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IHE: a model for driving adoption of standards
Computerized Medical Imaging and Graphics 27 (2003) 137–146 www.elsevier.com/locate/compmedimag
IHE: a model for driving adoption of standards Christopher D. Carra,*, Stephen M. Mooreb a
Radiological Society of North America, Oak Brook, IL, USA b Mallinckrodt Institute of Radiology, St Louis, MO, USA Received 15 July 2002; accepted 25 August 2002
Abstract The development of communication standards in healthcare is a major ongoing engineering effort. While there is little doubt that this effort has made possible significant advances in the performance of healthcare information and imaging systems, overall levels of systems interoperability have not improved as dramatically as one might reasonably expect and the cost of implementing effectively integrated systems remains high. The lag between the development of information standards and their implementation in real systems and institutions is a genuine problem in healthcare. This paper describes an ongoing initiative that attempts to bring together healthcare professionals and industry experts to coordinate the implementation of standards in ways that enhance operational efficiency and the quality of patient care. q 2002 Elsevier Science Ltd. All rights reserved. Keywords: Radiology; Informatics; Integration; Systems; Standards; Industry; Medical associations; Picture archiving and communication system; Modalities; Workflow; Presentation consistency; Structured reporting; Charge posting; Security; Post-processing
1. Introduction Despite the fact that great progress has been made in developing data communication standards in healthcare— notably, DICOM and HL7—the level of interoperability among systems in most healthcare institutions remains frustratingly low. By intention and by consequence of the process through which they are created, these standards often describe an information architecture somewhat more general and abstract than that required by engineers designing and implementing systems. They may leave issues open to interpretation or provide a range of choices to the implementer. Consequently, it frequently requires a major effort to achieve significant integration of multiple systems—even when all the systems involved comply with established standards. Moreover, there is not a reliable way for professionals seeking to acquire or upgrade systems to specify a level of adherence to communication standards sufficient to achieve truly efficient interoperability. There is not a clear road map from the vast body of technical information assembled by standards groups to its * Corresponding author. Tel.: þ 1-630-368-3739; fax: þ1-630-571-7837. E-mail address: [email protected] (C.D. Carr).
application in solving specific clinical problems. A gap persists between the establishment of standards to make interoperability possible and the actual implementation of integrated systems [1]. The integrating the healthcare enterprise (IHE) initiative was established to help bridge that gap [2]. The IHE process provides an organized way for healthcare professionals to communicate to industry the integration capabilities they need in order to work efficiently in providing optimal patient care. Representatives of imaging and information systems companies develop and document a consensus implementation of established communication standards to provide those capabilities. Their selections are recorded in the IHE Technical Framework, a detailed and freely available implementation resource. A testing process enables refinement of both the documented information model and each participating vendor’s implementation of the relevant pieces of it. Demonstrations and educational sessions disseminate information about the process and provide tools for purchasers to use in acquiring systems with specific integration capabilities. Overall, the process helps to build a market for standards-based integration by supplying incentives, education and tools for both providers and purchasers. It defines an iterative cycle of activity leading to a significant result
0895-6111/03/$ - see front matter q 2002 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0895-6111(02)00087-3
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Fig. 1. Overview of IHE process.
point (testing and public demonstration) and creates a feedback loop for the design, testing and implementation of standards-based integration solutions (Fig. 1). 1.1. Goals of systems integration The healthcare enterprise is understood to consist of a complex of facilities and care providers necessary to perform diagnosis and treatment across the spectrum of patient care. An increasingly vital element of this complex is an interconnected array of information systems that acquire, process, store and distribute data required for diagnosis and care, as well as the associated administrative and financial processes. For practical and historical reasons these information functions have evolved as discrete units, each addressing particular aspects of the overall data architecture. Connections among these systems have developed less rapidly, leading to a situation that can be described as ‘islands of data’, wherein much information acquired in the process of care is accessible only within a department or subunit of a department and no comprehensive view of all the information relevant to a given patient’s care is possible. IHE is organized to identify barriers to information sharing that can be removed through the coordinated application of established standards. Priority is given to improvements that will provide the greatest benefit for clinical care. It is anticipated that the work done under IHE will enable institutions to acquire integrated systems less expensively and more conveniently. One desired outcome of the activity is to contribute to the development of an overall information and communications infrastructure sufficient to give real substance to the concept of an electronic patient record. The broader goal is to make all relevant patient information available to care providers as needed to support optimal patient care. 1.2. History The Radiological Society of North America (RSNA) held initial meetings with interested parties in the summer of 1997 to collect ideas about the process of a more unified
approach to an integrated healthcare information infrastructure. Further discussion between the RSNA and the Healthcare Information and Management Systems Society (HIMSS) led to a joint project initially sponsored by the two organizations. This 5-year program would involve collaboration between the professional societies and equipment vendors with the end goal of producing commercial solutions that offer significantly enhanced information sharing capabilities. The RSNA and HIMSS convened a group of imaging and information systems vendors in the fall of 1998. Organizational meetings held to design a process for collaboration produced two clear results. The organizational structure was defined (and will be discussed in Section 1.3). The second result was a policy decision that this group would not become a standards organization, but rather would commit itself to clarifying how existing standards can be used to promote systems integration. Rather than competing with the already well-established standards efforts in healthcare, IHE would work in ways complementary to them, driving their adoption in commercial products and providing a feedback loop for their further development and refinement. 1.3. Organization Four separate committees were organized to guide this process. The Strategic Committee consists of a small number of vendor representatives (past chairs from other IHE committees) and RSNA and HIMSS staff and board members. This committee provides oversight to the other committees and provides longer-range advice on the direction of IHE (such as new technologies to pursue). The Review Committee consists of HIMSS and RSNA staff and board members. This group defines the rules of participation for vendors and intervenes in issues and conflicts involving the competitive interests of participating vendors. The Planning Committee consists of vendor representatives, with oversight from HIMSS and RSNA membership and logistical and secretarial support by HIMSS and RSNA staff. The Planning Committee determines the general scope of technical tasks to be completed each year, prioritizing them based on input from RSNA and HIMSS membership. It also outlines IHE demonstration and educational programs. The Technical Committee consists of technical representatives from the vendor community, again with oversight from the HIMSS and RSNA membership and support by staff. This group takes the integration goals defined by the Planning Committee and produces the detailed documentation—the IHE Technical Framework—that specifies the standards-based transactions required to achieve these goals. A final element in the structure has been the retention of a technical project management team to oversee the testing and demonstration process. The responsibilities of this team
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have included development of software testing tools, organization and supervision of face-to-face testing events, and management of the vendor demonstrations. For the first 3 years of the initiative, the Electronic Radiology Laboratory at the Mallinckrodt Institute of Radiology, Washington University, St Louis has played this role, under contract to RSNA and HIMSS. 1.4. IHE technical framework The IHE Technical Framework is a description of how to apply existing standards to solve system integration problems. Version 5.0 of the framework is available on the RSNA web site at http://www.rsna.org/IHE. The two volumes of the framework use the HL7 and DICOM standards to describe solutions for specific integration issues (Fig. 2). The Technical Framework defines and makes use of several key concepts. † A data model, adapted from HL7 and DICOM, which shows the relationships between the key frames of reference (e.g. Patient, Visit, Order, Study) defined in the framework. † The concept of IHE Actors, which allows systems in the enterprise to be described in generic, product-neutral terms. Actors exchange messages to achieve specific tasks. A commercial system may incorporate one or more IHE Actors. † The organization of the functionality described into discrete units, known as Integration Profile. These higher-level views of IHE functionality consist of a set
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of Actors and transactions required to address a particular clinical need. For example, the Scheduled Workflow Integration Profiles incorporates all of the process steps involved in performing a radiological procedure in a typical scheduled patient encounter, starting with patient registration and continuing through ordering, image acquisition and image viewing. As of the 2002 –2003 cycle of implementation and testing, IHE has defined ten Integration Profiles. Their number will grow over time. The Technical Framework documents in detail the transactions between Actors. For example in Figs. 3 and 4, Transaction 1, Patient Registration, describes the HL7 ADT messages sent for particular registration or admission processes. Transaction 2, Placer Order Management (ORM), describes the HL7 ORM messages that are sent from an Order Placer (Hospital Information System) to an Order Filler (Radiology Information System). For each transaction, the Technical Framework defines the scope of the transaction, presents its use-case, enumerates the Actors involved in the transactions and their respective roles, diagrams the interactions of the Actors, lists each event involved and provides detailed message semantics. In defining individual transactions, the Technical Framework often strengthens the requirements defined in a standard for the attributes in a message, usually by mandating the presence of, or a specific values for, attributes that might be optional or unspecified in the referenced standard. By mandating the values of certain attributes, the Technical Framework allows peer applications to communicate more dependably and perform at a higher level of
Fig. 2. Organization of Information in the IHE Technical Framework.
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Fig. 3. Sample IHE use-case diagram.
interoperability without custom, on-site interface development. The Technical Framework also provides important mappings from the messages in one domain to another. For example, HL7 describes order messages via ORM messages. DICOM describes a worklist procedure that allows a modality to query an information system for procedure information. The Technical Framework defines an explicit mapping from the data in the HL7 ORM message to the data supplied in the DICOM query response by the information system. This consistent mapping should provide for smoother systems integration between commercial Radiology Information System and Modalities. 1.5. IHE Integration Profiles IHE Integration Profiles provide a common language for purchasers and vendors to discuss integration needs of healthcare enterprises and the integration capabilities of
products. They are particularly useful for writing the integration portions of purchasing specifications. The goal for most healthcare organizations is to implement practical capabilities such as distributed access to diagnostic images or smooth departmental workflow. Integration Profiles allow communication about those high-level capabilities while referencing the underlying technical precision necessary to make them work. They give purchasers a tool that reduces the difficulty, cost and anxiety associated with implementing integrated systems. IHE Integration Profiles organize and leverage the integration capabilities that can be achieved by coordinated implementation of communication standards. They do not replace conformance to standards, and users are encouraged to continue to request that vendors provide statements of their conformance to relevant standards, such as DICOM and HL7. Integration Profiles rather provide a more precise definition of how standards are implemented. This implementation of standards is supported by the industry partners involved in the initiative, carefully documented, reviewed and tested in circumstances where multi-vendor integration must be achieved in a tightly compressed time frame. Each of the ten Integration Profiles defined by IHE thus far addresses a specific information management problem to answer a specific clinical need. 1.6. Scheduled workflow The scheduled workflow (Fig. 5) Integration Profiles establishes a seamless flow of information that supports efficient patient care workflow in a typical imaging encounter. It specifies transactions that maintain the consistency of patient information from registration through ordering, scheduling, imaging acquisition, storage and viewing. This consistency is also the foundation for subsequent workflow steps, such as reporting. Systems involved in this profile are † Enterprise-wide information systems that manage patient registration and services ordering (i.e. admit– discharge – transfer (ADT)/registration system and HIS. † Radiology departmental information systems that manage department scheduling (i.e. radiology information system (RIS))and image management/archiving (i.e. picture archiving and communication system (PACS)). † Acquisition modalities. 1.7. Patient information reconciliation (Fig. 6)
Fig. 4. Sample IHE interaction diagram.
This Integration Profiles extends Scheduled Workflow by providing the means to match images acquired for an unidentified patient (for example, during a trauma case) with the patient’s registration and order history. In the example of the trauma case, this allows subsequent reconciliation of the patient record with images acquired
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Fig. 5. Scheduled workflow.
(either without a prior registration or under a generic registration) before the patient’s identity could be determined. Enabling this after-the-fact matching greatly simplifies these exception-handling situations. Systems involved in this Integration Profiles are † Enterprise-wide information systems that manage patient registration and services ordering (ADT/registration system, HIS). † Radiology departmental information systems that manage department scheduling (RIS) and image management/archiving (PACS). † Acquisition modalities.
1.8. Consistent presentation of images (CPI) The CPI Integration Profiles (Fig. 7) specifies a number of transactions that maintain the consistency of presentation for grayscale images and their presentation state information (including user annotations, shutters, flip/rotate, display area, and zoom). It also defines a standard contrast curve, the Grayscale Standard Display Function, against which different types of display and hardcopy output devices can be calibrated. Thus it supports hardcopy, softcopy and mixed environments. The systems included in this profile are hospital-wide and radiology-department image rendering systems such as
Fig. 6. Patient information reconciliation.
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Fig. 7. Consistent presentation of images.
† Review or diagnostic image softcopy display stations (stand-alone or integrated with a HIS, RIS or PACS). † Image management and archiving systems (PACS). † Hardcopy image producing systems on various media such as film or paper. † Acquisition modalities. 1.9. Presentation of grouped procedures (PGP) The PGP Integration Profiles (Fig. 8) addresses the complex information management problems entailed when information for multiple procedures is obtained in a single acquisition step (for example CT of the chest, abdomen and pelvis). PGP provides the ability to view image subsets resulting from a single acquisition and relate each image subset to a different requested procedure. A single acquired image sets produced, but the combined use of scheduled workflow and consistent presentation of images transactions allows separate viewing and interpretation of the subset of images related to each requested procedure. Among other benefits, this allows generating reports that match local billing policies without additional intervention. The PGP Integration Profiles extends the Scheduled Workflow Integration Profiles and the Consistent Presentation of Images Integration Profiles. Systems involved include
providing access to radiology information, including images and related reports. Such access is useful both to the radiology department and to other departments such as pathology, surgery and oncology. Non-radiology information (such as lab reports) may also be accessed if made available in DICOM format. This profile includes both enterprise-wide and radiologydepartment imaging and reporting systems such as † Review or diagnostics image softcopy display stations (stand-alone or integrated with a HIS, RIS, PACS or Modality). † Reporting stations (stand-alone or integrated with a HIS, RIS, PACS or Modality). † Image management and archiving systems (PACS). † Report repositories (stand-alone or integrated with a HIS, RIS or PACS). 1.11. Key image note The Key Image Note Integration Profile (Fig. 10) specifies a transaction that enables a user to flag as
† Acquisition modalities. † Image management and archiving systems (PACS). † Radiology departmental information systems that manage department scheduling (RIS). † Diagnostic image softcopy display stations (integrated with a RIS or a PACS). 1.10. Access to radiology information The access to Radiology Information Integration Profile (Fig. 9) specifies support of a number of query transactions
Fig. 8. Presentation of grouped procedures.
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Fig. 9. Access to Radiology Information.
significant one or more images in a study by referencing them in a note linked with the study. This note includes a title stating the purpose of the flagged images and a user comment field. These notes will be properly stored, archived and displayed as the images move among systems that support the profile. Physicians may attach key image notes to images for a variety of purposes: referring physician access, teaching files selection, consultation with other departments, and image quality issues, to name a few. This Integration Profiles includes both the department imaging systems and the hospital-wide image distribution such as † Review or diagnostics image softcopy display stations (stand-alone or integrated with a HIS, RIS, PACS or modality).
† Image management and archiving systems (PACS). † Acquisition modalities. 1.12. Simple image and numeric report The simple Image And Numeric Report Integration Profiles (Fig. 11) facilitates the growing use of digital dictation, voice recognition, and specialized reporting packages, by separating the functions of reporting into discrete actors for creation, management, storage and viewing. Separating these functions while defining transactions to exchange the reports between them enables a vendor to include one or more of these functions in an actual system. The reports exchanged have a simple structure: a title; an observation context; and one or more sections each with
Fig. 10. Key image note.
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1. User accountability. To allow security officer in an institution to audit activities, to detect non-compliant behavior in the enterprise, and to facilitate detection of improper creation, access, modification and deletion of protected health information (PHI). PHI is considered to be the information records (Registration, Order, Study/Procedure, Reports and to a lesser degree Images/Presentation States), not the flow of information (IHE transactions) between the systems. This includes information exported to and imported from every secured node in the ‘secured domain’. The audit trail contains information so that questions can be answered such as † † † †
Fig. 11. Sample simple image and numeric report.
a heading, text, image references, and, optionally, coded measurements. Some elements can also be coded to facilitate computer searches. Such reports can be input to the formal radiology report, thus avoiding reentry of information. This Integration Profile involves both the department imaging and reporting systems and the hospital-wide information systems such as † Review or diagnostics image softcopy display stations (stand-alone or integrated with a HIS, RIS, PACS or Modality). † Reporting stations (stand-alone or integrated with a HIS, RIS, PACS or Modality). † Report management systems (standalone or integrated with a HIS, RIS, PACS or Modality). † Report repositories (stand-alone or integrated with a HIS, RIS or PACS). 1.13. Basic security (SEC) The Basic Security Integration Profiles establishes security measures which, together with the Security Policy and Procedures of the enterprise, provide patient information confidentiality, data integrity and user accountability. The goals of the Basic Security Integration Profile are
For some user: which patients’ PHI was accessed. For some patient PHI: which users accessed it. What failed user authentication. What failed node authentication.
2. Access control. To limit access to all ‘secured nodes’ in a ‘secured domain’ (defined as a set of cross-connected secured nodes) to ‘authorized users’. 3. Centralized audit record repository. To provide central Audit Record repository as the simplest means to implement security requirements. An immediate transfer of Audit Records from all the IHE Actors to the Audit Record repository is required, reducing the opportunities for tampering and making it easier to audit the department. 4. PHI data integrity. To allow tracking of the life of PHI information (creation, modification, deletion and location). The key features of the Basic Security Integration Profile are the following † Authentication of the user. † Authentication of the node. † Audit record generation. 1.14. Charge posting (CHG) The Charge Posting Integration Profile specifies information exchange from the Department System Scheduler/ Order Filler to the Charge Processor about charges associated with particular procedures, as well as communication about patient demographics, accounts, insurance, and guarantors between ADT Patient Registration and Charge Processor. The Charge Posted Transaction contains some information to generate a claim. Currently, these interfaces contain fixed field formatted or HL7-like data. The goal of including this in the IHE Technical Framework is to standardize interface between clinical systems and the Charge Processors. Additionally, the Charge Posted Transaction reduces the need of the billing system to have knowledge of the radiology internals. The result is that the Charge Processor will receive more complete, timely and accurate data.
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The Department System Scheduler/Order Filler indicates to the Charge Processor that procedures are available for TECHNical and/or Professional Billing. The Charge Posted transaction may occur at various times in the workflow. Regulations and site operating procedures determine when a procedure is eligible for Charge Posting. Often, the events are different for technical and professional charges. Technical charges are typically eligible at procedure completion. Professional charges are typically eligible at result verification. 1.15. Post-processing workflow (PWF) The PFW Integration Profile addresses the need to schedule and track the status of the typical PFW steps, such as Computer Aided Detection or Image Processing. Worklists for each of these tasks are generated and can be queried, work items can be selected and the resulting status returned from the system performing the work to the system managing the work. Typically the workitems will involve the creation of objects such as images and evidence documents. The created images and evidence documents contain the necessary references for maintaining continuity of order information. The PFW Integration Profiles is a continuation of the Scheduled Workflow Integration Profiles. 1.16. Implementation testing The testing phase of the IHE demonstration process takes place in two stages. The first round is performed with a set of software tools called medical enterprise simulators and analyzers (MESA), developed by the Technical Project Management team with funding from HIMSS and RSNA. Participating vendors use the tools to test their implementation of IHE Actors. The tools simulate the exchange of messages with complementary Actors and analyze discrepancies between the vendor’s implementation and the transactions defined in the Technical Framework. Successful completion of these tests is a mandatory part of the IHE process. While not exhaustive, the MESA tests indicate a substantial baseline of success in implementing IHE transactions. The second round is a face-to-face testing event dubbed the ‘Connectathon’, which takes place several weeks before the actual demonstration. The event allows for broad interoperability testing among all participating vendors and systems. Vendors are given the opportunity to test with all participating complementary Actors. Successful results are recorded and documented. This information becomes one of the most publicized aspects of the IHE process, providing a significant incentive for vendors to work out any remaining incompatibilities and successfully complete interoperability testing. As a practical matter, the vendors who attend the Connectathon find the scheduled and unscheduled cross
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vendor testing of great importance. The engineers who staff the equipment have the opportunity to test with a large number of other systems in a short time. In this environment controlled by the HIMSS and RSNA professional organizations, the vendors have a chance to test with potential partners in a non-competitive setting. Time is spent solving issues rather than trying to convince a customer that one product is correct while another product is not. Each Connectathon event has included between 24 and 35 vendors testing a total of between 40 and 75 systems. In the 5 days of the Connectathon, using the transactions defined in the IHE Technical Framework, the participating vendors set up, configure, integrate, and test their systems. In all, hundreds of vendor-to-vendor connections are tested and thousands of transactions passed among the systems present. The Connectathon offers vendors a unique opportunity for connectivity testing—removing barriers to integration that would otherwise have to be dealt with on site, at the client’s expense. Companies taking part have responded overwhelmingly that the IHE process addresses important issues in their product development plans. 1.17. Public exhibitions and education The effort to increase market awareness of the integration capabilities available under IHE (and thereby stimulate demand for this functionality) has involved a series of public demonstrations at the annual HIMSS and RSNA conferences [3]. For the first 3 years of the initiative, these public forums have featured actual systems from a broad array of vendors performing all of the IHE transactions, Actors and Integration Profiles. No simulators were used in these demonstrations. This combination has been highly successful in establishing recognition of IHE in the healthcare community, and providing evidence of its accomplishments, as evidenced both by the broad and continuing support of industry and by the high level of recognition of the IHE project in the medical imaging and informatics community. Having achieved this initial progress as a demonstration project, IHE has now shifted its focus to driving the implementation of IHE functionality in commercial products and healthcare institutions. This involves implementing an enhanced testing process and developing better tools for purchasers and vendors to use in communicating about the integration capabilities of commercial products. Educational sessions about IHE at the HIMSS and RSNA annual meetings will target specific groups of interested parties (e.g. clinicians, administrators, information technologists, developers and consultants) and provide detailed information about the clinical and operational benefits of systems integration and instructions on how to acquire integrated systems.
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1.18. Expansion and evolution
2. Summary
IHE was started—and continues to be sponsored—by two professional societies whose membership is in the imaging and IT domains. The professional and industry experts have been able to attract into the process have proven successful in addressing systems integration issues within the radiology department. The procedural model they have developed for solving system integration issues would seem equally applicable to other domains. Certain of the functions they have worked to implement using established standards, such as patient registration and ordering, also could address problems encountered in other domains. These functions could potentially provide building blocks for an enterprise-wide information technology infrastructure, if sufficient representation of all the stakeholders involved could be brought together. HIMSS and RSNA have been in communication with professional societies in other domains to encourage them to join in broadening the initiative. An important step towards the expansion of IHE into a truly multi-disciplinary effort began with the formation of the IHE Strategic Development Committee in September 2001. This committee consists of representatives from multiple clinical and operational domains. Its task is to begin defining the key integration issues within and among these domains and populating additional committees of professionals and industry experts to explore solutions. The domains initially targeted by the committee are: Cardiology, Laboratory, Pharmacy/Medication Administration, and Interdepartmental Information Sharing. Work to identify key problems and expertise in these domains has progressed significantly. Meanwhile, IHE has expanded internationally, as well. IHE demonstrations have taken place or are scheduled in several European countries and Japan. A process has been put in place to enable all of the nationally based IHE initiatives to contribute to a global Technical Framework. Provision has been made to document nationally based differences stemming from healthcare policies and typical practices, while at the same time seeking the highest possible level of uniformity in the recording and exchange of medical information. Achieving successful integration within other units of the enterprise, and establishing a broader set of information links between departments, will depend on the willingness of professionals and industry sectors representing these domains to become engaged in the IHE process. The evident success of this process in the radiology domain should provide persuasive evidence that they have much to gain in doing so.
While the development of messaging standards for sharing patient information in healthcare is now well advanced, the implementation of closely integrated systems using these standards lags far behind. IHE initiative is a combined effort of the medical professions and healthcare information and imaging technology industry to coordinate the implementation of standards for systems integration. The authors discuss the process used by IHE to gain consensus among professionals and industry on integration priorities and solutions; the way information is structured in the guide for implementing standards developed by the IHE committees, the IHE Technical Framework; the tools IHE has made available to help administrators implement integrated systems, including the ten IHE Integration Profiles; and the possible future expansion of IHE across the many domains and departments comprising the healthcare enterprise.
References [1] Crossing the Quality Chasm. A New Health System for the 21st Century, The National Academy of Sciences, 2000. [2] Eliot L, Siegel MD, David S, Channin MD, et al. IHE primer. Radiographics 2001;21:1339–41. see also pages1343 –1350, 1351– 1358, 1597–1603. [3] Integrating the Healthcare Enterprise (HIMSS Target Issues Monograph), edited by by Paul R. Vegoda, FHIMSS, HIMSS 2001.
Christopher D. Carr is Director of Informatics for the Radiological Society of North America (RSNA). While in graduate school in the humanities, he became involved in projects creating electronically enhanced texts. He came to RSNA in 1997 as a manager in the publications department, responsible for launching the electronic versions of RSNA’s journals, RadioGraphics and Radiology. In his current position at RSNA, he is responsible for the Society’s Web initiatives and several special informatics projects, including serving as staff liaison to the Integrating the Healthcare Enterprise (IHE) initiative.
Stephen M. Moore, MS, is Assistant Professor of Radiology at the Mallinckrodt Institute of Radiology, St Louis, MO. His main interests are in imaging informatics and system integration of radiology operation.
IHE: a model for driving adoption of standards Christopher D. Carra,*, Stephen M. Mooreb a
Radiological Society of North America, Oak Brook, IL, USA b Mallinckrodt Institute of Radiology, St Louis, MO, USA Received 15 July 2002; accepted 25 August 2002
Abstract The development of communication standards in healthcare is a major ongoing engineering effort. While there is little doubt that this effort has made possible significant advances in the performance of healthcare information and imaging systems, overall levels of systems interoperability have not improved as dramatically as one might reasonably expect and the cost of implementing effectively integrated systems remains high. The lag between the development of information standards and their implementation in real systems and institutions is a genuine problem in healthcare. This paper describes an ongoing initiative that attempts to bring together healthcare professionals and industry experts to coordinate the implementation of standards in ways that enhance operational efficiency and the quality of patient care. q 2002 Elsevier Science Ltd. All rights reserved. Keywords: Radiology; Informatics; Integration; Systems; Standards; Industry; Medical associations; Picture archiving and communication system; Modalities; Workflow; Presentation consistency; Structured reporting; Charge posting; Security; Post-processing
1. Introduction Despite the fact that great progress has been made in developing data communication standards in healthcare— notably, DICOM and HL7—the level of interoperability among systems in most healthcare institutions remains frustratingly low. By intention and by consequence of the process through which they are created, these standards often describe an information architecture somewhat more general and abstract than that required by engineers designing and implementing systems. They may leave issues open to interpretation or provide a range of choices to the implementer. Consequently, it frequently requires a major effort to achieve significant integration of multiple systems—even when all the systems involved comply with established standards. Moreover, there is not a reliable way for professionals seeking to acquire or upgrade systems to specify a level of adherence to communication standards sufficient to achieve truly efficient interoperability. There is not a clear road map from the vast body of technical information assembled by standards groups to its * Corresponding author. Tel.: þ 1-630-368-3739; fax: þ1-630-571-7837. E-mail address: [email protected] (C.D. Carr).
application in solving specific clinical problems. A gap persists between the establishment of standards to make interoperability possible and the actual implementation of integrated systems [1]. The integrating the healthcare enterprise (IHE) initiative was established to help bridge that gap [2]. The IHE process provides an organized way for healthcare professionals to communicate to industry the integration capabilities they need in order to work efficiently in providing optimal patient care. Representatives of imaging and information systems companies develop and document a consensus implementation of established communication standards to provide those capabilities. Their selections are recorded in the IHE Technical Framework, a detailed and freely available implementation resource. A testing process enables refinement of both the documented information model and each participating vendor’s implementation of the relevant pieces of it. Demonstrations and educational sessions disseminate information about the process and provide tools for purchasers to use in acquiring systems with specific integration capabilities. Overall, the process helps to build a market for standards-based integration by supplying incentives, education and tools for both providers and purchasers. It defines an iterative cycle of activity leading to a significant result
0895-6111/03/$ - see front matter q 2002 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0895-6111(02)00087-3
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Fig. 1. Overview of IHE process.
point (testing and public demonstration) and creates a feedback loop for the design, testing and implementation of standards-based integration solutions (Fig. 1). 1.1. Goals of systems integration The healthcare enterprise is understood to consist of a complex of facilities and care providers necessary to perform diagnosis and treatment across the spectrum of patient care. An increasingly vital element of this complex is an interconnected array of information systems that acquire, process, store and distribute data required for diagnosis and care, as well as the associated administrative and financial processes. For practical and historical reasons these information functions have evolved as discrete units, each addressing particular aspects of the overall data architecture. Connections among these systems have developed less rapidly, leading to a situation that can be described as ‘islands of data’, wherein much information acquired in the process of care is accessible only within a department or subunit of a department and no comprehensive view of all the information relevant to a given patient’s care is possible. IHE is organized to identify barriers to information sharing that can be removed through the coordinated application of established standards. Priority is given to improvements that will provide the greatest benefit for clinical care. It is anticipated that the work done under IHE will enable institutions to acquire integrated systems less expensively and more conveniently. One desired outcome of the activity is to contribute to the development of an overall information and communications infrastructure sufficient to give real substance to the concept of an electronic patient record. The broader goal is to make all relevant patient information available to care providers as needed to support optimal patient care. 1.2. History The Radiological Society of North America (RSNA) held initial meetings with interested parties in the summer of 1997 to collect ideas about the process of a more unified
approach to an integrated healthcare information infrastructure. Further discussion between the RSNA and the Healthcare Information and Management Systems Society (HIMSS) led to a joint project initially sponsored by the two organizations. This 5-year program would involve collaboration between the professional societies and equipment vendors with the end goal of producing commercial solutions that offer significantly enhanced information sharing capabilities. The RSNA and HIMSS convened a group of imaging and information systems vendors in the fall of 1998. Organizational meetings held to design a process for collaboration produced two clear results. The organizational structure was defined (and will be discussed in Section 1.3). The second result was a policy decision that this group would not become a standards organization, but rather would commit itself to clarifying how existing standards can be used to promote systems integration. Rather than competing with the already well-established standards efforts in healthcare, IHE would work in ways complementary to them, driving their adoption in commercial products and providing a feedback loop for their further development and refinement. 1.3. Organization Four separate committees were organized to guide this process. The Strategic Committee consists of a small number of vendor representatives (past chairs from other IHE committees) and RSNA and HIMSS staff and board members. This committee provides oversight to the other committees and provides longer-range advice on the direction of IHE (such as new technologies to pursue). The Review Committee consists of HIMSS and RSNA staff and board members. This group defines the rules of participation for vendors and intervenes in issues and conflicts involving the competitive interests of participating vendors. The Planning Committee consists of vendor representatives, with oversight from HIMSS and RSNA membership and logistical and secretarial support by HIMSS and RSNA staff. The Planning Committee determines the general scope of technical tasks to be completed each year, prioritizing them based on input from RSNA and HIMSS membership. It also outlines IHE demonstration and educational programs. The Technical Committee consists of technical representatives from the vendor community, again with oversight from the HIMSS and RSNA membership and support by staff. This group takes the integration goals defined by the Planning Committee and produces the detailed documentation—the IHE Technical Framework—that specifies the standards-based transactions required to achieve these goals. A final element in the structure has been the retention of a technical project management team to oversee the testing and demonstration process. The responsibilities of this team
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have included development of software testing tools, organization and supervision of face-to-face testing events, and management of the vendor demonstrations. For the first 3 years of the initiative, the Electronic Radiology Laboratory at the Mallinckrodt Institute of Radiology, Washington University, St Louis has played this role, under contract to RSNA and HIMSS. 1.4. IHE technical framework The IHE Technical Framework is a description of how to apply existing standards to solve system integration problems. Version 5.0 of the framework is available on the RSNA web site at http://www.rsna.org/IHE. The two volumes of the framework use the HL7 and DICOM standards to describe solutions for specific integration issues (Fig. 2). The Technical Framework defines and makes use of several key concepts. † A data model, adapted from HL7 and DICOM, which shows the relationships between the key frames of reference (e.g. Patient, Visit, Order, Study) defined in the framework. † The concept of IHE Actors, which allows systems in the enterprise to be described in generic, product-neutral terms. Actors exchange messages to achieve specific tasks. A commercial system may incorporate one or more IHE Actors. † The organization of the functionality described into discrete units, known as Integration Profile. These higher-level views of IHE functionality consist of a set
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of Actors and transactions required to address a particular clinical need. For example, the Scheduled Workflow Integration Profiles incorporates all of the process steps involved in performing a radiological procedure in a typical scheduled patient encounter, starting with patient registration and continuing through ordering, image acquisition and image viewing. As of the 2002 –2003 cycle of implementation and testing, IHE has defined ten Integration Profiles. Their number will grow over time. The Technical Framework documents in detail the transactions between Actors. For example in Figs. 3 and 4, Transaction 1, Patient Registration, describes the HL7 ADT messages sent for particular registration or admission processes. Transaction 2, Placer Order Management (ORM), describes the HL7 ORM messages that are sent from an Order Placer (Hospital Information System) to an Order Filler (Radiology Information System). For each transaction, the Technical Framework defines the scope of the transaction, presents its use-case, enumerates the Actors involved in the transactions and their respective roles, diagrams the interactions of the Actors, lists each event involved and provides detailed message semantics. In defining individual transactions, the Technical Framework often strengthens the requirements defined in a standard for the attributes in a message, usually by mandating the presence of, or a specific values for, attributes that might be optional or unspecified in the referenced standard. By mandating the values of certain attributes, the Technical Framework allows peer applications to communicate more dependably and perform at a higher level of
Fig. 2. Organization of Information in the IHE Technical Framework.
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Fig. 3. Sample IHE use-case diagram.
interoperability without custom, on-site interface development. The Technical Framework also provides important mappings from the messages in one domain to another. For example, HL7 describes order messages via ORM messages. DICOM describes a worklist procedure that allows a modality to query an information system for procedure information. The Technical Framework defines an explicit mapping from the data in the HL7 ORM message to the data supplied in the DICOM query response by the information system. This consistent mapping should provide for smoother systems integration between commercial Radiology Information System and Modalities. 1.5. IHE Integration Profiles IHE Integration Profiles provide a common language for purchasers and vendors to discuss integration needs of healthcare enterprises and the integration capabilities of
products. They are particularly useful for writing the integration portions of purchasing specifications. The goal for most healthcare organizations is to implement practical capabilities such as distributed access to diagnostic images or smooth departmental workflow. Integration Profiles allow communication about those high-level capabilities while referencing the underlying technical precision necessary to make them work. They give purchasers a tool that reduces the difficulty, cost and anxiety associated with implementing integrated systems. IHE Integration Profiles organize and leverage the integration capabilities that can be achieved by coordinated implementation of communication standards. They do not replace conformance to standards, and users are encouraged to continue to request that vendors provide statements of their conformance to relevant standards, such as DICOM and HL7. Integration Profiles rather provide a more precise definition of how standards are implemented. This implementation of standards is supported by the industry partners involved in the initiative, carefully documented, reviewed and tested in circumstances where multi-vendor integration must be achieved in a tightly compressed time frame. Each of the ten Integration Profiles defined by IHE thus far addresses a specific information management problem to answer a specific clinical need. 1.6. Scheduled workflow The scheduled workflow (Fig. 5) Integration Profiles establishes a seamless flow of information that supports efficient patient care workflow in a typical imaging encounter. It specifies transactions that maintain the consistency of patient information from registration through ordering, scheduling, imaging acquisition, storage and viewing. This consistency is also the foundation for subsequent workflow steps, such as reporting. Systems involved in this profile are † Enterprise-wide information systems that manage patient registration and services ordering (i.e. admit– discharge – transfer (ADT)/registration system and HIS. † Radiology departmental information systems that manage department scheduling (i.e. radiology information system (RIS))and image management/archiving (i.e. picture archiving and communication system (PACS)). † Acquisition modalities. 1.7. Patient information reconciliation (Fig. 6)
Fig. 4. Sample IHE interaction diagram.
This Integration Profiles extends Scheduled Workflow by providing the means to match images acquired for an unidentified patient (for example, during a trauma case) with the patient’s registration and order history. In the example of the trauma case, this allows subsequent reconciliation of the patient record with images acquired
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Fig. 5. Scheduled workflow.
(either without a prior registration or under a generic registration) before the patient’s identity could be determined. Enabling this after-the-fact matching greatly simplifies these exception-handling situations. Systems involved in this Integration Profiles are † Enterprise-wide information systems that manage patient registration and services ordering (ADT/registration system, HIS). † Radiology departmental information systems that manage department scheduling (RIS) and image management/archiving (PACS). † Acquisition modalities.
1.8. Consistent presentation of images (CPI) The CPI Integration Profiles (Fig. 7) specifies a number of transactions that maintain the consistency of presentation for grayscale images and their presentation state information (including user annotations, shutters, flip/rotate, display area, and zoom). It also defines a standard contrast curve, the Grayscale Standard Display Function, against which different types of display and hardcopy output devices can be calibrated. Thus it supports hardcopy, softcopy and mixed environments. The systems included in this profile are hospital-wide and radiology-department image rendering systems such as
Fig. 6. Patient information reconciliation.
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Fig. 7. Consistent presentation of images.
† Review or diagnostic image softcopy display stations (stand-alone or integrated with a HIS, RIS or PACS). † Image management and archiving systems (PACS). † Hardcopy image producing systems on various media such as film or paper. † Acquisition modalities. 1.9. Presentation of grouped procedures (PGP) The PGP Integration Profiles (Fig. 8) addresses the complex information management problems entailed when information for multiple procedures is obtained in a single acquisition step (for example CT of the chest, abdomen and pelvis). PGP provides the ability to view image subsets resulting from a single acquisition and relate each image subset to a different requested procedure. A single acquired image sets produced, but the combined use of scheduled workflow and consistent presentation of images transactions allows separate viewing and interpretation of the subset of images related to each requested procedure. Among other benefits, this allows generating reports that match local billing policies without additional intervention. The PGP Integration Profiles extends the Scheduled Workflow Integration Profiles and the Consistent Presentation of Images Integration Profiles. Systems involved include
providing access to radiology information, including images and related reports. Such access is useful both to the radiology department and to other departments such as pathology, surgery and oncology. Non-radiology information (such as lab reports) may also be accessed if made available in DICOM format. This profile includes both enterprise-wide and radiologydepartment imaging and reporting systems such as † Review or diagnostics image softcopy display stations (stand-alone or integrated with a HIS, RIS, PACS or Modality). † Reporting stations (stand-alone or integrated with a HIS, RIS, PACS or Modality). † Image management and archiving systems (PACS). † Report repositories (stand-alone or integrated with a HIS, RIS or PACS). 1.11. Key image note The Key Image Note Integration Profile (Fig. 10) specifies a transaction that enables a user to flag as
† Acquisition modalities. † Image management and archiving systems (PACS). † Radiology departmental information systems that manage department scheduling (RIS). † Diagnostic image softcopy display stations (integrated with a RIS or a PACS). 1.10. Access to radiology information The access to Radiology Information Integration Profile (Fig. 9) specifies support of a number of query transactions
Fig. 8. Presentation of grouped procedures.
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Fig. 9. Access to Radiology Information.
significant one or more images in a study by referencing them in a note linked with the study. This note includes a title stating the purpose of the flagged images and a user comment field. These notes will be properly stored, archived and displayed as the images move among systems that support the profile. Physicians may attach key image notes to images for a variety of purposes: referring physician access, teaching files selection, consultation with other departments, and image quality issues, to name a few. This Integration Profiles includes both the department imaging systems and the hospital-wide image distribution such as † Review or diagnostics image softcopy display stations (stand-alone or integrated with a HIS, RIS, PACS or modality).
† Image management and archiving systems (PACS). † Acquisition modalities. 1.12. Simple image and numeric report The simple Image And Numeric Report Integration Profiles (Fig. 11) facilitates the growing use of digital dictation, voice recognition, and specialized reporting packages, by separating the functions of reporting into discrete actors for creation, management, storage and viewing. Separating these functions while defining transactions to exchange the reports between them enables a vendor to include one or more of these functions in an actual system. The reports exchanged have a simple structure: a title; an observation context; and one or more sections each with
Fig. 10. Key image note.
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1. User accountability. To allow security officer in an institution to audit activities, to detect non-compliant behavior in the enterprise, and to facilitate detection of improper creation, access, modification and deletion of protected health information (PHI). PHI is considered to be the information records (Registration, Order, Study/Procedure, Reports and to a lesser degree Images/Presentation States), not the flow of information (IHE transactions) between the systems. This includes information exported to and imported from every secured node in the ‘secured domain’. The audit trail contains information so that questions can be answered such as † † † †
Fig. 11. Sample simple image and numeric report.
a heading, text, image references, and, optionally, coded measurements. Some elements can also be coded to facilitate computer searches. Such reports can be input to the formal radiology report, thus avoiding reentry of information. This Integration Profile involves both the department imaging and reporting systems and the hospital-wide information systems such as † Review or diagnostics image softcopy display stations (stand-alone or integrated with a HIS, RIS, PACS or Modality). † Reporting stations (stand-alone or integrated with a HIS, RIS, PACS or Modality). † Report management systems (standalone or integrated with a HIS, RIS, PACS or Modality). † Report repositories (stand-alone or integrated with a HIS, RIS or PACS). 1.13. Basic security (SEC) The Basic Security Integration Profiles establishes security measures which, together with the Security Policy and Procedures of the enterprise, provide patient information confidentiality, data integrity and user accountability. The goals of the Basic Security Integration Profile are
For some user: which patients’ PHI was accessed. For some patient PHI: which users accessed it. What failed user authentication. What failed node authentication.
2. Access control. To limit access to all ‘secured nodes’ in a ‘secured domain’ (defined as a set of cross-connected secured nodes) to ‘authorized users’. 3. Centralized audit record repository. To provide central Audit Record repository as the simplest means to implement security requirements. An immediate transfer of Audit Records from all the IHE Actors to the Audit Record repository is required, reducing the opportunities for tampering and making it easier to audit the department. 4. PHI data integrity. To allow tracking of the life of PHI information (creation, modification, deletion and location). The key features of the Basic Security Integration Profile are the following † Authentication of the user. † Authentication of the node. † Audit record generation. 1.14. Charge posting (CHG) The Charge Posting Integration Profile specifies information exchange from the Department System Scheduler/ Order Filler to the Charge Processor about charges associated with particular procedures, as well as communication about patient demographics, accounts, insurance, and guarantors between ADT Patient Registration and Charge Processor. The Charge Posted Transaction contains some information to generate a claim. Currently, these interfaces contain fixed field formatted or HL7-like data. The goal of including this in the IHE Technical Framework is to standardize interface between clinical systems and the Charge Processors. Additionally, the Charge Posted Transaction reduces the need of the billing system to have knowledge of the radiology internals. The result is that the Charge Processor will receive more complete, timely and accurate data.
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The Department System Scheduler/Order Filler indicates to the Charge Processor that procedures are available for TECHNical and/or Professional Billing. The Charge Posted transaction may occur at various times in the workflow. Regulations and site operating procedures determine when a procedure is eligible for Charge Posting. Often, the events are different for technical and professional charges. Technical charges are typically eligible at procedure completion. Professional charges are typically eligible at result verification. 1.15. Post-processing workflow (PWF) The PFW Integration Profile addresses the need to schedule and track the status of the typical PFW steps, such as Computer Aided Detection or Image Processing. Worklists for each of these tasks are generated and can be queried, work items can be selected and the resulting status returned from the system performing the work to the system managing the work. Typically the workitems will involve the creation of objects such as images and evidence documents. The created images and evidence documents contain the necessary references for maintaining continuity of order information. The PFW Integration Profiles is a continuation of the Scheduled Workflow Integration Profiles. 1.16. Implementation testing The testing phase of the IHE demonstration process takes place in two stages. The first round is performed with a set of software tools called medical enterprise simulators and analyzers (MESA), developed by the Technical Project Management team with funding from HIMSS and RSNA. Participating vendors use the tools to test their implementation of IHE Actors. The tools simulate the exchange of messages with complementary Actors and analyze discrepancies between the vendor’s implementation and the transactions defined in the Technical Framework. Successful completion of these tests is a mandatory part of the IHE process. While not exhaustive, the MESA tests indicate a substantial baseline of success in implementing IHE transactions. The second round is a face-to-face testing event dubbed the ‘Connectathon’, which takes place several weeks before the actual demonstration. The event allows for broad interoperability testing among all participating vendors and systems. Vendors are given the opportunity to test with all participating complementary Actors. Successful results are recorded and documented. This information becomes one of the most publicized aspects of the IHE process, providing a significant incentive for vendors to work out any remaining incompatibilities and successfully complete interoperability testing. As a practical matter, the vendors who attend the Connectathon find the scheduled and unscheduled cross
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vendor testing of great importance. The engineers who staff the equipment have the opportunity to test with a large number of other systems in a short time. In this environment controlled by the HIMSS and RSNA professional organizations, the vendors have a chance to test with potential partners in a non-competitive setting. Time is spent solving issues rather than trying to convince a customer that one product is correct while another product is not. Each Connectathon event has included between 24 and 35 vendors testing a total of between 40 and 75 systems. In the 5 days of the Connectathon, using the transactions defined in the IHE Technical Framework, the participating vendors set up, configure, integrate, and test their systems. In all, hundreds of vendor-to-vendor connections are tested and thousands of transactions passed among the systems present. The Connectathon offers vendors a unique opportunity for connectivity testing—removing barriers to integration that would otherwise have to be dealt with on site, at the client’s expense. Companies taking part have responded overwhelmingly that the IHE process addresses important issues in their product development plans. 1.17. Public exhibitions and education The effort to increase market awareness of the integration capabilities available under IHE (and thereby stimulate demand for this functionality) has involved a series of public demonstrations at the annual HIMSS and RSNA conferences [3]. For the first 3 years of the initiative, these public forums have featured actual systems from a broad array of vendors performing all of the IHE transactions, Actors and Integration Profiles. No simulators were used in these demonstrations. This combination has been highly successful in establishing recognition of IHE in the healthcare community, and providing evidence of its accomplishments, as evidenced both by the broad and continuing support of industry and by the high level of recognition of the IHE project in the medical imaging and informatics community. Having achieved this initial progress as a demonstration project, IHE has now shifted its focus to driving the implementation of IHE functionality in commercial products and healthcare institutions. This involves implementing an enhanced testing process and developing better tools for purchasers and vendors to use in communicating about the integration capabilities of commercial products. Educational sessions about IHE at the HIMSS and RSNA annual meetings will target specific groups of interested parties (e.g. clinicians, administrators, information technologists, developers and consultants) and provide detailed information about the clinical and operational benefits of systems integration and instructions on how to acquire integrated systems.
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1.18. Expansion and evolution
2. Summary
IHE was started—and continues to be sponsored—by two professional societies whose membership is in the imaging and IT domains. The professional and industry experts have been able to attract into the process have proven successful in addressing systems integration issues within the radiology department. The procedural model they have developed for solving system integration issues would seem equally applicable to other domains. Certain of the functions they have worked to implement using established standards, such as patient registration and ordering, also could address problems encountered in other domains. These functions could potentially provide building blocks for an enterprise-wide information technology infrastructure, if sufficient representation of all the stakeholders involved could be brought together. HIMSS and RSNA have been in communication with professional societies in other domains to encourage them to join in broadening the initiative. An important step towards the expansion of IHE into a truly multi-disciplinary effort began with the formation of the IHE Strategic Development Committee in September 2001. This committee consists of representatives from multiple clinical and operational domains. Its task is to begin defining the key integration issues within and among these domains and populating additional committees of professionals and industry experts to explore solutions. The domains initially targeted by the committee are: Cardiology, Laboratory, Pharmacy/Medication Administration, and Interdepartmental Information Sharing. Work to identify key problems and expertise in these domains has progressed significantly. Meanwhile, IHE has expanded internationally, as well. IHE demonstrations have taken place or are scheduled in several European countries and Japan. A process has been put in place to enable all of the nationally based IHE initiatives to contribute to a global Technical Framework. Provision has been made to document nationally based differences stemming from healthcare policies and typical practices, while at the same time seeking the highest possible level of uniformity in the recording and exchange of medical information. Achieving successful integration within other units of the enterprise, and establishing a broader set of information links between departments, will depend on the willingness of professionals and industry sectors representing these domains to become engaged in the IHE process. The evident success of this process in the radiology domain should provide persuasive evidence that they have much to gain in doing so.
While the development of messaging standards for sharing patient information in healthcare is now well advanced, the implementation of closely integrated systems using these standards lags far behind. IHE initiative is a combined effort of the medical professions and healthcare information and imaging technology industry to coordinate the implementation of standards for systems integration. The authors discuss the process used by IHE to gain consensus among professionals and industry on integration priorities and solutions; the way information is structured in the guide for implementing standards developed by the IHE committees, the IHE Technical Framework; the tools IHE has made available to help administrators implement integrated systems, including the ten IHE Integration Profiles; and the possible future expansion of IHE across the many domains and departments comprising the healthcare enterprise.
References [1] Crossing the Quality Chasm. A New Health System for the 21st Century, The National Academy of Sciences, 2000. [2] Eliot L, Siegel MD, David S, Channin MD, et al. IHE primer. Radiographics 2001;21:1339–41. see also pages1343 –1350, 1351– 1358, 1597–1603. [3] Integrating the Healthcare Enterprise (HIMSS Target Issues Monograph), edited by by Paul R. Vegoda, FHIMSS, HIMSS 2001.
Christopher D. Carr is Director of Informatics for the Radiological Society of North America (RSNA). While in graduate school in the humanities, he became involved in projects creating electronically enhanced texts. He came to RSNA in 1997 as a manager in the publications department, responsible for launching the electronic versions of RSNA’s journals, RadioGraphics and Radiology. In his current position at RSNA, he is responsible for the Society’s Web initiatives and several special informatics projects, including serving as staff liaison to the Integrating the Healthcare Enterprise (IHE) initiative.
Stephen M. Moore, MS, is Assistant Professor of Radiology at the Mallinckrodt Institute of Radiology, St Louis, MO. His main interests are in imaging informatics and system integration of radiology operation.