ࡱ> z|yy ZbjbjEE .''P0   +++8c,t+7/EEXv$6666666$8;6TX6EE6%%%EE6%6%%S4|5EP72+94{66074t< 0t<$5t<5$% 663$7t< : RANZCR/ ADIA Joint Technical Committee on Radiology Information Technology Report on Diagnostic Image delivery on CDs: November 2007 Summary: With the increasing uptake of digital image delivery by Diagnostic Imaging practices, many referring and treating doctors are not able to access these images, creating difficulties for patients and the health professions. The radiology profession acknowledges the need for many treating doctors to have access to diagnostic quality images and has identified a number of barriers with digital media such as CDs. There is an industry accepted standard for the format of portable media (eg CDs) which is described in a profile created by Integrating the Healthcare Enterprise (IHE). A recent study in Australia found that, of 30 CDs tested, none fully complied with the standards. The same study identified a number of usability and workflow problems. The further issue elates to the availability of digital images and IT facilities in healthcare settings such as doctors rooms, outpatients, hospitals and theatre. A key issue is the need for appropriate hardware and software to display the images. A change of this type invariably creates issues of training, support and a business case. New Technology also brings changes in work practices. An x-ray film can be pulled out of the bag and be ready for review in seconds during the consultation, whereas portable media can take a minute or so to load.. A image carried on portable media such as CDs or data cards may need to be preloaded, while the patient is waiting and is then accessible via a patient list on a computer screen What is being done?: The problem is now recognised as requiring urgent action at all levels, both professional and government. The AMA has convened a workshop, clarified a range of professional roles and responsibilities and set the scene for development of a plan to resolve the problem. A meeting was held with the IT industry to draw this problem to their attention and get their engagement in a joint profession and industry approach to achieving the implementation of the IHE profile and improvement of the usability of the CDs and other options. A workshop on Dec 10-12 is planned to further tackle this issue, introduce the collaborative process used by IHE and consider next steps to move towards an online approach to image delivery. The issue of the readiness of healthcare organisations to accept digital images has to be tackled also. The College has established a project under the Quality Use of Diagnostic Imaging which will work with users of images. The Royal Australian College of Surgeons and the Orthopaedic Association have produced position statements outlining their broad requirements. Following the work done so far the College and ADIA are drafting aresponse to the valid concerns of the end users of the Diagnostic Imaging. This will be the basis of further consultation and exploration of the problems and solutions in more depth. Lastly there are a number of unresolved issues which have arisen with the move to digital technology such as how long images should be kept and in what format. Further information: Jane Grimm qudi@ranzcr.edu.au Background: The issue of the acceptability to referrers of digital images supplied on CD was identified in the QUDI eHealth Scoping Study (Attachment B), and is now a policy issue as the result of official complaints by key procedural specialist groups, and a call for provision by DI services of diagnostic quality images as a requirement for medical imaging rebates under Medicare. The previous work by the College has enabled a speedy response, and a summary of progress is attached for information. It is possible that the inability of specialists to access images on CDs is delaying treatment, inconveniencing consumers and potentially leading to the repeating of examinations. In June 2007 the AMA convened a workshop to scope the issues in relation to the transmission and receipt of digital diagnostic images by procedural specialists, physicians and GPs. All groups, including DoHA, accepted that it is appropriate for the AMA to take this forward; however complaints by individual specialists are continuing to be received by Government and the Department. While these have had a useful outcome in that they are keeping the issue on the policy agenda, it is important that the surgeons representative organisations are seen to be committed to working within the AMA process, and cooperatively with RANZCR. Activity by RANZCR/ADIA has established the following points: Agreement by radiologists that diagnostic image delivery is a core component of the professional service to consumers, referring doctors and subsequent treating procedural specialists. These principles have been entered into the RANZCR accreditation standards, and, when these are implemented, will become a requirement for practices to remain accredited and access Medicare payments. Specialist colleagues and organisations accept that the move away from film is inevitable, yet should not occur until reasonable steps have been taken to ensure an appropriate transition. The DI digital revolution has been driven by a complex raft of technology changes, which have resulted in positive outcomes for patients and treating doctors (through improved diagnostic techniques). Savings and productivity gains from film replacement are a core component of the radiology business case for implementing the new technologies. There is acknowledgement that the current approach to delivering images is not technically satisfactory, for a whole raft of reasons, and that an appropriate national change management process, with adequate cross-professional consultation, did not occur early enough. While this is regrettable, we now all have to move forward to achieve solutions to the problem, and gain some experience from this process. As a principle the preferences of referrers and treating doctors who require diagnostic images should be considered. Accepting that there is an inevitable move in the direction of digital image delivery, during the phase of change and uptake of systems to view digital images it may be necessary to continue to supply images on film until acceptable digital alternatives for image delivery can be reasonably adopted. CDs are only part of a bigger technical and change management process, and may well be superseded as a means of image delivery in the medium to long term by other portable data media (DVDs, compact flash cards, USB drives) and internet-based options. However, CDs seem to be a cost-effective strategy for delivery, and, in some cases, archival, of images, and are being commonly used now. Many of the technical issues apply equally to the other portable media, and to internet-based solutions, so effort in addressing the CD problems will not be wasted. A DI project group has been formed, led by the RANZCR and ADIA, to oversee a program of work with both long and short term views. This group will provide technical advice to the QUDI project working on delivery of diagnostic images. The College has specified that a project be created under the Quality Use of Diagnostic Imaging program to rapidly address this issue. The QUDI program has engaged MacIsaac Informatics as consultants to provide technical and policy advice. A poster and awareness raising exercise occurred at the recent RANZCR ASM, including a CD challenge to test the compliance of current image CDs with the international IHE profile. The CD challenge has confirmed that most CDs do not comply with all aspects of international interoperability profiles, yet the majority did load and could be viewed on software provided on the CD. These problems may make it difficult to load the DICOM images into a range of third party viewers operating on different computer platforms (Windows, Apple, Linux) The compliance problems were largely due to technical implementation issues with aspects of the DICOM standard and most problems can be readily rectified. A workshop has been planned for December to focus on the technical issues and enable local IT companies and DI practices to comply with the IHE profile for CDs. Chris Lindop, chair of the international IHE radiology committee will lead this workshop. The workshop will also promote the use of other IHE profiles for radiology IT integration and web based delivery of images to other radiologists, treating health professionals, and the health IT industry. NEHTA, Standards Australia, and the AMA are invited to have input. Direct communication between the RANZCR/ADIA and procedural specialists is needed to clearly define referrers technical requirements and business issues. How best to do this will be the subject of further discussions with procedural special organisations. These discussions will also examine views about how to specify the detailed technical requirements of each craft group and to plan a strategy to deal with the other key issues going beyond the CDs. One option is to hold a DI users requirements workshop which could make use of the international IHE specialists who will be visiting Australia to lead the technical workshop described below. The College will be guided by the professional bodies representing the users of diagnostic imaging as to what process they feel is appropriate and best able to achieve the required outcomes. The AMA will prepare a document setting out the functional requirements for the transmission and receipt of digital diagnostic images for procedural specialists, physicians and GPs. The AMA document along with the Departments policy issues paper will inform the proposed workshops. The AMA has also offered to provide avenues for publicising this issue to the broader profession. A workshop will be held (December 10-12 see attachment A) for the radiology and IT industry to support the business case and technical aspects of moving to adopt the IHE profile and to explore the role of IHE profiles in delivering images in a standards based manner over the internet. A preliminary program for the industry workshop is at  HYPERLINK "http://www.ihe.net.au" www.ihe.net.au A meeting between the RANZCR and the eHealth and DI sections of DoHA has found a common understanding of the problems, and agreement on a process to go forward. The Department has specifically asked the RANZCR to ensure that the views of other professional groups, the AMA and NEHTA are considered. The Department has indicated that it has been directed to independently develop an n issues paper to address the concerns raised, review current legislative requirements , and scope out policy options. One option that the Department is exploring is the inclusion in legislation of general principles to provide a guide to all providers of DI services linked with payment for Medicare services. These principles would refer to detail spelt out in an appropriate place. Another option for enshrining the agreed principles is through the Mandatory Accreditation System. Once complete this paper will be circulated for comment through the AMA. . The interests of Allied Health professions do need to be considered and the QUDI Program will contact them and discuss a process of engagement on this issue. The RANZCR and the ADIA are jointly drafting a Code of Practice which encapsulates the above issues. There are a range of other issues which have to be explored, including: image retention policy ( how long to keep images); required image quality for archival(all data or a representative sample eg thick slices); access to images by third parties such as treating doctors other than the referring doctor; issues of security, authentication, validation/integrity, non repudiation and confidentiality of CD based images and reports. technical requirements for, and availability of, IT systems within specialists rooms, hospital-based consulting suites, outpatients, and theatres ; mobile access to images recognising this requirement of specialist practice; consistency across all image services that are not governed by RANZCR processes; creating and supporting a business case and strategies for supporting uptake and change among image users outside the DI practice understanding of the benefits of moving to digital imaging and managing negative perceptions about the cost saving from film replacement; integration with medium to long term move to internet based delivery so that current investments in systems can be used and the transition period will be managed; consideration of how requests and reports may be moved electronically and potential linkage with associated images the adequacy of broadband internet services for these purposes. Use of other formats such as high quality paper prints to convey images. Further consideration of these issues will await the detailed analysis of the CD challenge experience, the outcomes of the specialist and industry workshops, the DoHA issues paper, and further input from the AMA. Attachment A: Report on DI IT issues flowing from the eHealth Scoping Study The RANZCR has produced an eHealth (Diagnostic Imaging) scoping paper as an outcome of the QUDI QR1 project. Key areas are identified for advancement in information management and to commence discussion we have returned to the QUDI eHealth scoping study and analysed progress on key items. 1Establish a DI project groupAn informal project group between the RANZCR and ADIA has been formed to tackle IT issues. The AMA convened a cross professional workshop (with Peter Garcia Webb as chair). Discussion is underway with HISA with regard to setting up a DI IT discussion list and forming a special interest group covering DI professionals (radiologists, imaging technologists, practice managers and IT managers), RANZCR, ADIA and DI IT industry. In the interim an email discussion list will be established. Likewise discussions are occurring with the MSIA regarding the formation of a DI industry subgroup to provide a forum for and represent DI IT industry players. Again in the interim a list will be established to provide a means of communication with DI industry.2Engagement of NEHTAReport provided and subsequent DI data specifications fed into the NEHTA specifications (with RANZCR consultants engaged to assist NEHTA). As yet no public progress has been made on DI coding/terminology issues by NEHTA. It is likely that SNOMED in its current form is not sufficiently developed to support DI data management and communication.3Standardisation of HL7 messaging for DIRevision of AS4700.7 undertaken by Standards Australia. The RANZCR has been a sponsor of the three interoperability demonstrations (the last of which focused on improving quality of path and DI messages). HL7 are running a workshop at end October to follow-up on this.4Move from handwritten requests to computer printedQUDI Project (QR03.i) developed a draft dataset for the DI request. This has been followed up with a project (QR03.ia - underway) to develop a standard format for requests which will support both handwritten and computer generation (common layout for all DI requests)5Electronic Transmission of requestsOne pilot project (West VIC Division) supported electronic transfer of requests using HL7 v2 (point to point message) in an environment of one practice one DI service. A managed health network project scoped out business and technical models for e-referrals for pathology, radiology and pharmacy and hospital discharge summaries using a common infrastructure. A prototype of this model was developed by SUN Microsystems and implemented in the 2007 interoperability demonstration. The model is based on an extension of the IHE XDS profile.6Adoption of IHE profiles in DI in AustraliaSeveral presentations have been held on IHE at various meetings. The IHE profiles for Cross Enterprise Document sharing were demonstrated in the 2007 Interoperability Demonstration for pathology reports and hospital summary and demonstrating transition between messaging/EHR formats and HL7 CDA document format (HL7v2/OpenEHR). An industry forum following the demonstration indicated commitment of HL7, HISA, MSIA, RANZCR, and ADIA to the formation of IHE (Australia/Asia-Pacific). The CD image standardisation project has identified IHE profiles as appropriate. A full scale IHE conference and technical workshop is planned for December 2007. 7Support for the move from film to digital image deliveryThis recommendation was not actioned until approaches from the surgeons indicated that there are significant problems with the ad hoc approach being adopted by the DI industry. THE RANZCR however was primed to respond quickly to this issue. These concerns have been acknowledged by RANZCR and ADIA, the right of treating doctors to have access to diagnostic quality images has been publicly acknowledged at the AMA workshop and in the draft radiology accreditation standards. The RANZCR has established a QUDI project to develop and implement the international standards for CDs and to extend them where needed to meet local requirements. A CD challenge was held at the recent RANZCR conference to highlight the issue with the DI profession and scope the extent of the problem. A consultation meeting has been held with the DI technology industry. The forthcoming IHE workshop will provide technical support to industry to adopt the standard and a conformance testing process is being planned for early 2008. Avenues for providing incentives for uptake and incorporation of the CD standards in radiology accreditation are being explored. A consultation process with the procedural specialists and GPs and AMA is needed to investigate the other known barriers to electronic imaging uptake and the technical needs for systems (hardware and software) for those receiving electronic DI images. The RANZCR in QUDI project (QS07.ii) has outlined the technical requirements for equipment for viewing digital imaging. CD technology is an interim phase in image delivery and storage and this issues needs to be looked at in a wider context of internet based proprietary and open approaches.8Long term access to images and reportsThere are anecdotal reports of problems which relate to long term storage and access to images. There are a range of issues which need further exploration. These include: How long should images be stored? How should they be stored? Who should store them? Cost and benefits? How can access be facilitated? IHE have developed an open standard profile for this (XDS-Imaging which is being adopted initially in Canada and France) based on and extension of the XDS profile. Long term access to reports was one of the hoped for outcomes of HealthConnect, however the likelihood of a government funded shared EHR systems has faded considerably (despite the pilots that have continued). IHE have a working open standards solution (XDS) which allows for sharing of reports (either independently or along with images)9High Bandwidth accessIt is accepted that high bandwidth access to the internet is a requirement to support both internal movement of data within DI practices and to delivery access to images externally. The AMA has endorsed the need for improved bandwidth. A proposal for a DI industry wide collaboration to aggregate demand and create standards of service was unsuccessful in the MNH grant process. This is an area of high priority.10Supporting and managing the change from film to digitalIn order to achieve the business and health outcome gains anticipated and to identify unexpected adverse consequences a process is needed to assist DI services manage the change. This has to happen internally and externally (involving referrers as been seen with the CD problem). As yet no formal progress has occurred on this issue, yet as we have seen with the CD issue, change management is equally as important as technical innovation and solutions.11Improving the effectiveness and volume of DI orderingQUDI project (QR03.i) investigated issues involved in test ordering and the application of decision support. Other QUDI projects have looked at the issue of demand (ES02) and consumer issues (CS04). Some of the QUDI /NICS research fellows have looked at clinical pathways and evidence based practice in radiology ordering. Work overseas on IT systems to integrate clinical data with DI requests thus supporting a process of order critiquing is being monitored. 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