Who’s who

Harry Solomon

Jan 2012HL7 Working

GroupCytometryMeeting

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Interoperability Standards Development Organizations (SDO’s)

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Four level model of “use” in interoperability

business process : tasks exchange : mail

data record : documentterminology : words

Workflow

Messaging

Format

Vocabulary

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Vocabulary for lab tests and observationsResponsive for new tests/measurements

Vocabulary for medicine, anatomy, procedures, clinical findingsRobust concept model

Workflow

Messaging

Format

Vocabulary

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General organization for cytometry; standards committee

Focused on cytometry research, small standards group

Example standards:• Data File Standard for Flow Cytometry (FCS)• Minimum Information about a Flow Cytometry

Experiment• Image Cytometry Experiment Format (proposed)

Workflow

Messaging

Format

Vocabulary

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Standards for clinical labs

Mostly process quality specifications, some interoperability specs

Example standards:• Laboratory Automation: Communications With

Automated Clinical Laboratory Systems, Instruments, Devices, and Information Systems

• Laboratory Automation: Data Content for Specimen Identification

• Point-of-Care Connectivity

Workflow

Messaging

Format

Vocabulary

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Interoperability standards for healthcare

Broadest healthcare standards organization, robust information modeling framework

Example standards:• HL7 v2 ADT (Patient Demographics), Orders,

Observations (Results), Lab Automation Control• HL7 v3 Reference Information Model• Clinical Document Architecture• Electronic Health Record Functional Model

Workflow

Messaging

Format

Vocabulary

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Interoperability standards for medical imaging

Supports bulk binary data, persistent object model, department workflow, universally implemented in radiology

Example standards:• Microscopic Image, Whole Slide Image• Modality Worklist / Performed Procedure Step• Storage Commitment

Workflow

Messaging

Format

Vocabulary

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Integrating the Healthcare Enterprise, a pubilc-private collaboration promoting standards-based interoperabilityUse cases from professional society participants (CAP, NAACCR) drive implementation guides, Connectathons, demonstrationsExample standards:• Anatomic Pathology Workflow Profile• Physician Reporting to Public Health – Cancer

Registry• Cross-Enterprise Document Sharing Profile

Workflow

Messaging

Format

Vocabulary

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Cooperation

HL7 cooperative agreements / MoU’s / affiliations with all other SDO’s

HL7 & DICOM – Joint Working Group (IIWG/WG-20) meets at 3 annual HL7 WGMs

DICOM & LOINC / IHTSDO – DICOM submits proposed concepts for coding

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HL7 v2

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HL7 v2 Messaging Standard: What

HL7 Messaging Standard - An Application Protocol for Electronic Data Exchange in Healthcare Environments

Enables disparate healthcare applications to exchange clinical and administrative data

Defines the data content and provides the layout of messages that are exchanged between applications based upon a particular trigger event

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HL7 Version 2 Messaging

SENDINGAPPLICATION(Patient Administration)

RECEIVINGAPPLICATION(Lab System)

ADMIT MESSAGE (A

DT)

ACKNOWLEDGEMENT (ACK)

TRIGGER EVENT:Patient is Admitted!

PID attributesSEQ ELEMENT NAME1 Set ID - Patient ID2 Patient ID3 Patient ID List4 Alternate Patient ID5 Patient Name6 Mother’s Maiden Name7 Date/Time of Birth8 Sex9 Patient Alias

ETC.

….PID|||12345||Lorenzi^Virginia||19811231|F…

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HL7 specification terms

Message - an ordered collection of segments, associated with a trigger eventTrigger event - a real world cause for the exchange of dataSegment - an ordered collection of data elements that typically share a common subject• Specifies whether the data element is required or optional and

whether it may repeat.

Data element - a unit of exchanged meaning, with a data type and suggested length, and possibly a table of valid valuesData types - encoding of meaning in a constrained character string, or constructs of component data types• Limited to two levels of defined construct (components,

subcomponents)

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Example HL7 v2 ADT Message

MSH|^~\&|ADMIN|MCM|LABADT|MCM|198808181126|SECURITY|ADT^A01^ADT_A01|MSG00001|P|2.4| <cr>EVN|A01|198808181123||<cr>PID|1||PATID1234^5^M11^ADT1^MR^MCM~123456789^^^USSSA^SS||JONES^WILLIAM^A^III||19610615|M-||C|1200 N ELM STREET^^GREENSBORO^NC^27401-1020|GL| (919)379-1212| (919)271-3434||M||PATID12345001^2^M10^ADT1^AN^A|123456789|9-87654^NC|<cr>NK1|1|JONES^BARBARA^K|WI^WIFE||||NK^NEXT OF KIN<cr>PV1|1|I|2000^2012^01||||004777^LEBAUER^SIDNEY^J.|||SUR||-||ADM|A0-|<cr>

Patient William A. Jones, III was admitted on August 18, 1988 at 11:23 a.m.His wife, Barbara K. Jones is a related family member (next of kin).He has been assigned to room 2012, bed 01 on nursing unit 2000.To be attended by doctor Sidney J. Lebauer (ID# 004777) for surgery.

Character based, similar to mag tape records

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Example HL7 v2 ADT Message

MSH|^~\&|ADMIN|MCM|LABADT|MCM|198808181126|SECURITY|ADT^A01^ADT_A01|MSG00001|P|2.4| <cr>EVN|A01|198808181123||<cr>PID|1||PATID1234^5^M11^ADT1^MR^MCM~123456789^^^USSSA^SS||JONES^WILLIAM^A^III||19610615|M-||C|1200 N ELM STREET^^GREENSBORO^NC^27401-1020|GL| (919)379-1212| (919)271-3434||M||PATID12345001^2^M10^ADT1^AN^A|123456789|9-87654^NC|<cr>NK1|1|JONES^BARBARA^K|WI^WIFE||||NK^NEXT OF KIN<cr>PV1|1|I|2000^2012^01||||004777^LEBAUER^SIDNEY^J.|||SUR||-||ADM|A0-|<cr> Message

Type – 3 char code for the type of message sent

Trigger Event – 3 char code for the real world event causing the message

Segment Type – 3 char code for the logical group of information

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HL7 implementation architecture

“The Standard is written from the assumption that an event in the real world of healthcare creates the need for data to flow among systems. The real-world event is called the trigger event.”

“HL7 does not explicitly support, but can be used with, systems that support store and forward and data broadcast facilities.”

HL7 push model issues• Handling multipoint ACKs• Offline systems

Typical implementation withstore and forward interface engine

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v2 Table of Contents

Chapter 1 - IntroductionChapter 2 - Control (Conformance added v2.5)Chapter 3 - Patient AdministrationChapter 4 - Order EntryChapter 5 - Query (in Chap 2 in v2.2-v2.3.1)Chapter 6 - Financial ManagementChapter 7 - Observation ReportingChapter 8 - Master Files (added v2.2)Chapter 9 - Medical Records (Document Mgmt) (added v2.3)Chapter 10 - Scheduling (added v2.3)Chapter 11 - Patient Referral (added v2.3)Chapter 12 - Patient Care (added v2.3)Chapter 13 - Clinical Laboratory Automation (added v2.4)Chapter 14 - Application Management (added v2.4)Chapter 15 - Personnel Management (added v2.4)Chapter 16 - eClaims (added v2.6)Chapter 17 - Materials Management (added v2.6)

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Look at ToC’s for Chapters 3, 4, 7, 13

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HL7 CDA

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HL7 Clinical Document Architecture

The scope of the CDA is the standardization of clinical documents for exchange.

A clinical document is a record of observations and other services with the following characteristics:• Persistence• Stewardship• Potential for authentication• Wholeness• Human readability

A CDA document is a defined and complete information object that can exist outside of a message, and can include text, images, sounds, and other multimedia content.

A CDA is not an isolated finding or measurement, or an aggregation of documents

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Key Aspects of the CDA

CDA documents are encoded in Extensible Markup Language (XML)

CDA documents derive their meaning from the HL7 v3 Reference Information Model (RIM ) and use HL7 v3 Data Types

A CDA document consists of a header and a body• Header is consistent across all clinical documents - identifies

and classifies the document, provides information on patient, provider, encounter, and authentication; allows document management, compilation of an individual patient's clinical documents into an electronic patient record

• Body contains narrative text / multimedia content (level 1), optionally structured into sections with coded titles and tagged narrative content (level 2), optionally augmented by coded equivalents to narrative (level 3)

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CDA Release 2 Information Model

Header Body

ParticipantsSections/Headings

Clinical Statements/Coded Entries

ExtlRefsContext

Doc ID&Type

StartHere

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CDA Structured Body

Structured Body

Section

Text

Section

Text

Section

Text

Section

Text

Section

Text

Section

Text

Entry

Coded statement

Entry

Coded statement

Entry

Coded statement

Arrows are Act Relationships • Has component, Derived from, etc.

Entries are coded clinical statements• Observation, Procedure, Substance administration, etc.

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Narrative and Coded Info

CDA structured body requires human-readable “Narrative Block”, all that is needed to reproduce the legally attested clinical content

CDA allows optional machine-readable coded “Entries”, which drive automated processes

Narrative may be flagged as derived from Entries • Textual rendering of coded entries’ content, and contains no

clinical content not derived from the entries

General method for coding clinical statements is a hard, unsolved problem• CDA allows incremental improvement to amount of coded

data without breaking the model

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Narrative and Coded Entry Example

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Implementation Guides

CDA is a very generic structure focused on human-readable content• Great for minimally marked-up documents• Not much required to render narrative

content

Machine processing (more powerful apps) requires standardization of CDA structures and entries• Implementation guides for specific clinical

uses• Templates for documents, sections, entries

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PCC Technical Framework

EDR

Continuity of Care Document Ancestry

HL7 RIMData TypesVocabulary

CDA

CRS

CCR

CCD

ClinicalStatement

Model

XDS-MS(R3)

C32

APS

EDES

FSA

2004 - 2006

1998 - 2004

2002 - 2005

2003 – 2007

O&ODomainModelGenomicsDomainModelPatient Care

DomainModel

Other DomainModels

2005 - 2006

2005 - 2006

2006 - 20072006 -

2007

2006 - 2007

C37

2006 - 2007

ASIG

1999 - 2007

XDS-MS (R1)

2006 - 2007

2006 - 2007

2006 - 2007

2007 - 2008

2007 - 2008

2007 - 2008

CDA4CDT

2007

XD*-LAB

QED

2007 - 2008XPHR

C83

C80

2008

Inherits from

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CDA Consolidation

Need one-stop shop for CDA templates

Consolidated CDA implementation guide incorporating HL7, IHE, and Health Story projects

Funded by ONCHIT

Basis for care coordination interoperability under Meaningful Use Stage 2 incentives (2014)

Balloted through HL7 May 2011, Approved as DSTU December 2011

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DICOM

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Scope of DICOM Standard

The International Standard for Medical Imaging and related information

Standard object formats for images, waveforms, derived structured data (measurements and assessments)

Workflow management in the imaging department

Service-based network protocol over TCP/IP; media interchange

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DICOM Key Features

Object-oriented, persistent information objects

Tagged data elements, binary encoding

Client-server network services, service negotiation

Image compression by encapsulation

Conformance Statements

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DICOM Image Information Object Definition

PatientModule

PatientStudy

Module

GeneralSeriesModule

GeneralStudy

Module

Frame ofReferenc

eModule

GeneralEquipme

ntModule

GeneralImageModule

ImagePlane

Module

Contrast/

BolusModule

ImagePixel

Module

ModalityImageModule

Multi-frame

Module…

VOILUT

Module

SOPCommonModule

PatientInformation

StudyInformation

SeriesInformation

Image(Instance)

Information

Patient NamePatient ID

Patient SexPatient Birthdate

Study Unique ID

Accession NumberStudy

Date/TimeStudy

DescriptionReferring MD

Rows/ColumnsBits per PixelPhotometric

DICOM Composite

Information Model

Hierarchy

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DICOM Network Services

Information object exchange

Reliable object storage (commitment)

Object repository (PACS) query / retrieve

Modality worklist query

Performed procedure step status notification

Image print

Application protocol riding on TCP/IP

(at same level as FTP, HTTP)

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Data Element Encoding

0020000DhexUI 1.2.840.1.113709.9.0.0.5743.14575602.126hex

Study InstanceUnique Identifier

(0020,000D)

Instance UID encoded as “dotted decimal”

Data Set

Data Element

Tag Value Length Value Field

optional field - dependent on negotiated Transfer Syntax

ValueRepresen

-tation

Data Elem. Data Elem.Data Elem. Data Elem.

order of transmission

Attributes are the logical concepts associated with an information entity

Data elements are how attributes are encoded in an information object

Similar to TIFF

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Part of a DICOM object(0008,0005)

CS30

ISO 2022 IR 13\ISO 2022 IR 87

(0008,0008)

CS22

ORIGINAL\PRIMARY\AXIAL

(0008,0016)

UI26

1.2.840.10008.5.1.4.1.1.2

(0008,0018)

UI58 1.2.392.200036.9116.2.6.1.48.12393615.1211874194

.564494

(0008,0020)

DA8

20080527

(0008,0021)

DA8

20080527

(0008,0022)

DA8

20080527

(0008,0023)

DA8

20080527

(0008,0030)

TM10

163836.000

(0008,0031)

TM10

164306.390

(0008,0032)

TM10

164039.850

(0008,0033)

TM10

164040.397

(0008,0050)

SH8

5162581

(0008,0060)

CS2

CT

(0008,0070)

LO8

TOSHIBA

…

(7FE0,0010)

OW52428

800 00 00 00 ff ff ff ff 00 0f 4c 4a 49 46 00 01...

Tags in increasing numeric orderValue length always an even numberAttributes related to modules and

information model levels NOT contiguous

PatientInformation

StudyInformation

SeriesInformation

Image(Instance)

Information

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The Service-Object Pair (SOP) Class

The unit of interoperability and conformance

Service: network function between user (client) and provider (server)

• Store (transfer), query, move, create, notify …

∴ SOP Classes represent functionality on information objects

• Store a CT image • Store an MR image• Find (list) all studies for a patient • Find the worklist for a

modality• Move a set of images • Create an image print job• Request/Notify the secure storage of images• Notify the performance of a procedure step

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DICOM Network Negotiation

First step application level handshake in setting up Association (network connection)

Agreement on SOP Classes, roles (client/server), image compression, security

One message roundtrip (initiator to acceptor and back)

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Storage Commitment

“Object Storage” is basic DICOM service for network transfer of images – but has no required receiver behavior• C-STORE acknowledgment simply means the objects were

received whole• Objects can be successfully received by an image archive

system, but a system failure could cause them to be lost prior to reliable storage

Storage Commitment provides an explicit acknowledgment of reliable storage of specific objects• The sending system can then safely delete objects from local

store, e.g., auto-purge

Storage Commitment may incur a substantial delay• E.g., after overnight copy to tertiary storage

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Storage and Storage Commitment

Modality Transmits Images (or other Objects) to PACS:

C-STORE transfer of images (acknowledged)

Modality Issues Storage Commitment Request to PACS:

N-ACTION including List of objects to be committed (acknowledged)

PACS Notifies Modality of Success (or Failure) :N-EVENT-REPORT including List of objects committed (acknowledged)

PACSModality

③

①

①

②

②③

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DICOM Query/Retrieve

Allows a system to query another system for a list of available images (query)

Also allows a system to request another system to send images (retrieve)

Query Request

Retrieve Request

Image(s) Send

Store Response(s)

Retrieve Response

Query Match(es)PACS

Query/RetrieveSCP

Query/RetrieveSCU

Workstation

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Managed Workflow Concepts

PROCEDURE STEP : The smallest unit of managed workin the workflow

Scheduled Procedure Step: ‘A unit of work to do’Performed Procedure Step: ‘A unit of work done’

ORDER : A request for departmental service

REQUESTED PROCEDURE : Unit of work resulting in one Report

with associated codified, billable acts

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Workflow structuring is user oriented

ORDER:A request for departmental service

(Accession Number)

REQUESTED PROCEDURE : Unit of work resulting in one Report

with associated codified, billable acts(Requested Procedure ID)

PROCEDURE STEP :The smallest unit of managed

workin the workflow

(modality worklist entry)

CLINICIANOR REFERRING DOC:

The Imaging Dept Customer

RADIOLOGIST/ PATHOLOGIST :

In Charge of producing the Report

TECHNOLOGISTIn charge of

acquiring images, etc.

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Simple Workflow

One Order – One Procedure – One Study – One Report

AcquisitionModality

ORDERA request for DepartmentalService

Imaging Department

Set of Codifiab

le,Billable,

Acts

One or more series of images

PerformedProcedure

StepRequestedProcedure

ScheduledProcedure

Step

Report

DICOMModality Worklist

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AcquisitionModality

AcquisitionModality

Multiple Modality Steps

ORDERA request for DepartmentalService

Imaging Department

Set of Codifiab

le,Billable,

Acts

One or more series of images

PerformedProcedure

Step P1

ScheduledProcedure

Step B

RequestedProcedure

ScheduledProcedure

Step A

Report

One or more series of images

PerformedProcedure

Step P2

DICOMModality Worklist

DICOMModality Worklist