Friday, January 29, 2016

IHE connectathon day 5: How imaging became an IT project

IHE connectathon (final) day 5: 2570 tests verified.

Last minute testing,
trying to beat the Friday
noon deadline
The majority of the IHE connectathon tests are from the ITI (IT Infrastructure domain), i.e. 62%. This is quite a shift from when it started being a pure radiology imaging test event. Radiology tests made up only 15% of all the testing this year.

At the first connectathon in 1999 held in the garage of the RSNA in Chicago, we were focusing on interfacing a radiology imaging modality with an information system by querying a worklist, and having them reliably send to a PACS for viewing and reporting, i.e. the Scheduled Workflow (SWF) profile. Since then, other domains have been added such as for cardiology, pharmacy, patient care coordination and devices, quality and research/public health, laboratory, dentistry, eye care, pathology, radiation oncology and even national extensions, and last but not least the IT Infrastructure. Not all of these domains were tested during this connectathon week, about 50% as, for example, eyecare and dental might do their own testing, but this was definitely the most extensive event.

The shift in testing to the ITI domain is an indication of how imaging is becoming an IT project: the emphasis is on how to manage and exchange documents and images within and across the enterprise. Just as an indication, the X* profile family with includes all of the XDS (cross enterprise document sharing) and cross community sharing included an impressive 1475 test instances. This does not include all of the PIX/PDQ (patient ID cross referencing and query) and CDA (clinical documents) verifications, another approximate 600 test instances.

This indicates a shift and focus which also impacts the supporting staff. I remember the often heated discussions at trade conferences and within panels of whether a PACS should be supported by radiology, meaning a PACS administrator reporting to the radiology manager, or IT, which is a non-issue today. Most of these people I talk with are already moved or will be. This reflects the trend toward enterprise image management, including multiple specialties and making them available outside the enterprise, therefore it is only for the better.

Overall the connectathon was a very successful event, someone estimated that, for this week only, the people investment is a few million dollars (think 500 people times 40 hours), not taking into account the facility cost and weeks of preparation. But there is no question that the money saved by getting together and testing your product is multiple times that. Already looking forward to next year! And...remember that there are a lot of resources available on, and if you like to learn more about the details, there are regular webcasts by OTech, see link.

Thursday, January 28, 2016

HIMSS Interoperability workshop: Certification to the max?

Day 4 of the connectathon: 2465 tests performed (one more day to go!).

An important part of the IHE connectathon is the education through a series of workshops which are
Global center for health innovation,
site of  IHE connectathon
held simultaneously with the testing event. I participated in the Interoperability Workshop, and a  couple of observations from this workshop are:

·         The healthcare imaging and IT testing and certification landscape is still in flux and blurry (to me): as of now there are six options which seem to overlap at least to certain degree: 1) the connectathon, 2) the ONC certification of what used to be called Meaningful Use (MU) and is re-coined as MACRA, 3) the Concert certification, 4) the Continua certification activity, 5) the IHE international conformance assessment, and 6) the IHE Image share project with Sequoia. There are strong voices raised, especially among several of the vendors, to request some kind of reciprocity between these activities and there could be a significant opportunity for sharing of tools, tests, and specifications to avoid duplication of work and related cost.

·         HL7 FHIR is still very much under development, and is expected to have widespread implementations. Resources are still being developed and trial implementations are being tested. All major EMR vendors have either announced support or offer a FHIR in their latest release.

·         There is an interest to define a profile for the physical infrastructure, e.g. HVAC. For example, based on patient location (or absence), one could adjust the temperature and/or A/C in a room which could result in significant savings. This would allow “intelligent” buildings, similar to an “intelligent home” which can be controlled and monitored though the IOT (Internet of Things).

Overall, these educational events are very affordable (this was only $95), and one gets access to seasoned healthcare IT professionals who are very good presenters, they are very worthwhile attending (next year maybe).

Wednesday, January 27, 2016

IHE Connectathon day 3: Patient Care Devices

Day 3 of the IHE connectathon in Cleveland at the HIMSS global center for health innovation
One of the several bed-site monitors that was
tested and verified for interoperability
resulted in 2004 tests being performed so far, of which 90% have been verified. A remarkable feat; imagine all of the hours and money saved by this effort that otherwise would have been spent resolving issues in the clinical environment.

One of the major benefits of healthcare IT technology is integration of Patient care devices, such as infusion pumps, EKG and other vital monitors, and even implantable devices such as pacemakers. I witnessed personally only a few weeks ago, when my spouse was admitted in the ER for an emergency procedure, how the medications and IV pump information was entered manually in the EMR at the bedsite. The vital monitoring system was not integrated either, a nurse would read the temperature, oximetry and pulse from the monitor every hour and enter that manually as well. 

In contrast, here at the test floor in Cleveland, I see the vendors with the same equipment, which interfaces seamlessly to the EMR using the applicable profiles. The good news is that our community hospital had at least a closed loop medication system as the meds were barcoded, as well as the patient’s wristband to verify and record the dose. But further integration would be so much more effective.

The PCD domain was formed 10 years ago, almost ten years after IHE started its roots in radiology and it has come a long way. For example, in addition to recording clinical measurements and data, there is now also a profile to facilitate managing the devices such as unique device identification, real-time location tracking, hardware/software configuration and patch management, battery management, and more. It is not only important to share information between medical record systems electronically, the automated acquisition and recording of the input data into these EMR’s is even more important. I surely hope it is just a matter of time before what is demonstrated and verified in Cleveland will become the norm in the very near future.

Tuesday, January 26, 2016

IHE day 2: testing XCPD

Our night out in Cleveland at the
House of Blues
It is day 2 at the IHE connectathon at the HIMSS global center for Health Innovation in Cleveland and the monitors have cleared 1158 tests so far, amazing.... I have started to test XCPD profile implementations (Cross Community Patient Discovery). This is a critical feature in case there is no central registry in place for an EMR to go to, such as a public or even private Health Information Exchange (HIE), which is used to register the patients and the documents as well as images which are available for these patients. 

A typical use case of the XCPD profile implementation would be of a retiree who is in Florida in the winter, gets lab work and potentially imaging done at the local hospital, and upon returning back to the North, to spend the summer close to his or her family, needs to provide access to this information.

We call these geographical areas that are connected “local communities”, which has a gateway that can be queried using patient information such as name, sex, birthdate, gender, address, etc. An EMR would talk with the local gateway who would talk with the remote gateway, and upon successful “discovery” of the patient, a query for the applicable documents and images can be done and they can be retrieved, for example by the primary physician. This is a good alternative to the architecture that requires multiple HIE’s, which were kind of a mixed success: some states have abandoned these due to lack of a sustainable business model, and therefore, ad-hoc discoveries using these community gateways might become the standard way for cross-enterprise information exchange.

Testing and validating these transactions is somewhat of a puzzle as you need to dig into the log files and search for the applicable XML coded tags for the appropriate returns, but it is exciting to see the support of this by the major EMR vendors who are present. It shows their commitment to true interoperability.

Monday, January 25, 2016

How often do you check your audit trails?

Connectathon day 1 in Cleveland: 539 tests verified, amazing… 

Nice view from the Cleveland conference
center to Rock and Roll Hall of Fame
I am testing ATNA (Audit Trail and Node Authentication) among others at the USA connectathon event in Cleveland, which is the profile dealing with audit trails. 

Especially with healthcare being the next target for hackers and source of identity theft, having a central audit trail repository that stores the events in a standard manner makes a lot of sense. Unfortunately, a lot of PACS and EMR systems use a semi-proprietary protocol and data format to store these events, which makes it hard for a system administrator and/or security and privacy officer to mine all of these logs on a regular basis. 

Having a central repository and requiring all systems to use the well-defined standard by IHE would make life a lot easier. It is not that hard to support: the ATNA profile defines a standard set of events to be reported as defined by DICOM and having all systems using the same format would make the reporting easy.

How often would you check an audit trail? There is no hard rule, but based on my informal poll with the administrators I get in our training classes, a weekly random check for a couple of accesses seems to be the norm. These checks would be documented so that if there is an audit, there is proof that someone would actively monitor these events.

If you like more information about this profile, visit www.ihenet and look for the ITI domain. I strongly suggest that you require ATNA support for any new healthcare IT system you are specifying and/or purchasing, it would make the life of your administrators and security officers much easier than having to deal with disparate logs in many different formats.