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Meet the Group Striving for Seamless Clinical Workflows

October 09, 2015

Sun Nuclear Staff

In today's clinic, you'd expect all your systems—imaging, treatment planning systems (TPS), treatment management systems (TMS), and so on to easily transfer and accept data within the clinical workflow. A little more than a decade ago, this was not a given.

"You could run into situations where you had a CT scan, and the data wouldn't import into the treatment planning system, or there would be details missing. It wasn't always certain that a particular system would work with another," explained University of Michigan Assistant Professor Scott Hadley, Ph.D.

The cause of this problem was often how different vendors implemented the DICOM data standard. Some data elements within DICOM, such as the color of a particular structure on a CT set, could vary from one system to the next.

"Clinical software systems may follow the same standard, but in the end, what we want is interoperability. To accomplish that, we've been coordinating how those standards are used," said Walter Bosch, D.Sc, Associate Professor at Washington University.

Dr. Bosch and Dr. Hadley are part of IHE-RO—Integrating Healthcare Enterprise in Radiation Oncology, which is sponsored by ASTRO. IHE-RO is a domain of IHE, International, a non-profit organization that coordinates how DICOM and HL7 data standards are used in software systems.

IHE-RO has facilitated a lot of progress in interoperability within Radiation Oncology. But their efforts continue, most recently, with their Fall Connectathon hosted at the Sun Nuclear Training Center in Melbourne, Florida.

IHE-RO Connectathon—Where the Rubber Meets the Road

Anyone can submit to IHE-RO a clinical scenario where there is an interoperability problem. Committees within IHE-RO prioritize these cases, and then create profiles for each case. The profiles spell out additional DICOM constraints that vendors have to follow to ensure everyone uses the data standard in the same way.

At the Connectathon, vendors can test whether their system actually adheres to the appropriate profile. Representatives from the participating companies gather in the same room, and run head-to-head tests with each other's systems, all the while supervised by a judge from IHE-RO.

"The Connectathon is really where the rubber hits the road," said Hadley. "If a vendor finds that they cannot read a plan from a different planning system, they can work side by side with the other vendor to troubleshoot the issue."

To demonstrate complete adherence to a profile, a vendor must produce plans that can be read by systems from three other vendors, or consume three plans from different vendors. It's a way for vendors to set aside concerns about competition, and efficiently improve the connectivity of their products. "It's a very collegial environment with excellent working relationships and mutual respect," adds Bosch.

Interoperability—The Unsung "Hero"

The first IHE-RO profile was the Basic RT Objects Profile. It constrained the use of DICOM objects in the basic radiotherapy workflow, from scanning the patient, to contouring and planning. They also created profiles that allowed a treatment plan from one TPS to be interpreted the same way by a different TPS.

They have developed more than 20 profiles to date, covering basic and advanced radiotherapy, image registration, and multimodality workflows. Vendors continue to adhere to most of these profiles today.

"The vendors, to their credit, have done a lot of work to fix all of those issues and use DICOM standards in a reliable way," said Dr. Hadley. "Now, for the most part, when you import a plan into a TMS, the image guidance works, the monitor units are correct and all the correct tags are in there."

Since interoperability isn't as widespread an issue, IHE-RO isn't as recognizable as it could be. Still, their work continues. As new DICOM standards are created, IHE-RO updates interoperability specifications. They are also working on new profiles like one that allows prescriptions created in one system to be seamlessly transferred to another, and edited in a TPS.

IHE-RO Impact Spans Different Domains.

Efficiency in the clinic: If there is an interoperability problem, it typically falls to the physicist to research a solution, manually correct inconsistencies, or implement other time-consuming work-arounds.

"We used to do a lot of testing to make sure that the data was going in correctly in the treatment management system," said Dr. Hadley. "And it used to be you'd have to import a plan, then import the DRRs, then attach the DRRs to the plan, and now it's much more integrated."

Patient safety: Much of the work IHE-RO does is to ensure a plan is interpreted the same way by both the system that produced it, and by different system receiving the plan. If the plan is interpreted differently, there could be serious implications for patient safety.

Take MRI scans of the brain for example, the fact that there's no way to just look at it and tell which side is left or right means a clinician would have to rely on a system labeling the image. IHE-RO's work ensures the left side of the brain MRI is still labeled as the left side when that DICOM data is transferred into the TMS.

Radiotherapy research: The most important and most ambitious research projects requires you to accumulate a lot of data, typically from various facilities all using systems from different vendors. Of course these plans, images, and doses all have to be interpreted and analyzed in a common framework. It's a scenario with which Dr. Bosch is all too familiar.

"My responsibility is in collecting data for clinical trials, so that involves collecting a broad spectrum of data from different environments. We collected data from over 700 different hospitals for the last 10 to 15 years. Doing this a decade ago, you would lose your hair," said Dr. Bosch. Today, if researchers are losing hair, it's most likely for a different reason. With interoperability in place, when the data comes in to the researcher, they have enough information to do their work.

"Standardization is now firmly embedded in clinical software," said Dr. Bosch. "The number of complaints, I think, have been reduced, and the frustration level in a number of clinics has been reduced. But still, it's not quite plug and play, and that's why there's still reason for us to be here."

IHE-RO would like to hear from clinicians about what your integration needs are. You can use the ASTRO website to submit your ideas:

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