The IHE demonstrations: Carving healthcare's Rosetta stone

Using the polyglot of digital medical data to maximum patient advantage requires a Rosetta stone to integrate various enterprise-wide information systems -- a monumental task that is being addressed by an industry initiative called Integrating the Healthcare Enterprise, or IHE.

The IHE is spurring the information systems industry to devise methods for integrating healthcare's clinical tongues, which until now did not communicate with one another.

To demonstrate that such communication is possible, the RSNA and the Healthcare Information and Management Systems Society (HIMSS) are co-sponsoring a series of IHE showcases at their annual meetings.

At the most recent RSNA and HIMSS gatherings, IHE year-one demonstration proved that 24 vendors (representing 47 separate information and imaging systems) could indeed exchange information in an integrated, open-standards environment, while maintaining the integrity of the data and images exchanged between systems.(See IHE demonstration proves image data can be shared; multivendor exercise not without technical glitches, DI In Review supplement, January 2000)

"The primary accomplishment of year one was getting the process in place," said Christopher Carr, the RSNA's assistant director of informatics. "Representatives from major imaging and information systems vendors sat down and agreed on a framework for implementing established standards, such as DICOM and HL7."

The year-one scope was fairly narrow, focusing on basic registration, scheduling, image acquisition, and storage procedures in the radiology department.

During the demo, four simulated healthcare enterprises, each modeling a different hospital, featured patients with conditions ranging from a torn knee ligament to suspected appendicitis. Within each simulation, spectators were introduced to the patient's ailment and watched information being entered into the hospital's records system, where it became instantly available to the radiology department. There, x-ray, ultrasound, and other images were integrated into the record.

"It's hard to underestimate the importance of the year-one IHE demonstrations," said Dr. R. Gilbert Jost, interim head of the Mallinckrodt Institute in St. Louis, and a member of the RSNA board of directors.

Without this consensus, vendors are forced to develop expensive proprietary interfaces that are often incomplete and must be reconfigured and separately maintained at a customer's site.

"The eventual goal is to provide better methods for computers to interoperate in a vendor-neutral fashion across the entire healthcare enterprise," Jost said.

FIRST-YEAR DEMONSTRATION
Philips Medical Systems attended the IHE year-one demonstration with its PACS and x-ray angio modality. The company's participation allowed it to identify problems in workflow during interactions with clinicians and other vendors, said Kees Smedema, Philips' international manager for interoperability.

"We now have an increasing number of modalities and PACS solutions that comply with IHE year one," he said.

One year-one milestone addressed the perplexing RIS/PACS modality loop.

"That's significant," Carr said. "The standards provide mechanisms for that but actually doing it in a given implementation is a complex process. IHE simplifies it."

The RIS/PACS interface is important, experts say, because the full benefit of the IHE and PACS can be achieved only if the HIS and RIS also comply. In a number of cases, however, radiologists put IHE requirements on the modality vendor but not on their RIS and HIS vendors.

"This is a major problem," Smedema said. "Standards only give benefit if we all use them. Our customers should require the same from their HIS and RIS vendors as they require from modality and PACS vendors."

The IHE addresses integration of systems through messages between the systems, a robust method relying on standards developed primarily for the medical domain.

"This type of integration is necessary, but not sufficient," Smedema said. "Our customers ask for integration of information at their desktop. They want to improve the diagnostic process by having not only images and radiology reports, but also laboratory data and allergy information."

Therefore, he said, the IHE should start to include other standards that were developed for desktop integration, such as XML, a language used in Web-based communication.

"The demonstration itself is only a means, not the goal itself," Smedema said. "IHE currently addresses only the precise definitions related to DICOM and HL7, but this will have to evolve to include other standards."

PLANS FOR YEAR TWO
IHE year two widens the scope, expanding to include 33 vendors representing 74 distinct systems at the RSNA meeting.

New features include mechanisms to deal with a patient who is incompletely identified at the time of registration, access to nonradiology information such as lab values, image consistency across disparate display systems, and structured reporting.

"Year one showed that this process for achieving coordinated integration by a group of vendors could be done," Carr said. "In year two that process is used to make real gains for users in terms of functionalities available in these systems. It advances the state of integration."

Vertically, new transactions and greater detail will be added to the year-one protocols within the radiology unit.

IHE is also considering incorporating "horizontal integration" technologies, fostering linkage between various medical specialists within the enterprise.

Vendors themselves have increased their activities for year two. Agfa, for instance, has expanded its role and is participating in four ways: as an image manager and an order filler with its IMPAX product, a CR modality, and a print server.

"Part of Agfa's goal this year is to actually demonstrate IHE in our booth at RSNA and HIMSS, to show demonstrators what it is that the IHE effort means to customers," said Dean Kaufman, director of strategic marketing for Agfa's IMPAX Solutions. "A lot of customers are asking about IHE and starting to look for evidence of IHE integration and what it means."

Customers seeking IHE benefits in the year-one demonstrations were sometimes disappointed. Last year's goals were presented in more abstract terms and it was a bit more difficult to understand the implication and the effect of IHE on the end user, Kaufman said.

"This year, IHE is bringing us to the next level of interoperability, which is important because last year was just an initial step," he said.

Smedema agreed that the year-one demonstration was too technical.

"Many visitors did not get the message and left wondering what problem was solved," he said.

Other perspectives:

• European radiologists launch integration initiative (DI.com, August 2000):
• The information page for the European IHE
• X-ray vision: IHE initiative could become another Y2K nonevent (DI, August 2000)
• HIMSS and RSNA dress up their joint technology project (DI.com, April 2000)
• Project aims to get PACS and HIS systems talking to each other (DI, May 1999)

RSNA links

The RSNA Web site provides detailed technical information about the IHE and its objectives. You'll need an Acrobat Reader to view many of the files. Here's some of what you'll find:

• Mission statement for the IHE
• Index and opening page. Includes a search mechanism
• A 26-page concept document provides an overview of the project, including objectives, operating structure, technical framework, and timelines
• Vendor rules of participation and commentaries by participating vendors
• A 197-page year-two IHE technical framework document identifies components of the healthcare enterprise and describes, in considerable detail, how they will interact

IHE Year Two demo participants table, RSNA 2000 (Source: the RSNA)

A.L.I. Technologies Inc.

• Ultrasound

ADAC Healthcare Information Systems

• Image Mgr/Archive
• Order Filler
• Order Placer

Agfa Medical Imaging

• CR
• Print Server
• Ultrasound
• Order Filler
• Image Mgr/Archive

Algotec Systems Ltd.

• Image Mgr/Archive
• Image Display

Analogic Corp.

• DR - Mammo

Applicare Medical Imaging B.V.

• Image Mgr/Archive

ATL Ultrasound, a Philips company

• Ultrasound

Binnacle

• Order Filler

Canon Medical Systems

• Image Mgr/Archive
• DR

Cedara Software

• Image Display
• Image Mgr/Archive

CSIST

• Image Mgr/Archive

Direct Radiography Corp., a Hologic company

• CR/DR

Eastman Kodak Co.

• Image Display
• Print Server
• Image Display (DMI)
• Print Server (color)

Emageon

• Image Mgr/Archive

Fujifilm Medical Systems U.S.A. Inc.

• CR

GE Medical Systems

• MR
• Image Display
• CT
• Image Creator/Display

GMD Inc.

• Order Placer

IDX Systems Corp.

• Order Filler
• ADT/Order Placer

Imco Technologies

• Image Mgr/Archive

Konica

• CR
• Print Server

Marconi Medical Systems

• Image Creat/Disp/Print
• MR
• Image Creator/Display
• Nuc Med
• Image Mgr/Archive

medQ Inc.

• Order Filler

Merge Technologies Inc.

• Image Mgr/Archive
• Ultrasound
• Angio

Mitra Imaging Inc.

• Order Filler
• ADT/Order Placer

Philips Medical Systems

• Image Disp/Creator
• MR
• Report Reader
• CT

RASNA Imaging Systems

• Image Mgr/Archive
• Image Display

Siemens Medical Systems

• MR
• CT
• Image Display/Creator
• Image Mgr/Archive

Softmedical

• Image Mgr/Archive
• Order Filler
• External Report Repos

SMS, a Siemens company

• ADT
• ADT

StorCOMM Inc.

• Image Creator/Display
• Image Mgr/Archive

Swissray International Inc.

• CR

Tiani Medgraph GMBH

• Image Mgr/Archive

Vital Images Inc.

• Image Creator/Display