New standards improve interhospital dialogue

December 2, 2004

Achieving a truly integrated healthcare enterprise might have been easy had all hospitals and healthcare institutions agreed to adopt common software from day one. Alas, real life is not so straightforward. Communications between hospitals with differing digital solutions can be more problematic now than in the days of paper request forms, telephone calls, and hard-copy films in brown envelopes. Regions laden with a patchwork of heterogeneous e-health solutions are using a combination of existing standards, recommendations from the Integrating the Healthcare Enterprise initiative, and their own common sense to grapple with incompatibility and workflow glitches.

Achieving a truly integrated healthcare enterprise might have been easy had all hospitals and healthcare institutions agreed to adopt common software from day one. Alas, real life is not so straightforward. Communications between hospitals with differing digital solutions can be more problematic now than in the days of paper request forms, telephone calls, and hard-copy films in brown envelopes. Regions laden with a patchwork of heterogeneous e-health solutions are using a combination of existing standards, recommendations from the Integrating the Healthcare Enterprise initiative, and their own common sense to grapple with incompatibility and workflow glitches.

The IHE initiative is taking steps to improve interinstitutional communications through a series of new and emerging profiles, according to Kees Smedema, senior director of radiology IT for Philips Medical Systems and a member of the IHE's strategic development committee.

While the IHE does not itself create standards, the organization uses its profiles to detail how existing standards should be adopted. Vendors can check whether their solutions meet these criteria during comprehensive testing sessions known as connect-a-thons. The IHE's initial profiles covered radiology workflow alone. Efforts are now under way to generate profiles for cardiology, laboratory medicine, and IT infrastructure as well.

Nine integration profiles for IT infrastructure have been established over the past 12 months, four of which are still under development, Smedema said. One of these, the Cross-Enterprise Document Sharing (XDS) profile, is of particular relevance to institution-independent access to records.

"If you have a patient who is moving between institutions, you want to share information about the patient," Smedema said. "The issue that the IHE is now addressing is the electronic health record (EHR), not inside institutions but across institutions."

The XDS profile is essentially based on the centralized registration of relevant clinical documents created according to existing standards such as DICOM, HL7, or PDF. The community sharing the documents would choose the format. Access to documents, which could be held anywhere, should be as simple and intuitive as possible, Smedema said.

"Collaborative service provision works only if information is available in an appropriate format," he said. "Healthcare workers are usually working in an environment where there is no time for long searches and reformatting of information."

Emergence of the XDS profile has been welcome in the Western Area Health Region of Norway, where officials are aiming to tighten IT integration between hospitals. Radiology departments have little trouble exchanging images from their PACS, thanks to the DICOM standard, said Dr. Edgar Gluck, senior consultant with the Norwegian Centre for Health Informatics (KITH) in Bergen. Both radiologists and clinicians, however, would like to have access to clinical documents as well when they participate in teleradiological exchanges.

"The transfer of images is not a problem, but the receiving service providers need more than that," he said. "They need to know what the requester expects them to do, they need to have the patient's relevant clinical information and reports of previous investigations, and they need to know what the sender has already done, with details of any preliminary diagnosis."

KITH started examining interhospital document sharing before discovering that the IHE was working on a standardized protocol, Gluck said. When the first public draft of the XDS profile appeared during summer 2004, project members were pleased to discover it matched their needs closely.

The XDS profile is sufficiently flexible to be implemented in a number of ways, Gluck said. It must contain both a document registry and a document repository (Figure 1). The former should be a database containing information about requested or performed services, while the latter contains actual evidence objects and related requests and reports. Workflow could be structured around a single, centrally located document repository for all service providers, or several distributed document repositories could be used.

An alternative approach, which is favored by KITH, is to have the document repository at the site of the document source. The center also envisions use of a Web server to facilitate access to information from the two databases (Figure 2).

CD OR NOT CD?

Interinstitution communications should also be aided by another new IHE profile. Portable Data for Imaging was released for trial implementation last summer and was demonstrated at the RSNA meeting. The profile should ease problems that arise when hospitals and healthcare practices eschew networked teleradiology and instead send patient images to neighboring institutions on CD-ROMs.

Radiology personnel at the Rikshospitalet University Hospital in Oslo are only too aware of the rising use of portable media to transfer imaging data. Staff believed they were well prepared for the switch to digital workflow when the hospital started using a PACS in December 2002. But the influx of patients bringing details of previous imaging examination on CD-ROMs caused a number of unexpected challenges, said Havard Roterud, senior IT radiographer at Rikshospitalet.

Rikshospitalet has an arrangement with just one hospital to receive radiological images via a network connection. Most externally acquired images arrive on CD-ROMs or film, although the proportion of patients bringing hard copy is steadily decreasing (Figure 3).

"Needless to say, we had to do something about the workflow," Roterud said. "It is difficult to manage conventional films, CD-ROMs, and teleradiology within the hospital."

The priority was to centralize the import and export of digital data from CD-ROMs and the hospital's PACS. This is now managed in the radiology department by four specially trained individuals, based at a single location and contactable via a single telephone number or e-mail address during working hours. Clinicians are also being trained to import imaging data from CD-ROMs, which eases the radiology department's workload and allows images to be viewed after hours, Roterud said.

"At the neurosurgical department alone, they import data from more than 10 CD-ROMs every day," he said. "These examinations are deleted from the system after 40 days if the clinician does not send the radiology department a request for a second opinion or ask that the images be archived in PACS or saved for use in a case conference."

Rikshospitalet's radiology department has devised a strict agreement for interinstitution exchange of data by CD-ROM. Although few hospitals have signed the agreement, most have standardized the way they transfer images by CD-ROM.

The agreement states that hospitals wishing to share data on CD-ROM must first provide a test CD containing representative examinations. The receiving institution can then check that import of images is technically feasible. Images must be marked with the name of the hospital that performed the study in the DICOM data element. Unique identification of the patient and examination (usually the accession number) must also be included.

The department's ideal requirements go beyond those outlined by the IHE, Roterud said. Contact information for referring physicians should also be included on the cover of the CD-ROM in case the data prove intractable.

"This has been painstaking and time-consuming, but we are making progress," he said. "We have improved the quality of data on our system and have become more efficient at handling CD-ROMs."

Radiologists at the Erasmus Medical Center in Rotterdam, the Netherlands, have also been forced to devise special procedures for handling images on CD-ROMs. The center manages around 160,000 outpatient visits each year, the majority following referral from other hospitals. About 10% of hospitals in the Netherlands have a PACS, so more and more patients arrive with images on CD-ROM, said Dr. Jan-Willen Kuiper, a radiologist at Erasmus.

None of the center's 1200 medical workstations is equipped with a CD-ROM drive, a measure to reduce the risk of externally introduced computer viruses. Clinicians can view the CDs only on their own PCs, but even then, they may be unable to open the files.

"So what you get is a very frustrated doctor calling the radiology department because he or she is unable to view these images, but we cannot help," Kuiper said.

An in-house software package, which acts as a "shell" over the hospital information system, and strict procedural rules help manage the workflow. Incoming CD-ROMs are opened by clinicians or administrators at dedicated terminals. Patients presenting with incompatible CD-ROMs must undergo a repeat examination. Readable data are uploaded to the hospital's storage area network, and patients not already in the HIS are registered. The shell-like software application then allows clinicians to access all data in a patient's electronic record, including that from the patient's CD-ROM.