Integrating the Healthcare Enterprise

IHE Radiology

Template Questionnaire for the

Cross-Enterprise Screening Mammography Workflow Definition

Date:	February, 2012

Authors:	Francesca Vanzo, Arianna Cocchiglia

Email:	fvanzo@consorzioarsenal.it, acocchiglia@consorzioarsenal.it

Introduction

This White Paper arises from the necessity to manage the process of breast screening and its distributed management across different sites of care. It provides a more general approach which allows to integrate the Radiology mammography exam in a complex scenarios and to manage the breast screening workflow.

The value statements of the Cross-Enterprise Screening Mammography Workflow Definition are the standardization of one, or more, workflow management processes as well as the associated workflow tracking structure linked with the clinical process of the breast screening and the creation of an instrument able to respond at the present needs and possibly to extend to future requirements.

The White Paper describes the orchestration of the screening workflow across different sites of care in order to allows the workflow participants to share a common understanding of the specific tasks, the dependencies between these tasks and a number of rules to effectively manage the workflow execution and leads the interoperability between different information systems.

All the details of the process differ among worldwide service programs. This document provides a template and a questionnaire, which will be used to analyse how breast screening is performed in different regions/healthcare systems. Each point in the questionnaire is related to the main sequences of the workflow and each information requested is necessary to determine, for example, whether a woman is eligible to participate in the program.

The main themes are:

General workflow

Facility/organizational descriptions

Recruitment

Admission/Examinations

Reporting

Report/s evaluation

Each of the following section is further divided or characterized by the particular attributes and features by which all workflow sequence accomplishes its function in the screening program.

Request for feedback

In order to match and to provide a reliably representation on most of breast or only mammography screening programs, please fill and submit this module to fvanzo@consorzioarsenal.it.

Definitions

Any comment or different use of the definitions can be added in the right column.

Table of Acronyms

Acronyms (to be completed)
CAD	Computer Aided Detection
CS	Central Information System
LHA	Local Health Authority
PACS	Picture Archiving and Communication System
RIS	Radiology Information System
XDS	Cross-Enterprise Document Sharing
XSM-WD	Cross-Enterprise Screening Mammography - Workflow Definition

General information about IHE can be found at: www.ihe.net

Information about the IHE Radiology may be found at: http://www.ihe.net/Domains/index.cfm

Information about the structure of IHE Technical Frameworks and Supplements can be found at: http://www.ihe.net/About/process.cfm and http://www.ihe.net/profiles/index.cfm

The current version of the IHE Technical Framework can be found at: http://www.ihe.net/Technical_Framework/index.cfm

General Information

In this section, the questionnaire focuses on the organization responsible for the management of the breast/mammography screening program and baseline recommendations.

Table 1.1 General Information

Institution Information
Institution/Organization

Name of the institution/organization
Country/City/Area
Name of the program(s)
Number of Screening Units

Number of modalities per unit

Population involved per year
Mean number of women, screened by a single Screening Unit in the previous year
Hospital / delivered services	Hospital

Mobile services (van,...)
Extension of the program	1 Hospital

>1 Hospitals in the same LHA

>1 Hospitals in different LHAs

Regional

National

Organizations:

Mobile services

Other:
Guidelines	National Guidelines
International Guidelines
Organization Guidelines and recommendations

Workflow diagram

<In order to provide a simple layout of a screening program, the following workflow is shown in the figure below. In this section we are asking you to please share your workflow, explaining crucial steps or other features that fit your region/nation or/and organization needs.>

Example: The italian use case is represented by the following simplified diagram. Some steps may vary among italian regions according to each local asset.

Figure 1.1 Italian Use Case Diagram

<Please write your workflow description filling the section below and please send your workflow picture of the basic screening service to: fvanzo@consorzioarsenal.it>

In case of multiple workflows please specify the sequence characteristics and differences.

Actors and transactions

<Please describe each actor (systems, people,...) in your diagram as well as the kind of actions occur between each actor and contextualize it in the workflow.>

Further information

<Please write here any further information you would like to provide in support of the analysis.>

Focus on the program sequence

In order to delve into the analysis of the workflow please fill the tables on the recruitment, admission, acquisition, reporting, report/s evaluation.

Recruitment

<A short description on how ‘Recruitment’ is performed >

Use Case

Actors

<List people and systems involved in this use case, indicate also where they are located>

Pre Condition

<Describe whether there are some pre-requisites that need to be fulfilled before this use case can start>

Main Flow

<List all steps that occur during normal workflow and provide the descriptions of the documents exchanged between each systems and people>

Alternate Flow

<List exception scenarios and describe workflow in this case>

Post Condition

<Describe outcome of this use case (documents, results, statistics ...)>

Additional Information

The eligibility criteria in the breast/mammography screening are different among different programs: parameters and approaches and the following table summarizes them.

Table 2.1 Recruitment Information

Recruitment information
Eligibility parameters and target population

Range of age (normal / other cathegories)	Normal: to years old

Other: to years old
Other parameters
Other parameters
Other parameters
Do all the Screening Units follow these criteria in the same way?	Yes

No:

Basic screening parameters	Frequency (normal cases)
Frequency (high risk categories or others)
High risk classification (genetics, previous cancer episodes)
Further information
Organizative features	How is the screening campain for the occasional recruitment organized? (brochures, television ads, commercials)

Who is responsible for the occasional recruitment?

Please describe how the appointments are scheduled.	Brochures, Posters,...

Television Ads

Other:

Responsible for occasional recruitment:

Scheduling process:
How is the organized screening recruitment planned? (letters: pre-scheduled appointment and/or a contact number, calls)

Who is responsible for the organized recruitment?	Letters with contact number

Letters with pre-scheduled appointment

Telephone calls

Responsible for organized recruitment:

Scheduling process:

What are, respectively, the percentages for the occasional and organized recruitment?	Occasional recruitment: %

Organized recruitment: %
Has the screening service a Central Information System or other solutions to supervise and/or manage the screening? (what parameters does it collect?)	Central Information System

Functions and parameters collected:
Are there different enterprises (or other) involved in the screening program?	Centralized programs

Decentralizated programs

Other:

If there are more enterprises what are the percentages of the centralized and decentralized settings?	Centralized programs: %. Further information:

Decentralizated programs: %

Further information:
Focus on the organized recruitment	Is the recruitment based on a population registry (anagraphycal system)? Are there other solutions?	Population Registry

General anagraphycal system

Other solution:
Does the institution/organization use a software to generate the list for the screening?

Is the list subdivided into other lists and provided to the Screening Unit?

Please describe the kind of communication (xml trace,...) and how the items are managed for the scheduling of the appointment

How are the patient identified in the screening process,e.g. creation of a unique screening ID?	Automatic list generation

Partitioning of the list

Each Screening Unit creates its screening list

Type of the communication of the list:

Description of the appointment scheduling (with and/or without RIS):

Patient identification:
Is the RIS worklist agenda automatically synchronized with the planning system of the screening? (if they are distinct)

How does it work? (kind of integration and format of messages,…)	The CS schedules the appointments in a screening planning system

The CS schedules the appointments in the RIS

Other:
<Please provide any further information on this topic to support of the analysis>

Admission

<A short description on how ‘Admission’ is performed>

Use Case

Actors

<List people and systems involved in this use case, indicate also where they are located>

Pre Condition

<Describe whether there are some pre-requisites that need to be fulfilled before this use case can start>

Main Flow

<List all steps that occur during normal workflow and provide the descriptions of the documents exchanged between each systems and people>

Alternate Flow

<List exception scenarios and describe workflow in this case>

Post Conditiom

<Describe outcome of this use case (documents, results, statistics ...)>

Additional Information

This step gathers the actual patient admission and the mammography examination (and/or other breast examinations).

Table 2.2 Admission Information

Admission information
Agenda

How are the worklist ruled/ composed/scheduled? (who and how: items entered manually,...)
When changes occur on an exam (time of the visit, acquisition modality), is it possible to update the exam data without creating a new “access number”?
Are there any other examinations planned for the screening? If so, which are they and how are these scheduled?
Are you equipped with a special screening RIS?
Other information	Is the patient asked to fill out a form in order to estimate risk for developing invasive breast cancer over her lifetime?	Questionnaire

Interview

Who and when ask the patient to ask the questions:

<Please provide any further information on this topic to support of the analysis>

Exam

<A short description on how the exam is performed>

Use Case

Actors

<List people and systems involved in this use case, indicate also where they are located>

Pre Condition

<Describe whether there are some pre-requisites that need to be fulfilled before this use case can start>

Main Flow

<List all steps that occur during normal workflow and provide the descriptions of the documents exchanged between each systems and people>

Alternate Flow

<List exception scenarios and describe workflow in this case>

Post Condition

<Describe outcome of this use case (documents, results, statistics ...)>

Additional Information

This step gathers information relevant to image acquisition and further examination (and/or other breast examinations).

Table 2.3 Examinations Information

Examination information
Image acquisition

Are there any specifics about the mammography (and other) image acquisition in the screening context? (legal/policy requirements)

Are prior images needed before taking new images?
Are there other categories of examinations in addition to the mammography (please provide a description) (nurse examination, Ultrasound, MR, technicians descriptive informations...)?

When, how are they scheduled/performed? Where and when are they submitted? (central Repository, paper,...)	MR

Submitted to/when:

Nurse examinations

Submitted to/when:

Case study information (anamnestic documents)

Submitted to/when:

Other:

Submitted to/when:
How is the recall for the repetition of mammograms or other examinations managed? (wrong projections,…)

How are these situations managed the following cases?

In case the woman is still available…

In case the woman is already gone...

Woman available for the repetition:

Woman already get out:
Describe mammography-specific exceptions (e.g. : wrong image labeling)
Other information	For each further examinations pointed out in the previous questions, please explain: how are they handled? (Please specify each type in the spaces)	Printed for the reporting:

Stored in a Repository:

Other:
Images Storage	Where are the images stored?	Separate screening PACS

PACS

XDS Repository

Other
Are the images stored automatically?
Is there a need for additional medical information to be stored such as Dose Report?

<Please provide any further information on this topic to support of the analysis>

Reporting

<A short description on how reporting is performed>

Use Case

Actors

<List people and systems involved in this use case, indicate also where they are located>

Pre Condition

<Describe whether there are some pre-requisites that need to be fulfilled before this use case can start>

Main Flow

<List all steps that occur during normal workflow and provide the descriptions of the documents exchanged between each systems and people>

Alternate Flow

<List exception scenarios and describe workflow in this case>

Post Condition

<Describe outcome of this use case (documents, results, statistics ...)>

Additional information

The reporting task could be managed with double blind reading or other methodologies. Please fill the table with your procedure.

Table 2.4 Reporting Information

Reporting information
General process	How are the screening applications handled? (integration with the RIS, manual entering of results, pre-compiled schemas,…)

Is reporting performed at the same facility as the image acquisition?

Describe management of reporting worklist?
Images reading

Presence of a PACS/workstation for the interpretation of the images and integration with the RIS	PACS stand alone

Standalone workstation

RIS/PACS

Other:
How is the reading chain organized? (single, double reading) and how is it handled?
Is there any diagnosis tool (CAD, …)?

Is one or more reports driven by the answer of it or does it represent the (first/second/third) report?	Presence of CAD

Other System

The CAD (or the system) submit a report. Description of the report:

The result or the report is submitted to:

The CAD/System report is considered as a second reading

The CAD/System report is considered as a third reading

The CAD/System report is considered as:
Are there any other steps in your program? (ask for further mammograms,…)
Are pior examinations available?

Which systems store the information about priors?	Central system

RIS/PACS

Other:
What are subsequent steps if double reading is performed and there is not the consensus between the two reports?
What happens if abnormalities are identified?
Radiologist recommendations	What is the level of expertise of the mammography radiologist who will interpret the images? (n. of mammograms readings per year, supervisor presence,…)
Report	What is/are the format/s of the report? (DICOM SR Template 4200 “Breast Imaging Report” modifications, legacy solutions)
Are key-images (or screenshots,...) of annotated images added to the report?
Digital signature:

What kind of digital signature is/are used in screening reports? (How is it managed in case of more type of reporting? Or more reports?)	p7m

pdf

XML Enveloped

XML Enveloping

XML Detached : One or more files?

None
Double or more reading case: Does the RIS (or other system) allow the single- report signature? In other words: if there are two reports, each report has the digital signature of the first and second radiologist respectively or, for instance, the last radiologist in charge signes an unique report?
Is there a system in charge to collect the boolean results of the reports?

How does it work in terms of input information to compute the result and how does it provide the answer?
How is the submission of the radiologist or CAD/System report(s) handled?	Repository

XDS Repository

Paper

Other:

Are there cases where the CAD/System report is digitally signed?
<Please provide any further information on this topic to support of the analysis>

Report/s evaluation

<A short description on how reporting is performed>

Use Case

Actors

<List people and systems involved in this use case, indicate also where they are located>

Pre Condition

<Describe whether there are some pre-requisites that need to be fulfilled before this use case can start>

Main Flow

<List all steps that occur during normal workflow and provide the descriptions of the documents exchanged between each systems and people>

Alternate Flow

<List exception scenarios and describe workflow in this case>

Post Condition

<Describe outcome of this use case (documents, results, statistics ...)>

Additional information

Since the report more reports are submitted they are evaluated for the next actions to be taken in the screening workflow.

Table 2.5 Evaluation Information

Evaluation information
Results evaluation	Is there a central system in charge to classify the next step in the workflow or are further actions triggered manually? (How does it work and what parameters rules the decision making process?)	Information System Trigger

Manual Trigger

Other:
Double reading: discurdant results	Are there implementations with “consensus conference” instead of another reports (third reader)? How is the last report/decision managed? (request for another report, submission of a third report)	Consensus Conference

Third Reading

Further information:
Communication of the result to the patient	Who is in charge to communicate the results and other information to the patient and how? (letter, call,...)	Negative result: Letter

Negative result: Call

Positive result: Letter

Positive result: Call

Time constraints	Does the letter needs to be sent out within a specific time frame?
Notify other	Is there a notifications management? ( to the national cancer registry)

How is it performed? (special functions of the reporting system, other applications,...)

<Please provide any further information on this topic to support of the analysis>

Inizio modulo

Fine modulo

IHE Radiology Template Questionnaire	XSM WD - Questionnaire

1

__________________________________________________________________________

13

<Rev. 10.00 - 2012-02-03>	Copyright © 2012: IHE International, Inc.

Copyright © 2012: IHE International, Inc.

White Paper XSM-WD Questionnaire

Francesca Vanzo

2012-02-03

Consorzio Arsenàl.IT