformable objects
• Variety of virtual human models
• Lifelike physiology and anatomy
• Fabrication model for custom prosthesis
• Template modelling
Modelling
tools
Generic and patient specific
modelling tools
•
•
•
•
Animated models
Multi-scale modelling (BC)
Fusion/integration of data/images
Registration between different models incl.
Patient, equipment and OR
• Modelling of the biologic continuum
• Modelling of workflows
• …
Modelling
tools
Some steps towards a surgical DICOM
Michael Gessat, Oliver Burgert
ICCAS, Leipzig
ICCAS Project timing:
2005 – 2010
Grant volume:
8,5 Mio €
• IOD surface mesh
• ...
Surgical DICOM Model of the real world
(exemplary, incomplete…)
Patient
Physician
conducts
Is subject
of
makes
makes
Visit
has
prepares
Intervention
includes
Study
defines
Repository
Plan
Comprise
d of
contains
Modality performed
procedure steps
includes
Bases on
/ uses /
contains
Data Library
contains
creates
Workflow
Tools
Diagnosis
Someone…
defines
reference
s
Series
creates
Frame of Reference
contains
Equipment
Image
Waveform
Report
Image Processing
Workflow
Ontologies
Tools
Navigation
Diagnosis
…
Information Model for Surgical DICOM
• ER-Diagram shows the complexity of the surgical
environment
• Multiple objects from different origins act together in
contexts given by patients, interventions… (the
column-like World Model has turned into a web of
entities)
• Representation of all necessary meta data with each
frame is no longer feasible (Overhead!)
• Normative IODs reflecting patient, study, series,
repository,… will be necessary  Patient Model
• Organization of data will become a primary task
IODs for Surgical DICOM
Actual DICOM
Registration
Presentation State
UPnP
RT
Conf. Mgmt
Img. Processing
Hanging Protocols
Images, WF…
Visible Light
Segmentation
Patient Model
Navigation
Geometric Models
Library, Repository
Augmented Reality
Video based Nav.
Intervention
Ontologies
Simulation
Manipulator
Workflows
IOD Entity-Relationship Model
Patient
1
Is the
subject of
1…n
Study
1
contains
0…n
0…n
spatially or
temporarily
defines
1…n
uses
0…n
0…n
Series
creates
0…n
0…1
1
Equipment
contains
Frame of reference
Algorithm
0…n
defines
0…n
Registration
Fiducials
Presentation State
Image
Waveform
Surface Mesh
Surface Mesh
Presentation State
Informatic Portals for Data Mining
Data Repositories
P2P „Best Practice“ Workflow Repository
Reference expert knowledge
Peer Expert I
Peer Expert II
Repository of workflow
Generic models and
patient-spec. models
reference models (WFs, SIPs)
for medical techniques, WF graph
operating instructions,
Peer Expert III
etc.
Peer Expert IV
etc.
Data Grid
• Provide a distributed fault-tolerant data
services for large data, eg, TeraGrid (100
GB ~ 10 TB)
• Data services include storage, share,
distribution, and metadata management.
• IPI (USC) Data Grid: an integration of
DICOM information object model with
general data services for clinical image
applications.
IPI Data Grid for PACS Image Data
Backup: The DICOM Data GRID
SJHC
PACS WS
HCC2
PACS WS
SJHC PACS
Server
HCC2 PACS
Server
SJHC SAN
P1
SJHC
DICOM
Data Grid
P2
HCC2 SAN
P2
HCC2
IPI SAN
PACS
Simulator
P1
IPI
Methods for HIPAA Security in PACS
• To make current PACS HIPAA compliant in
Access Control, Audit Control, and Integrity.
• IPI has developed:
– HIPAA compliant auditing system (HCAS) for
Audit Control
– Location Tracking and Verification System (LTVS)
for Access Control
– Lossless Digital Signature Embedding (LDSE)
method for Image Integrity assurance
Conclusion
1. S-WF definitions (on an appropriate granulation level)
and visualizations allow surgeons, interventionists and
associated disciplines to better understand IT
requirements for information guided intervention (IGI)
2. Selected S-WFs defined by some standard method
may be entered into a repository, providing a
reference base for the development of an
IT infrastructure such as a TIMMS
Therapy Imaging and Model Management System (TIMMS)
Interventional Cockpit/SAS modules
IT Model-Centric World View
Data Exch.
Repository
Therapy Imaging and Model Management System (TIMMS)
Images
and
signals
Modelling
tools
IO Imaging
and
Biosensors
Modelling
Computing
tools
Simulation
WF and
K+D
tools
Kernel for
WF and K+D
Management
Engine
Control
© H.U. Lemke, August 2006
Rep.
tools
Visualisation
Rep. Manager
Devices/
Mechatr.
tools
Validation
tools
Intervention
Validation
Therapy Imaging and Model Management System (TIMMS)
ICT infrastructure (based on DICOM-X) for data, image, model and tool communication for patient model-guided therapy
Data and
information
Models
(Simulated
Objects)
WF`s, EBM,
”cases”
Models and
intervention
records
Conclusion
3. Derive S-DICOM services and IOD`s
from TIMMS functionalities
Therapy Imaging and Model Management System (TIMMS)
WG 24 “DICOM in Surgery“
Project Groups
•
•
•
•
•
•
•
•
•
•
•
PG1
PG2
PG3
PG4
PG5
PG6
PG7
PG8
PG9
PG10
PG11
WF/MI Neurosurgery
WF/MI ENT and CMF Surgery
WF/MI Orthopaedic Surgery
WF/MI Cardiovascular Surgery
WF/MI Thoraco-abdominal Surgery
WF/MI Interventional Radiology
WF/MI Anaesthesia
S-PACS Functions
WFMS Tools
Image Processing and Display
Ultrasound in Surgery
WG24 “DICOM in Surgery”
Secretariat:
Secretary:
Howard Clark, NEMA
Franziska Schweikert, CARS/CURAC Office
fschweikert@cars-int.org
General Chair: Heinz U. Lemke, ISCAS, Germany
Co-Chair:
Ferenc Jolesz, Harvard Medical School, Boston
(Surgery/Radiology)
Co-Chair:
(Industry)
tbd
S-DICOM Cooperation Partners
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
CARS Institute/Foundation
SPIE
University of Geneva
ICCAS, University of Leipzig (ENT, Cardio, Neuro)
Technical University of Berlin (CG and CAM)
University of Southern California (IPI)
University of Rennes
Japan Institute of CARS
Industry (Agfa, Siemens, Philips, ...)
CURAC (AG S-WF and S-PACS)
University of Pisa, EndoCAS
The Interventional Centre, Oslo
Georgetown University, Washington
University of Chicago
ISCAS
…
IGT Workshop
Rockville, MD, 20th September 2006
(a) What do you believe are three important challenges
facing the engineering of IGT systems:
1. Development of appropriate standards for interfacing
software engines and repositories in IGI.
2. To specify and design an IGT system based on best
practice surgical workflows.
3. To complement the paradigm of Image Guided
Therapy (IGT) with Model Guided Therapy (MGT) and to
proceed towards Information Guided Intervention (IGI).
IGT Workshop
Rockville, MD, 20th September 2006
(b) How do you think that we at NCIGT (National
Center for Image-Guided Therapy) can help
address these challenges
1. To participate in DICOM Working Group 24 "DICOM
in Surgery".
2. To participate in building a repository of a
representative set of best practice surgical workflows.
3. To participate in raising awareness of information
guided intervention (IGI) through workshops, think
tanks, etc.
CARS 2007 Computer Assisted Radiology and Surgery
CARS / SPIE 7th Joint Workshop on
Surgical PACS and the DOR
Berlin, 30 June, 2007
9th Meeting of the
DICOM Working Group WG 24 “DICOM in Surgery“
30 June 2007