The Operating Room and the need for an IT Infrastructure and Standards Heinz U. Lemke, PhD Research...

The Operating Room and the need for an IT Infrastructure and Standards

Heinz U. Lemke, PhD

Research Professor of Radiology

University of Southern California, Los Angeles, USA

Senior Advisor for Research Strategies

Innovation Center Computer Assisted Surgery

University of Leipzig, Germany

IGT WorkshopRockville, MD, 20th September 2006

Content

1. Motivation, interfaces, workflow and standards

2. Interfacing examples

3. Patient model-guided therapy and DICOM in Surgery

IT Model-Centric World View Interventional Cockpit/SAS modules

Modelling

Models(Simulated Objects)

© H.U. Lemke, August 2006

Therapy Imaging and Model Management System (TIMMS)ICT infrastructure (based on DICOM-X) for data, image, model and tool communication for patient model-guided therapy

SimulationKernel for

WF and K+DManagement

VisualisationRep. Manager

Intervention Validation

Repo-sitory

EngineData Exch.

Control

IO Imagingand

Biosensors

Imagesand

signals

Modellingtools

Computingtools

WF and K+Dtools

Rep.tools

Devices/Mechatr.

tools

Validationtools

WF`s, EBM, ”cases”

Data andinformation

Models and intervention records

Therapy Imaging and Model Management System (TIMMS)

Workplace in a cardiac surgery OR with several monitors that can be seenfrom various positions.

Standards for Medical Technology

Source: K. Radermacher, RWTH Aachen

n

Presentation ofGrouped ProceduresSubset a single acquisition

10 IHE Integration Profiles

Patient Information

ReconciliationUnknown

patients and unscheduled

orders

ConsistentPresentation of

ImagesHardcopy and

softcopy grayscale and

presentation state

Access toRadiology

InformationConsistentaccess to

images andreports

Key ImageNotes

Exchange flaggingsignificant images

Simple Image andNumeric Reports

Exchange simplereports with image

links and, optionally,measurements

Scheduled WorkflowAdmit, order, schedule, acquire images, notify of completed steps

Postprocessing Work Flow

Schedule, perform,notify image processing

& CAD steps

Basic Security

Audid Trail Consolidation& Node Authentication

Charge Posting

Collection of billableprocedure details

imagesstored

patientinformation

RIS

examination orders

imagesretrieved

HIS

PACS

procedurescheduled

Prefetch any relevantprior studies

modalityworklist

report

report

Scheduled Workflow Profile

Registration

Orders Placed

Orders Filled

Film

FilmFolder

Image Manager& Archive

FilmLightbox

report ReportRepository

DiagnosticWorkstation

Modality

acquisitionacquisitionin-progressin-progressacquisitioncompleted

acquisitioncompleted

imagesprinted

AcquisitionModality

WG 24 “DICOM in Surgery“ Project Groups

• PG1 WF/MI Neurosurgery • PG2 WF/MI ENT and CMF Surgery• PG3 WF/MI Orthopaedic Surgery• PG4 WF/MI Cardiovascular Surgery• PG5 WF/MI Thoraco-abdominal Surgery• PG6 WF/MI Interventional Radiology• PG7 WF/MI Anaesthesia• PG8 S-PACS Functions• PG9 WFMS Tools• PG10 Image Processing and Display• PG11 Ultrasound in Surgery

End of operative

phase

Result Processing of instantaneous

section

Neck dissection

Disinfection of the neck

Aseptic dressing

Prepare for contralateral

neck dissection

Induction of narcosis

Suturation

Transfer to pathology

Lymph Node

Biopsy

Classification with TNM

Remove skin graft

Aseptic dressing

Marking on forearm

skin

Disinfection of skin

Team waits for skin graft from abdominal wall

Skin graft into resection situ

Suturation

Remove skin graft

Disinfection of abdominal

skin

Aseptic dressing

Vessel anastomosis

Suturation using OP-

microscope

End of narcosis and

transfer

End of neck dissection

Bilateral neck dis complet

e

End of operative phase (surgery)

Transplantation of skin graft

onto forearm

yes

no

Start of operating

phase

Resection of tumor and

staging

Start of operating

phase (surgery)

Partial and condensed workflow of “Resection of Tonsillar Carcinoma”

DICOM Workgroup 24

Workflow for Ablation Procedure

DICOM Workgroup 24

DICOM Workgroup 24

Pre-procedure Planning

1. Basic Imaging (Image-centric)

a. Pre-procedure evaluationi. Review of previous imaging studies

b. Post-Procedure i. Review of the performed Interventional Procedure ii. Follow-up to evaluate the outcome of the procedure

2. Real-Time Imaging (Image-centric)

a. Intra-procedural Imaging

3. Pre-Procedural and Intra-Procedural image manipulation (Model-centric)

a. In the case of tumor biopsy or ablation:i. Localization – evaluation of location and characteristics of pathologyii. Targeting – plan and determine access and trajectory of needles/probesiii. Image guidance – final plans and measurements for probe placementiv. Navigation v. Monitoring

4. Physiologic Monitoring (Model-centric)

Functional Categories

Table 1

IOD Related IOD FunctionalCategories

COMPUTED RADIOGRAPHY IMAGE 1

COMPUTED TOMOGRAPHY IMAGE 1,2 3

ENHANCED COMPUTED TOMOGRAPHY

1,2 3

MAGNETIC RESONANCE IMAGE 1,2 3

ENHANCED MR 1,2 3

MR Spectroscopy 1,2 3

NUCLEAR MEDICINE IMAGE

ULTRASOUND IMAGE 1,2 3

ULTRASOUND MULTI-FRAME IMAGE

1,2 3

Ultrasound (IVUS) 2,3

DIGITAL X-RAY IMAGE 1

Overlay Plane Module 3

POSITRON EMISSION TOMOGRAPHY IMAGE

1

STANDALONE PET CURVE 1

ENHANCED XA [X-RAY ANGIOGRAPHIC] IMAGE

2,3

ENHANCED XRF [X-RAY RF] IMAGE 2,3

Content




SOMIT Project: Minimal Invasive Orthopaedic Surgery

Project timing: 2005 – 2010

Partner institutions:25

Grant volume:12,5 Mio €

Integrated Workstation

– Integrated and consistent

user interface

– Context specific dialogue

and coordinated system

access

– Modular design with

standardised interfaces


State of the Art


OrthoMIT, Concept of an Integrated Workstation

• Modular Design („Plug and Play“)• Open standard and inclusion of present standards

(DICOM, HL7, future S-DICOM)• Different integrations levels• Usability of devices integrated as well as stand-

alone• Communication between devices (bus system,…)• Workflow-management• Integration of standard conforming modules without

renewed safety tests (MPG, etc.)


OR Integration:Dräger

SiemensStorz

Intraoperative Imagingand Navigation

OR ITIntegration

PreoperativePlanning

Postoperative Monitoring, e.g.. MRI

MIC

-CO

NT

RO

LM

IC-C

ON

TR

OL

SY

ST

EM

-IT

SY

ST

EM

-IT

Anesthesia Surgery

CO

CK

PIT

-IT

CO

CK

PIT

-IT

Cockpit

Projekt: Integration

Integration of Planning, Imaging, Navigation and Treatment

Source: C. Bulitta, SIEMENS

Integration-server

Pre-/intraop. Imaging

Link H-IT

Applications(Endonavigation)

Backend - Integration

Therapy-Planning

KARL STORZ

SIEMENS

Dräger

Frontend-Integration

Flatscreen Touchscreen

Technology-Integration: OR-Cockpit / OR-Anaesthesia

Themes, e.g. :

• Visualisation

• Device-Control

• Context Information

• RFID triggert Events

• Application specifice Data- and Event- Synchronisation (Workflow-controlled)


Concept of levels

1) Consolidation of frontend-exchange or integration on screenlevel

2) Data exchange via existing interfaces and ESB integration via inubit IS.

3) Connecting to external systems (HIS etc.).

4) Frontend integration via portlets (patient-oriented/ case oriented optimised visualisation).


System 2

System 3 System N

Frontend-1(KVM switch/RDP)

System 1

Frontend-2(anesthesia cockpit)

Frontend-3(surgery cockpit)

Frontend-4(image viewer)

Enterprise Service Bus

web-serviceenabled

conncector

HIS


Content




Archive

Modalities(X-ray,

CT, US, MR,SPECT, PET)

Images

(CAD etc.)

AcquisitionParameters

Identification(name, SS #, exam code,

date, …)

DICOM DICOM

Diagnostic Image-Centric World View

PACS

Biosensors (physiology, metabolism,

serum, tissue, …)

Omics EMRModalities

(X-ray,CT, US, MR,SPECT,

PET,OI)

Model-Centric World View

Integrated Patient Care

EBMWorkflow IHE

Image-Centric World View

Integration and Diagnosis

(Data fusion, CAD, …)

Modelling andIntervention(Simulation,

decision support,validation, …)

Data bases (Atlas, P2P repositories,data grids, ...)

Mechatronics(Navigation,ablation, …)

H. U. Lemke, CARS 2006

Future-PACS based on DICOM-X


Modelling








Repo-sitory

EngineData Exch.

Control

IO Imagingand

Biosensors

Imagesand

signals

Modellingtools

Computingtools

WF and K+Dtools

Rep.tools

Devices/Mechatr.

tools

Validationtools


Data andinformation



DICOM RT ModulesPS 3.3-2006 Annex A, Composite IOD

• RT Dose• ROI Contour• Structure Set• RT General Treatment Record• RT General Plan• RT Tolerance Tables• RT Brachy Application Setups

• …

Generic and patient specific modelling tools

• Geometric modelling• Prosthesis modelling• Properties of cells and tissue• Segmentation and reconstruction• Biomechanics and damage• Tissue growth• Tissue shift• Properties of biomaterials

Modellingtools


• Atlas-based anatomic modelling• FEM of medical devices and anatomic tissue• Collision response strategies for constraint

deformable objects• Variety of virtual human models• Lifelike physiology and anatomy• Fabrication model for custom prosthesis• Template modelling

Modellingtools


• Animated models• Multi-scale modelling (BC)• Fusion/integration of data/images• Registration between different models incl.

Patient, equipment and OR• Modelling of the biologic continuum• Modelling of workflows• …

Modellingtools

Some steps towards a surgical DICOM

• IOD surface mesh• ...

Michael Gessat, Oliver BurgertICCAS, Leipzig

ICCAS Project timing: 2005 – 2010

Grant volume:8,5 Mio €

Surgical DICOM Model of the real world (exemplary, incomplete…)

Patient

makes

Visit

includes

Study

Comprised of

Modality performed procedure steps

includes contains

Series

creates

Equipment

defines

Frame of Reference

has

Repository

Data Library

contains

creates

Someone…

Is subject of

Intervention

Plan

Physician

Diagnosis

Report

references

conducts

defines

prepares

Bases on / uses / contains

Image

contains

makes

Waveform

Image Processing

Tools

Ontologies

Workflow

Workflow DiagnosisTools

Navigation …

Information Model for Surgical DICOM

• ER-Diagram shows the complexity of the surgical environment

• Multiple objects from different origins act together in contexts given by patients, interventions… (the column-like World Model has turned into a web of entities)

• Representation of all necessary meta data with each frame is no longer feasible (Overhead!)

• Normative IODs reflecting patient, study, series, repository,… will be necessary Patient Model

• Organization of data will become a primary task

IODs for Surgical DICOM

Actual DICOM

Presentation StateRegistration RT Conf. Mgmt

SegmentationVisible LightHanging Protocols Images, WF…

Navigation

Augmented RealityVideo based Nav.

Simulation

Geometric Models

Manipulator

Patient Model

Ontologies

Library, Repository

Workflows

UPnP

Img. Processing

Intervention

IOD Entity-Relationship Model Patient

Is the subject of

1

Study

contains

1

1…n

contains

1

Registration

Frame of reference

1…n

0…1

Series

0…n

Presentation StateFiducials Image

0…n

Waveform Surface Mesh

defines

0…n

creates

Equipment

0…n

Algorithm

Surface Mesh Presentation State

spatially or temporarily

defines

0…n

uses0…n

0…n

Informatic Portals for Data Mining

Data Repositories

Repository of workflow

reference models (WFs, SIPs)

for medical techniques,

operating instructions,

etc.

Generic models and

patient-spec. modelsetc.

Peer Expert I

Peer Expert II

Peer Expert III

Peer Expert IV

Reference expert knowledge

P2P „Best Practice“ Workflow Repository

WF graph

WF

grap

h

Data Grid

• Provide a distributed fault-tolerant data services for large data, eg, TeraGrid (100 GB ~ 10 TB)

• Data services include storage, share, distribution, and metadata management.

• IPI (USC) Data Grid: an integration of DICOM information object model with general data services for clinical image applications.

IPI SAN

DICOMData Grid

P2 P2

SJHC PACSServer

SJHCPACS WS

SJHC SAN

P1

SJHC

HCC2 PACSServer

HCC2PACS WS

HCC2 SAN

P1

HCC2

IPIPACSSimulator

IPI Data Grid for PACS Image Data Backup: The DICOM Data GRID

Methods for HIPAA Security in PACS

• To make current PACS HIPAA compliant in Access Control, Audit Control, and Integrity.

• IPI has developed:– HIPAA compliant auditing system (HCAS) for

Audit Control– Location Tracking and Verification System (LTVS)

for Access Control– Lossless Digital Signature Embedding (LDSE)

method for Image Integrity assurance

Conclusion1. S-WF definitions (on an appropriate granulation level)

and visualizations allow surgeons, interventionists and associated disciplines to better understand IT requirements for information guided intervention (IGI)

2. Selected S-WFs defined by some standard method may be entered into a repository, providing a reference base for the development of an

IT infrastructure such as a TIMMS



Modelling








Repo-sitory

EngineData Exch.

Control

IO Imagingand

Biosensors

Imagesand

signals

Modellingtools

Computingtools

WF and K+Dtools

Rep.tools

Devices/Mechatr.

tools

Validationtools


Data andinformation



Conclusion


3. Derive S-DICOM services and IOD`s from TIMMS functionalities

WG 24 “DICOM in Surgery“ Project Groups

• PG1 WF/MI Neurosurgery • PG2 WF/MI ENT and CMF Surgery• PG3 WF/MI Orthopaedic Surgery• PG4 WF/MI Cardiovascular Surgery• PG5 WF/MI Thoraco-abdominal Surgery• PG6 WF/MI Interventional Radiology• PG7 WF/MI Anaesthesia• PG8 S-PACS Functions• PG9 WFMS Tools• PG10 Image Processing and Display• PG11 Ultrasound in Surgery

WG24 “DICOM in Surgery”

Secretariat: Howard Clark, NEMA

Secretary: Franziska Schweikert, CARS/CURAC Office [email protected]

General Chair: Heinz U. Lemke, ISCAS, GermanyCo-Chair: Ferenc Jolesz, Harvard Medical School, Boston

(Surgery/Radiology)

Co-Chair: tbd (Industry)

S-DICOM Cooperation Partners

• CARS Institute/Foundation• SPIE• University of Geneva• ICCAS, University of Leipzig (ENT, Cardio, Neuro)• Technical University of Berlin (CG and CAM)• University of Southern California (IPI)• University of Rennes• Japan Institute of CARS• Industry (Agfa, Siemens, Philips, ...)• CURAC (AG S-WF and S-PACS)• University of Pisa, EndoCAS• The Interventional Centre, Oslo• Georgetown University, Washington• University of Chicago• ISCAS• …

(a) What do you believe are three important challenges

facing the engineering of IGT systems:

1. Development of appropriate standards for interfacing software engines and repositories in IGI.

2. To specify and design an IGT system based on best practice surgical workflows.

3. To complement the paradigm of Image Guided Therapy (IGT) with Model Guided Therapy (MGT) and to proceed towards Information Guided Intervention (IGI).


(b) How do you think that we at NCIGT (National

Center for Image-Guided Therapy) can help address these challenges

1. To participate in DICOM Working Group 24 "DICOM in Surgery".

2. To participate in building a repository of a representative set of best practice surgical workflows.

3. To participate in raising awareness of information guided intervention (IGI) through workshops, think tanks, etc.


CARS / SPIE 7th Joint Workshop onSurgical PACS and the DOR

Berlin, 30 June, 2007

9th Meeting of the DICOM Working Group WG 24 “DICOM in Surgery“

30 June 2007

CARS 2007 Computer Assisted Radiology and Surgery

The Operating Room and the need for an IT Infrastructure and Standards Heinz U. Lemke, PhD Research...

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