The Integrating the Healthcare Enterprise initiative continues to attract interest from vendors and healthcare providers in a growing number of countries. In an effort to expand the venture's scope, committee members are examining how work done to integrate radiology IT systems can be extended hospital-wide.

As the initiative approaches its fifth anniversary, the initial vision of seamless digital data flow between medical departments has yet to be fulfilled, but considerable progress has been achieved in promoting multivendor and interdisciplinary collaboration. As the IHE extends into new territories, those responsible for turning the dream into deliverable reality remain conscious of the many challenges ahead.

"IHE has begun to realize its initial vision," said Chris Carr, IHE secretary and director of informatics for the RSNA. "We hear from vendors that the frequency with which IHE is requested in requests for proposals is growing steadily, and we are making efforts to learn more from institutions that have actually used IHE."

Delegates attending the special IHE session at CARS 2003 heard a summary of the movement's global accomplishments to date and predictions for 2004 and beyond.

The IHE initiative was established in 1998 by the RSNA and the U.S. Healthcare Information and Management Systems Society (HIMSS), though its influence now reaches far beyond North America. IHE-Europe and IHE-Japan committees work closely with their U.S. colleagues to help tailor the initiative's requirements to healthcare systems and markets across the Atlantic and Pacific Oceans.

The introduction of the IHE in Europe poses a significant challenge, due to the wide variation of healthcare standards among neighboring countries, according to Marco Eichelberg, technical manager for Germany's IHE-D. HL7 may be the accepted standard for interfacing IT healthcare systems in the U.S., but this is not the case in all European countries. Europe's IT healthcare market is also distributed among many small vendors, each focusing on specific national markets. Taking the IHE to Europe means persuading each of these companies to agree to the initiative's goals and to implement a standard they may not previously have used.

A subset of national groups that report to the IHE-Europe committee is tackling practical implementation of the initiative's technical framework. France, Germany, Italy, Norway, and the U.K. all have national IHE committees, and groups may eventually be established in Spain, Denmark, the Netherlands, Sweden, Belgium, and Luxembourg, Eichelberg said.

"We are not covering all of Europe yet, but the movement is growing. What will happen if IHE-Europe ever tries to cover the 25 countries we will have in the European Union next year is a good question, and I have no answer to that," he said.

National groups must identify any specific problems in implementing the IHE's integration profiles, which define precisely what functionality hospital information systems, radiology information systems, and/or PACS should deliver in various areas of clinical workflow. Critical, unchangeable differences must be added to the IHE technical framework document as a national amendment. National specificities currently account for just 1% of the total IHE technical documentation, indicating that a genuinely international series of rules has been attained, Eichelberg said.

Public IHE demonstrations in which the interoperability of different vendors' systems is showcased in virtual hospital scenarios are also organized country by country in Europe. Germany, Italy, and the U.K. hosted demonstrations at their national radiology congresses this year. Two additional IHE demonstrations are scheduled for the annual French radiological society meeting in Paris later this month, and at the MEDICA conference to be held in Dusseldorf, Germany, in November.

MAKING CONNECTIONS

Rigorous testing remains an important part of the IHE process. No software solution will be showcased at a demonstration unless it has first passed muster at a weeklong connection marathon called a connect-a-thon. As the IHE expands, vendor attendance and the number of solutions on trial are growing as well, adding to the logistical complexity of the testing events.

This year's European connect-a-thon, hosted by the department of diagnostic radiology at University Hospital Aachen in Germany, was the largest to date (Wein B, Connect-a-thon report 2003 [www.ihe-europe.org]). A total of 46 vendors produced 79 systems during the March event, surpassing the 2002 total of 33 vendors and 61 systems. A panel of nine independent testers validated almost 700 cross-vendor tests during the week.

The number of large-scale testing events is also growing. The IHE-Japan is hoping to host its first connect-a-thon next March, but this depends on whether Japanese extensions can be added to the IHE technical framework in time.

The next U.S. connect-a-thon is scheduled for this month, to be hosted at the RSNA headquarters in Oak Brook, Illinois. Systems that pass the rigorous tests will participate in a public demonstration at the annual RSNA meeting in early December. HIMSS is organizing a joint HL7/IHE connect-a-thon early next year that will lay the groundwork for a public demonstration at the society's annual conference in Orlando, Florida, in February.

The HL7/IHE connect-a-thon marks an important step toward the much-discussed "horizontal integration," which refers to dissemination of the IHE initiative beyond radiology. The IHE technical framework specifies 10 integration profiles relevant to radiological workflow, and another two are in the process of being approved. Vendors participating in the inaugural event, however, will face five new integration profiles relating to IT infrastructure, the backbone of any electronic healthcare system (see table).

The joint IHE-HL7 demonstration offers a valuable opportunity to assess practical means of achieving an electronic health record (EHR), said Charles Parisot, a GE Medical Systems representative on the IHE technical and planning committee. Meeting the first IT integration profiles will help doctors access patient information or test results regardless of which department acquired them. But this is only the beginning of the universal EHR.

"Transferring complex information is a complex problem, and we have to solve that problem," he said. "All of these new IT integration profiles are necessary steps that bring us closer to the EHR. By adding about 10 to 15 more of these profiles, we can get much closer."

Efforts are also under way to bring laboratory information systems (LIS) and cardiology workflow under the IHE umbrella. Representatives from the IHE-Europe and the IHE-Japan have identified three possible integration profiles for LIS and have begun work to define one of them. The IHE and the American College of Cardiology have formed an exploratory committee to perform a "gap analysis" of the IHE technical framework to evaluate how cardiology workflow fits into existing integration profiles.

Horizontal integration will inevitably lead to an increased number of companies hoping to participate in IHE events, said Elizabeth Beckmann, director of Lanmark Multimedia in Beaconsfield, U.K., and a member of the British Institute of Radiology ICT committee. But many manufacturers involved with HIS and LIS technology may struggle to meet the costs that the IHE entails.

"There are smaller, localized manufacturers who have to be brought in and involved, and this is where things like the connect-a-thon start to get problematic," she said.

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IHE INTEGRATION PROFILES

Radiology (approved)

Scheduled workflow (for acquisition)

Patient information reconciliation

Consistent presentation of images

Presentation of grouped procedures

Access to radiology information

Key image notes

Simple image and numeric reports

Basic security

Charge posting

Postprocessing workflow

Radiology (under development)

Reporting workflow

Evidence documents

IT infrastructure (under development)

Retrieval of information for display integration

Enterprise user authentication

Patient identifier cross-referencing for multiple patient identification

Patient synchronized application

Consistent time