February 11, 2008

Cooking Up Interoperability
By Beth W. Orenstein
Radiology Today
Vol. 9 No. 3 P. 10

Radiology is at the core of the IHE initiative to create recipes for better communication among the computers of healthcare.

At the end of January, nearly 100 healthcare information technology vendors and users gathered in Chicago to test their ability to share electronic patient data within and across hospitals and healthcare systems.

The five-day, large-scale testing event is known as the Connectathon, and they have been held annually in North America since 1999 as part of the Integrating the Healthcare Enterprise (IHE) initiative.

IHE began in radiology in 1997 when it became obvious that the different information systems healthcare providers were increasingly employing—such as PACS, RIS, and hospital information systems (HIS)—often did not speak the same language and could not communicate with one another.

“It started with the recognition that even though there were very good, very detailed standards, such as DICOM in imaging and HL7 [Health Level Seven] in hospital administration, for formatting of information and how it was to be exchanged, they did not equate to perfect interoperability in the real world,” says Chris Carr, director of informatics for the Radiological Society of North America (RSNA). RSNA and the Healthcare Information and Management Systems Society (HIMSS) were the founding partners of IHE.

The initiative has gained enough momentum, especially in the last few years, that it now extends well beyond radiology, says David S. Mendelson, MD, chief of clinical informatics and director of RIS at Mount Sinai Medical Center in New York City.

However, it’s not surprising that IHE started in radiology, according to Didi Davis, senior director of IHE for HIMSS. “Radiologists are always ahead of the game and tend to adopt technology better than other physician specialties,” she says. “Today, IHE can thank radiologists who really started this initiative.”

Davis says interest has grown from all disciplines because healthcare providers recognize that interoperability, or the ability to share electronic health information easily and securely, improves care. “IHE is being looked at because of its success,” she says. “When providers have secure access to comprehensive patient records, they have the information they need when they need it to make more informed medical decisions and to do so faster.”

Davis says easily accessible and secure electronic health records can also reduce healthcare costs by eliminating the need to repeat imaging studies and laboratory tests and reduce errors by minimizing the number of times people must key in data.

IHE is organized by domains, the first being radiology. There are also eight other domains: IT infrastructure for healthcare, cardiology, laboratory, eye care, radiation oncology, patient care coordination, patient care devices, and quality, which is the most recent.

Launched in February 2007, the quality domain is designed to address the infrastructure needed to share information relevant to quality improvement. The quality domain is sponsored by HIMSS, RSNA, the American College of Cardiology, and the American Heart Association.

Each domain develops its own integration profiles, which are common workflow issues that users have identified as important for doing the best job possible. Use cases are described, and the technical components and the necessary communication protocols that would provide for a seamless and transparent solution are explicitly stated, Mendelson explains.

Think of IHE as a cookbook and the integration profiles as the recipes in it, says Paul Nagy, PhD, director of quality and informatics research at the University of Maryland School of Medicine in Baltimore. “The IHE integration profiles tell you what ingredients you need and how to put them together in the right shape and sequence so that you will always get the same outcome,” he says.

Users identify the areas where integration profiles are needed. “IHE is trying to make sure this is all driven by the voice of the customer,” Nagy says.

Once an area or problem is identified, technical experts are brought in. They work for months to find solutions by leveraging standards. They may use as many as 15 current standards to facilitate workflow and write a technical profile, according to Davis. More than 200 organizations worldwide have participated in developing and implementing the profiles.

But IHE does not make standards. “We use existing standards to achieve better practical integration,” Nagy says.

The Vendor Challenge
Writing a profile requires cooperation among different and sometimes competing vendors.

“One of the challenges with IHE is that you can’t do it with one vendor. You have to do it with your PACS vendor and your RIS vendor,” Nagy says. “The whole point is interoperability, so you have to work with both of them and that takes a period of time.”

IHE profiles are not small or quick fixes. “It’s really a long-term fix, and it has to start with your request for proposal and be part of your strategy of how you’re going to lower the cost of integration and increase interoperability in your department,” Nagy adds.

To date, radiology has identified 19 integration profiles addressing workflow, content, presentation, and infrastructure, and most have to do with workflow issues. For example, the IHE profile scheduled workflow defines the flow of information for the key steps in a typical patient imaging encounter (registration, ordering, scheduling, acquisition, distribution, and storage). Another profile—postprocessing workflow—extends the scheduled workflow profile to support steps such as computer-aided detection, imaging processing, and image reconstruction.

Reporting workflow addresses the need to schedule, distribute, and track the status of key reporting tasks such as interpretation, transcription, and verification.

Other integration profiles in radiology address observations and reporting. Key image note, for example, allows the addition of textual notes and pointers to certain images in a series. Following the IHE profile, it prevents the notes or pointers from getting lost.

“One of the things that is surprising to radiologists,” Nagy says, “is that if you don’t have an open standard for your annotations and key image selections, when you change PACS vendors, you might lose all your work, all your annotations that you put into it.” Following the standards established by the IHE profile “allows you to move the work product on top of the images.”

Of all the domains, radiology is the most advanced and has the most extensive set of profiles, Mendelson says. Scheduled workflow is probably the most widely adopted IHE profile. “That one is used by the majority of sizable practices today and has resulted in expediting and smoothing workflows,” he says. IHE is about to update it, but the basic premise hasn’t changed, he adds.

At the RSNA annual meeting in Chicago in November, two newer IHE profiles were the talk of the town, according to Mendelson. One was teaching file and clinical trial exports, which is for exporting data from workstations for teaching purposes and clinical trials. The other was cross enterprise document sharing for imaging (XDS-I) for sharing images, documents, medical summaries, and medical notes across a group of care sites. The XDS-I profile is paving the way for easy sharing of radiology exams such as CT and MRI across broad geographic regions and different countries while respecting patient confidentiality, Mendelson says.

Radiation oncology has three profiles and is writing more. One is normal treatment planning, which illustrates the flow of treatment planning data from CT to dose review. Another is multimodality registration for radiation oncology, which shows how radiation oncology treatment planning systems integrate PET and MRI data into the contouring and dose review process. The third is treatment workflow, which integrates daily imaging with radiation therapy treatments using workflow.

Within each domain, once the technical specifications are developed, vendors can build them into their products, and they are tested at the Connectathons and other events. Connectathons have been held not only in North America but also in Europe and Asia, Davis says. “A European Connectathon was held in Berlin in April 2007 and in China in November 2007. These Connectathon testing events are replicated throughout the world, which continue to improve and validate the profiles,” she says.

The Connectathons allow vendors to find any snags in the profiles, according to Nagy. “It’s far better to iron out the kinks at the Connectathon than at my hospital. In my hospital, you’re not dealing with the engineers. You’re dealing with the service and so they are dealing with what they have,” he says.

Connectathons occur under one roof in one location because of the need to test the tools on the same network, Davis says. But the demand for more frequent testing is growing, and IHE is developing tools that will allow that to happen, she adds.

Vendors release products more than once per year and want to be sure they have been tested for interoperability. Also, some testing can be done over the Internet. “So we’re looking at trying to appease those requirements,” Davis adds.

Systems engineers from more than 75 leading HIT vendors participated in the 2008 Connectathon in Chicago, testing the interoperability of more than 160 systems and applications. Detailed data, including previous years’ results, are available here.

HIMSS also puts on an interoperability showcase at its annual conference and exhibition, scheduled this year for February 24 to 28 at the Orange County Convention Center in Orlando, Fla. Six of the nine domains plan to demonstrate their capabilities at the showcase, Davis says.

Because of its growth and success, IHE is legally incorporating as a nonprofit organization. Applications for the governing board were due in early January, and elections should be held sometime in March, Davis says.

Supporters hope that the more formal structure will give IHE access to more resources, including financial, to help it keep up with its growth. Davis says it is costly to write the technical profiles and sponsor the Connectathon and other events.

Big Brother Is Watching
IHE also has attracted the attention of the federal government. A Healthcare Information and Technology Standards Panel (HITSP) has been charged with establishing a widely accepted and useful set of standards enabling and supporting widespread interoperability among healthcare software applications. The standards are meant to interact in a local, regional, and national health information network for the United States.

Such a network would allow physicians to have immediate access to the medical records of a patient from California who has a heart attack while visiting a relative in New York, for example, Davis says. IHE has some of the tools and a process in place that HITSP is leveraging, says Davis, “so there are all kinds of synergies happening.”

As it moves forward, Nagy also expects IHE will also focus on quality measures. With the Centers for Medicare & Medicaid Services starting pay-for-performance initiatives, “There will be a growing need for automating and extracting this type of data and aggregating it,” Nagy says. That’s one area where an IHE profile can help.

IHE is also working on a profile for better management of radiology’s dose equipment and critical test results to ensure they are documented and the necessary personnel are alerted when critical findings are delivered.

Like most quality efforts, Nagy says IHE is an ongoing process that will take time to develop and implement. Standards aren’t adopted over night, but once they are, they last for a long, long time, he says.

— Beth W. Orenstein is a freelance medical writer and frequent contributor to Radiology Today. She writes from her home in Northampton, Pa.