Professional Documents
Culture Documents
Agenda
Cardiology Workflows General
Cath Workflow
Echo Workflow Stress Workflow
Cardiology Workflows
Cardiology:
the study of the
heart
its action
and diseases
The Problem
This is an example of a cardiology workflow. Any questions! Workflow is the linchpin to data integrity
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General Workflow
Pt. Registration [RAD-1] Patient Update [RAD-12] ADT Pt. Registration [RAD-1] Patient Update [RAD-12] Order Placer DSS/ Order Filler Placer Order Management [RAD-2] Filler Order Management [RAD-3] Procedure Scheduled [RAD-4] Patient Update [RAD-12] Procedure Updated [RAD-13] Instance Availability Notification [RAD-49] Evidence Creator Image Display
Image Manager Modality PS in Progress [CARD-1] Modality PS Completed [RAD-7] Storage Commitment [CARD-3] Modality PS in Progress [CARD-1] Modality PS Completed [RAD-7] Query Modality Worklist [RAD-5]
Image Archive
Acquisition Modality
Agenda
Cardiology Workflows General
Cath Workflow Echo Workflow Stress Workflow
Cath Lab
6 7 5 8 9 10 11 3 4
2 1
Multiple re-entry of Patient ID Error prone Results fragmented across systems Results inconsistently time-tagged
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Create Order Placer Order Mgmt New [Rad-2] Schedule Procedure Procedure Scheduled [Rad-4] Start Procedure Query Modality Worklist [Rad-5]
Select Patient
Modality Procedure Modality Procedure Step In Progress Step In Progress [Card-1] [Card-1]
Update Schedule
Query Modality Worklist [Rad-5] Modality Procedure Step In Progress [Card-1] Modality Procedure Step In Progress [Card-1] Modality Images/ Evidence Stored [Card-2]
Modality Images/Evidence Stored [Card-2] Modality Procedure Modality Procedure Step Completed Step Completed [Rad-7] [Rad-7] Order Status Update [Rad-3] Storage Commitment [Card-3]
Use Cases
Case C1:
Patient Registered at ADT and Procedure Ordered at the Order Placer Case C2: Patient Registered at ADT and Procedure Ordered at DSS/OF Case C3: Patient Registered at ADT and Procedure Not Ordered Case C4: Patient Registered at DSS/OF and Procedure Ordered Case C5: Patient Not Registered Case C6: Patient Updated During Procedure Case C7: Change Rooms During Procedure Case C8: Cancel Procedure Case C9: Post-Procedure Evidence Creation Case C10: EP Ablation / Implantation Lab
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Case C1: Patient Registered at ADT and Procedure Ordered at the Order Placer
Clinical Context
Corresponds to traditional Radiology workflow Order placed in central system Also deals with case where emergency
identifier has been created Common identifiers known ahead of time IHE Context
MPPS in Progress from first modality used to
system Typical of many institutes, relieves need for HIS terminal in lab
IHE Context
Filler Order Management (New Order) transaction [RAD-3]
system The first modality must initiate the process of creating common procedure identifiers (usually hemo) The common procedure identifiers are created by the departmental system based on the information available from the first modality Can generate a generic cath procedure if no coded procedural type is available
IHE Context
Upon receiving the first MPPS the DSS/OF will auto generate a
Requested Procedure and its associated Scheduled Procedure Steps utilizing the Study UID provided in the first MPPS. All other modalities use the Query Modality Worklist transaction.
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not enough time to register the patient on ADT system A temporary patient identifier is created at the department level The order placer is notified only after the patient is registered and manually reconciled on the department system
IHE Context
The DSS/OF assigns a temporary Patient ID with a temporary
name and schedules the required procedures The DSS/OF does not send the Filler Order Management (New Order) transaction to the Order Placer until the patient is registered on the ADT system and reconciliation occurs on the DSS/OF.
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known or there is not enough time to enter the information A temporary ID is assigned by the department and entered at the first modality and forwards that information to the departmental system to be shared with the other modalities Like in C4 information is sent to the Order Placer post patient registration and reconciliation on the departmental system
IHE Context
Patient ID and name are selected based upon locally (usually
department) base rules The first modality will send an MPPS with the appropriate information to the DSS/OF which will in turn generate the appropriate requested procedure(s) using the Study UID assigned by the first modality
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brought into the cath lab with the temporary ID During the procedure the patient information is updated on the ADT which sends the patient update information This can results is some of the information been associated with the temp ID and the rest with the permanent ID The case defines how the reconciliation occurs.
IHE Context
The modality may have requested information from the DSS/OF
prior the patient update The Image Manager needs to update the items stored to Image Archive as well as any subsequent items received.
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NOTE: This case does not cover the scenario where a patient is moved to the holding area from a procedure room. IHE Context
Each modality will issue a MPS (Completed or Discontinued) The DSS/OF will reassign the requested procedure to the new
room In the event the DSS/OF does not reassign, each modality in the new room would use the broad Modality Worklist Query This insures consistency of the Study UID for all information
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Query Modality Worklist [Rad-5] Modality Procedure Step In Progress [Card-1] Update Schedule Query Modality Worklist [Rad-5] Modality Procedure Step In Progress [Card-1] Modality Procedure Step In Progress [Card-1] Modality Procedure Step In Progress [Card-1]
Perform Acquisition
Perform Acquisition
Reassign Procedure
Query Modality Worklist [Rad-5] Modality Procedure Step In Progress [Card-1] Modality Procedure Step In Progress [Card-1]
Perform Acquisition
Update Schedule Query Modality Worklist [Rad-5] Modality Procedure Step In Progress [Card-1] Modality Procedure Step In Progress [Card-1]
Perform Acquisition
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cancelled procedures allowing the cath lab staff to appropriately respond to queries regarding that patient.
IHE Context
When the procedure is cancelled within the department the
DSS/OF notifies the Order Placer system and Image Manager The length of time this procedural information is maintained is determined by local policy.
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post-procedure using specialized software (e.g., QCA, QLV, derived images) This case does NOT apply to core lab analysis for clinical trials or outcome analysis
IHE Context
This analysis must be performed on a station that groups the
Image Display and Evidence Creator Actors The Evidence Creator notifies the IM/IA and DSS/OF of the activity via the MPPS In Progress and Complete transactions The Evidence Creator stores its evidence to the IM/IA via the Storage Commit Transaction.
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IHE Context
Initial implementation is an extension of the CATH profile Support for use cases C1 C9 Emergency use cases C3 and C5 are highly unusual in the EP
lab.
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Agenda
Cardiology Workflows General
Cath Workflow
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Use Cases
Case E1: Patient Registered at ADT and Procedure Ordered Case E2: Intermittently Connected Modality
Case E3: Intermittently Connected Modality with Ad Hoc Procedure, Patient Registered, Scheduled Procedure
Case E4: Intermittently Connected Modality with Ad Hoc Procedure, Patient Registered, Unscheduled Procedure Case E5: Intermittently Connected Modality with Ad Hoc Procedure, Patient Unregistered, Unscheduled Procedure Case E6: Stress Echo Staged Protocol Case E7: Echo Measurements Evidence Creation
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network Also covers the case of the modality being turned off
IHE Context
Process flow identical to Case E1 Must be paired with an Image Manager/Image Archive that
also supports Intermittent Connectivity MPPS are stored and sent when connection established Image Manage must queue N-Event Report messages for storage commitment
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Case E3: ICM with Ad Hoc Procedure, Patient Registered, Scheduled Procedure
Clinical Context
This extends Case E2 to allow for a scheduled procedure
but the modality cant query the worklist since it is not connected to the network
IHE Context
The modality will treat this as unscheduled procedure
The patient ID and demographics must be manually entered The modality must create the Study Instance UID Manual matching process at DSS/OF to reconcile the
scheduled and performed procedure information Post match the DSS/OF will reconcile with the Image Manager to correct for the Study Instance UID
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Case E4: ICM with Ad Hoc Procedure, Patient Registered, Unscheduled Procedure
Clinical Context
This is the drive by echo or Stat echo performed without an
IHE Context
This case is identical to other unscheduled procedure cases
automatically based on patient ID The Image Manager will use the Patient Update transaction to update the demographics
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Case E5: ICM with Ad Hoc Procedure, Patient Unregistered, Unscheduled Procedure
Clinical Context
This case is similar to Case E4 except the patient is not yet
IHE Context
Temporary Name and ID entered into the modality
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IHE Context
Similar to Case E1
Protocol Code Sequence or Scheduled Step Description Within the perform acquisition activity there are several stages but typically considered the same procedure step A status of Discontinued can indicate technical failure to reach the end point of the exam.
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acquisition on the modality. This case supports the ability to obtain additional measurements on the clinical workstation post acquisition and update the study data.
IHE Context
This case is similar to Cath C9 The actor participates in both the ECHO and ED
Agenda
Cardiology Workflows General
Cath Workflow
Echo Workflow
Stress Workflow
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Stress Testing
Image Intensivemultiple samples of 12 lead ECG during the protocol Summary report usually one page in length Physician will do comparisons to previous studies
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Stress Options
Stress Echo
Began in the early mid 1990s Observation of wall motion and ejection fractions with the
heart under stress High specificity for correlating ischemia to functional abnormalities Can be done with exercise but mainly chemical
Nuclear Stress
Most often combined with exercise or chemical stress testing Use of radioisotope to detect presence and resolution of
ischemic regions of the heart Scan immediately post Scan 4 hours to 1 day later Resolution of ischemic area determines viability of muscle
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Image Manager Modality PS in Progress [CARD-1] Modality PS Completed [RAD-7] Storage Commitment [CARD-3] Modality PS in Progress [CARD-1] Modality PS Completed [RAD-7] Query Modality Worklist [RAD-5]
Image Archive
Acquisition Modality
Report Creator
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Option Name
Patient Based Worklist Query Broad Worklist Query PPS Exception Management Stress ECG Stress Echo Nuclear Medicine (see note 3)
Optionality
O R (see note 1) O R (see note 2) R (see note 2) R (see note 2) O R R R R O R R R
PPS Exception Management Intermittently Connected Modality Stress ECG Echocardiography Nuclear Medicine (see note 3) Availability of PPS-Referenced Instances
Image Display
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Use Cases
Case S1: Cardiac Stress Test, ECG Only
Limited use with lower sensitivities and specificities
Echocardiography requires Consistent Time to combine clinical data from Stress Monitor and Echo Modality
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Agenda
Cardiology Workflows General
Cath Workflow
Echo Workflow Stress Workflow
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Views
Apical two chamber
P5-01201 P5-01202
Right Ventricular Inflow Tract View Right Ventricular Outflow Tract View Subcostal long axis Subcostal short axis Suprasternal long axis Suprasternal short axis
SRT
SRT SRT
P5-01203
P5-01204 P5-01205
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Agenda
Cardiology Workflows General
Cath Workflow
Echo Workflow Stress Workflow
Stress
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Protocol Stages
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Protocol: Bruce
Stages:
Standard Bruce has 7 stages
Important Note: A procedure can be considered complete irrespective of the protocol being complete!
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Attribute Summary
Concept Requested Procedure Modality Worklist Requested Procedure Code Sequence (0032,1064) Scheduled Protocol Code Sequence (0040,0008) Echo Procedure Code Sequence (0008,1032) Performed Protocol Code Sequence (0040,0260) CID 12001* ECG Procedure Code Sequence (0008,1032) Performed Protocol Code Sequence (0040,0260) CID 3261 NM Procedure Code Sequence (0008,1032) Performed Protocol Code Sequence (0040,0260) CID 3261**
Protocol
Patient State
Acquisition Context Sequence (0040,0555) >(109054, DCM, Patient State) CID 3262
Acquisition Context Sequence (0040,0555) >(109054, DCM, Patient State) CID 3101
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