SCHEDULED WORK FLOW

AND PIR

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 SCOPE

• SCHEDULED WORK FLOW PROCESS

• PATIENT INFORMATION RECONCILIATION [PIR]

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 SCHEDULED WORK FLOW PROCESS
• Scheduled Workflow [SWF]
• Terminology
• Value Propositions
• Scheduled Workflow Profile
• CASE: SWF improves efficiency of Modality
• Flow of Information:
Acquisition Modality to Image Manager
• Modality Performed Steps
• List of Images for Performed Procedure
• Modality Without Storage Commitment
• Modality With Storage Commitment
• SWF Concepts in Practice
• Tracking
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PATIENT INFORMATION RECONCILIATION [PIR]
• Introduction
• Unidentified Patient Image Acquisition and Reconciliation
• Handling Unidentified Patients
• Case 1:Unidentified Patient Reg at ADT and Ordered at the Order Placer
• Case 2:Unidentified Patient Reg at ADT and Ordered at DSS/Order Filler
• Case 3:Unidentified Patient Reg at ADT but Completed at Modality Prior
to Order
• Case 4: Unidentified Patient Assigned Temporary Departmental ID and
Scheduled at
• DSS/Order Filler.
• Case 5:Image Acquisition Completed Without Scheduling at Department
System
• Scheduler/Order Filler
• Case 6: Patient Information Reconciliation During Image Acquisition

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 Scheduled Workflow [SWF]

• Considered as ‘Foundation and Backbone’ of IHE

• Integrates Registration, Scheduling, Acquisition Workflow and Image
Content
• Establishes continuity, integrity of basic departmental imaging data.
• Specifies a number of transactions that maintain the consistency of patient
and order information
• Provides scheduling and imaging acquisition procedure steps.
• Determines whether images, evidence objects associated with procedure
step are available to enable subsequent workflow steps- Reporting.
• Provides central coordination of processing, reporting steps and
notification of appointments to the order placer.
• Improves workflow efficiency and provides reliable storage commitment.

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 Terminology
• Actors:
• are information systems or components of information systems that produce,
manage, or act on information associated with operational activities in the
enterprise.
• Acquisition Modality, ADT Patient Registration, Evidence creator, Order Placer,
Dept System Scheduler / Order Filler, Image Manager, Image Archive
• Transactions:
• Transactions are interactions between actors that transfer the required information
through standards-based messages.
• Procedure Scheduled, Order Placer management, Filler order Mgmt, MPPS In
Progress, MPPS Completed, Storage Commitment, Patient update, Procedure
update and others.
• Order:
• A request for an Imaging Service
• Requested Procedure:
• Unit of work resulting in one report with associated codified, billable acts.

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 Contd.,
• Scheduled Procedure Step:
• The smallest unit of work in the workflow that is scheduled [work to do]
• Performed Procedure Step:
• The smallest unit of work in the workflow that has been completed / work
done.
• Procedure Step:
• A part of a managed workflow that is considered an elementary unit of work
that is part of a Requested Procedure that cannot be divided for scheduling
purposes.
• Worklist:
• A worklist contains scheduled procedure steps or workitems from one or more
requested procedures to be performed by a target (e.g., a human, a device, or
an application) within an explicit workflow.
• Evidence creator:
• System that creates objects such as images, presentation states, Key Images
Notes, and or Evidence Documents and transmits them to Image Archive.
• Also retrieves worklist entries for post processing steps from post –Processing
manager
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 Value Propositions
• Bridges HL7 and DICOM Spaces
• Preserve Order Continuity-
• “Close the Loop”
• maintain accession number,
• avoid confusion with Filler #, Placer #, etc.
• Improve Demographic Integrity
• Data entry Errors
• significant occurrence
• significant consequences
• Improve Workflow Efficiency
• Use of Worklists
• less time spent doing data entry/selection
• enables semi-automation of setup
• Reliable Storage
• Storage Commitment
• fewer lost studies
• more confidence in results
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 Scheduled Workflow Profile

report
report
Registration report Report
Repository

HISpatient Diagnostic Film

information Workstation Lightbox
images
PACS retrieved

Orders Placed
procedure
scheduled Film
Prefetch any relevant Image Manager
Folder
examination orders prior studies & Archive

modality Acquisition
images
worklist Modality
Orders Filled stored
RIS acquisition
completed
acquisition Film
in-progress
completed images
printed

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Modality
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 CASE: SWF improves efficiency of Modality
• Key component:
• Modality Work List [MWL]
• Actions:
• Retrieves the list of scheduled procedure steps
• Performs and automates the process of correct patient identification
• Information needs to be placed on the images at the modality.
• Two transactions:
• Modality Performed Step In Progress
• Modality Performed Step Completed
• Image Manager and the Order Filler should know:
• What was performed
• How many images were acquired
• Three types of Actors:
• Acquisition Modality
• Department System Scheduler / Order Filler
• Image Manager / Image Archive

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 Flow of Information:
Acquisition Modality to Image Manager

Department
System Acquisition Images
Scheduler / Modality
Modality Modality
Order Filler Worklist Worklist
Response Information

Image
Manager

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 Further Options
• Assisted Acquisition Protocol:
• Allows MWL provider to supply detailed codes
• Interpret code values in MWL there by providing intelligent choices to
radiologist

Selected MWL Entry Suggested Protocol

Name: Robert Smith
DOB: 12/12/1978
History: Stroke Stroke General
Description: MR Head Hyperacute Stroke
Code: MR 1234 Carotid Dissection
MR Head
Western
Hospital

Benefit:
Shorter list of protocol to search through and simple procedure a simpler
procedure for configuring the modality.

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 Modality Performed Steps

What procedure steps were

performed at work Station
How many images were
captured for procedure
steps

Acquisition MPS In Progress DSS /

Modality MPS Complete OrderFiller

MPS In Progress
MPS Complete
Procedure steps & number
of Images captured are not
available at Images

Image
Manager

What procedure steps

were performed at work
Station
How many images were
captured for procedure
steps

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 List of Images for Performed Procedure

• Automatic Generation of Images:

• With ‘Assisted Acquisition protocol’, the modality has the list of images for
each procedure.
• Also helps the Order Filler in knowing the status of the procedure and the
images created
• This helps the technologist / radiologist:
• For the same procedures, the historical trends
• Average number of Images
• Storage Commitment
• A DICOM service included in IHE
• Assists the modality with management of local storage
• Two scenarios:
• Modality without Storage Commitment
• Modality with Storage Commitment

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 Modality Without Storage Commitment
• Modality with out Storage commitment:

Technologist
reviews Manually
the Studies at work Selects the
station studies

Albert 10-Oct
John 12-Oct
Smith 10-Oct
Thomas 11-Oct
DELETE

There can be studies which were not sent to Long term archive, hence can be
LOST

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 Modality With Storage Commitment

Modality Image Manager

√ Albert 10-Oct
√ John 12-Oct
√ Smith 10-Oct
Storage Commitment Thomas 11-Oct

Storage Icon DELETE

Indicate that the images the work station has confirmed that the Image
manager has taken the responsibility for the Images.
The workstation automatically activates the check boxes allowing the user
to ‘deselect’ any study that needs to be retained.
In the above illustration, there is no ‘check sign’ for Thomas.
There is no Storage Icon.
The modality does not allow the technologist to delete this study

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 SWF Concepts in Practice
• Three major levels of control are:
– Order
– Requested procedure
– Scheduled and Performed Procedure Step
• Order Filler / Department System Scheduler uses the ‘Universal ID’ in
each order it receives to determine specific requested procedures.
• For each requested procedure, the procedure step that need o be scheduled.
Example:
• Order ‘Rule Out Pulmonary Embolism’
• Breakdown of the order
• Use of departmental procedure plan in Order Filler actor to predefine for
each one of the types of orders that may be requested from imaging
department
• Order break down to Requested Procedure further to Scheduled Procedure
step.

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Order:
R/O Pulmonary Embolism

Requested Procedure: Chest x-Ray

Scheduled Procedure Step: Chest PA & Lateral

Requested Procedure: NM Ventilation Perfusion

Scheduled Procedure: NM Ventilation Acquisition

Scheduled Procedure: NM Perfusion Acquisition

• Chest X-Ray and NM Ventilation Perfusion are read & reported by different
radiologists, hence two different requested procedures.
• Patient will have two acquisitions performed at different timings thereby allowing
for patient preparation between two examinations
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 Tracking

SWF addresses:
– Breakdown of orders into requested Procedures and Scheduled steps
– Allows tracking the Procedure Steps that have actually been performed.
– Requested Procedure forms the ‘Folder’ where radiologists find images to be read
resulting from the Scheduled Procedure Steps.
Order:
R/O Pulmonary Embolism

Requested Procedure: Chest X Ray

Performed Procedure Step:

Scheduled Procedure: Chest PA & Lateral Chest PA & Lateral

Requested Procedure:: NM Ventilation Perfusion

Scheduled Procedure Step: Performed Procedure Step:

NM Ventilation Acquisition NM Ventilation Acquisition

Scheduled Procedure Step: Performed Procedure Step:

NM Perfusion Acquisition NM Perfusion Acquisition
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 PATIENT INFORMATION
RECONCILIATION [PIR]

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 Introduction

• An extension of SWF and Reporting Work flow Integration Profile

• Matches Images, diagnostic reports and other evidence objects acquired for
misidentified / unidentified patients.
• Emergency cases:
• Allows reconciliation of patient record with images that are acquired [either
without a prior registration or under a generic registration]
• Images can be acquired, interpreted immediately and later when the patient’s
official registration and order information in entered into ADT, Order Placer and
Order Filler Systems, this information is matched with the acquired image set and
reports.
• Allows the Image Manager and Report Manager to receive patient Update
messages to maintain consistency of patient information.
• The Image Manager and Report Manager do not receive those transactions in the
SWF integration profile.

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 Unidentified Patient Image Acquisition and Reconciliation

Trauma / Emergency Case:

• Procedure be conducted immediately.
• Done before registration, ordering and or scheduling of the procedure
• Patient / Study information must be later reconciled and properly updated at ADT,
Order Placer, DSS/ Order Filler, Image Manager and Report Manager.
Cases:
• Unidentified Patient Registered at ADT and ordered at Order Placer.
• Unidentified Patient registered at ADT an ordered at Department system scheduler /
order filler.
• Unidentified Patient registered at ADT but acquisition completed at Modality prior to
order.
Also supports when registration or temporary registration of a patient by ADT is
not applicable / desired:
• Emergency dept patient can be identified but, due to time / system availability
constraints, the procedure must be performed before proper order entry & scheduling

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 Other Scenarios..,
• Valid Patient ID was not propagated to all actors due to communication failures, or the wrong patient record
was used in ordering/scheduling.
• Valid Patient ID has been mistyped at the modality.

• Patient cannot be registered at the ADT by the time of the procedure.

• The patient presents to the Order Filler Actor (Imaging Department) and the order is placed and performed
in the department.

• Additional use cases:

– Unidentified Patient assigned temporary Departmental ID and scheduled at Department System Scheduler/Order Filler.
– Image Acquisition completed without scheduling at Department System Scheduler/Order Filler.

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 Handling Unidentified Patients

Patient assigned ORDER placed Procedure performed

Temporary ID by OF / DSS on Acqu Modal
in dept

DSS / OF sends new

Order to OP

ADT registers/ Patient ID shared by Image Mgr,

Patient Identity
admits patient DSS/ OF, Order Placer NOT
known
with correct ID KNOWN to ADT

Each system locally

ADT msg to Ord merges the new
Placer, OF/DSS record

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Case 1:Unidentified Patient Registered at ADT and Ordered at the Order
Placer

• Process:
– The ADT is a single point of patient reconciliation in the enterprise.
– Assign permanent Patient ID and a temporary name
– When the real patient identity is known, the ADT is responsible for reconciliation of
its own records as well as informing the Order Placer and Department System
Scheduler/Order Filler about corresponding changes.
– The ADT sends a Patient Update message to both the Order Placer and DSS / Order
Filler.
– The DSS/Order Filler sends the Patient Update message to the Image Manager and
the Report Manager.
• Significant Transactions:
– To reconcile the patient information, the ADT may register a new patient and merge
the temporary patient with the correct patient and send both Patient Registration
[RAD-1] and Patient Update [RAD-12] (Merge) transactions.
– If a permanent Patient ID was assigned, then the ADT may only send a Patient
Update [RAD-12] transaction with proper information.

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 Case 1:Unidentified Patient Registered at ADT and Ordered at the Order
Placer
Order
RAD1
Placer

ADT
RAD 2
Perm ID Placer Ord Mgmt
Temp
N ame Image
RAD 4
Order Manager
RAD1
Filler / DSS
RAD 7
MPSCompl Images
acquired

Acquisition
RAD 7
Modality
Patient Reconciliation

Merge RAD 1 Order

RAD 1& 12 ADT RAD 12 Placer
RAD 12

Image Report
RAD 12 RAD 12
Mgr Manager
Order
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Case 2:Unidentified Patient Registered at ADT and Ordered at DSS/Order
Filler

• Order generated by the DSS/Order Filler, submitted to the Order Placer.

• RAD 4 followed by image acquisition uses modality worklist.
• When the patient information is reconciled, the ADT sends the Patient Update
messages to both the Order Placer and Department System Scheduler/Order Filler.
• The Department System Scheduler/Order Filler sends the Patient Update message to
the Image Manager and the Report Manager.
• Significant Transactions:
– To reconcile the patient information, the ADT may register a new patient and
merge the temporary patient with the correct patient and send both registration and
merge transactions.
– If a permanent Patient ID was assigned, then the ADT may only send a Patient
Update transaction with proper information.
– A Filler Order Management (New Order) transaction [RAD-3] is sent from
DSS/Order Filler to the Order Placer

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Case 2:Unidentified Patient Registered at ADT and Ordered at DSS/Order
Filler

Order Image
ADT RAD1
Placer Manager

RAD 4
RAD 3
FOMgmt RAD 7
MPSCompl Images
acquired

Order
RAD1
Filler / DSS Acquisition
RAD 7 Modality

Patient Reconciliation

RAD 1 Order
ADT
RAD 12 Placer

RAD 12
Image Report
RAD 12 RAD 12
Mgr Manager
Order
Filler / DSS
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 Case 3:Unidentified Patient Registered at ADT but Completed at
Modality Prior to Order
• Uses a permanent Patient ID generated by the ADT.
• No order entry or scheduling takes place before the Acquisition Modality performs
the procedure.
• A permanent Patient ID and a temporary name are manually entered at
the Acquisition Modality (typically, from a card) and conveyed to the
DSS/Order Filler and the Image Manager by the Acquisition Modality.
• Subsequently, the DSS/Order Filler generates and submits an order to the Order
Placer.
• When the patient information is reconciled, the ADT sends the Patient
Update messages to both the Order Placer and the DSS/Order Filler.
• The DSS/Order Filler sends a Patient Update message to the Image Manager
and the Report Manager.

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• Significant Transactions
• On receiving a Modality Procedure Step Completed [RAD-7], the DSS/Order
Filler recognizes it as an unscheduled case.
• The DSS/Order Filler sends a Filler Order Management (New Order)
transaction [RAD-3] to the Order Placer.
• Using the information from the Procedure Step Completed transaction and the
placed order, the DSS/Order Filler creates a new Requested Procedure
record and sends a RAD 4 Procedure Scheduled transaction to the Image
Manager.
• To reconcile the patient information, the ADT may register a new patient and
merge the temporary patient with the correct patient and send both registration and
merge transactions.
• If a permanent Patient ID was assigned, then the ADT may only send a Patient
Update transaction with proper information.
• The DSS/Order Filler sends a Patient Update transaction to the Image Manager.

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 Case 3:Unidentified Patient Registered at ADT but Completed at
Modality Prior to Order

RAD 1 Order
ADT
Permnant PT ID Placer

RAD 1

Order
RAD 2
Image Filler / DSS
Mgr
PT ID & Temp Name
Acquisition entered into
Modality Modality manually

Patient Reconciliation

Order
ADT RAD 12
Placer

RAD 12

Order Filler / Report

RAD 12
DSS Mgr

RAD 12

Image
Mgr
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 Case 4: Unidentified Patient Assigned Temporary Departmental ID and
Scheduled at DSS/Order Filler

• No valid Patient ID is available to the Department System Scheduler/Order Filler.

• It assigns a temporary Patient ID and a temporary name and schedules the required
procedure.
• The Department System Scheduler/Order Filler must ensure that the assigned
temporary Patient ID is unique within its scope.
• The temporary Patient ID is conveyed to the Image Manager. When patient
information becomes known, the ADT sends new patient information to both the
Order Placer and the Department System Scheduler/Order Filler.
• The Department System Scheduler/Order Filler reconciles received patient
information with that associated with the temporary Patient ID and merges the
permanent patient record with its own temporary one and sends a Patient Update
transaction to the Image Manager and the Report Manager.
• At the same time, the Department System Scheduler/Order Filler generates and
submits an order to the Order Placer using a permanent Patient ID.

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 • Significant Transactions:
• Patient information is reconciled internally by the Department System
Scheduler/Order Filler using the Patient Registration from ADT.
• The Department System Scheduler/Order Filler sends the Patient Update [RAD-12]
transaction to the Image Manager.
• The Department System Scheduler/Order Filler sends the Filler Order Management
(New Order) transaction [RAD-3] to the Order Placer.

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Case 4: Unidentified Patient Assigned Temporary Departmental ID and
Scheduled at DSS/Order Filler

Order Image
ADT RAD 4
Filler / DSS Manager

Rad 1

MPS Compl Acquisition

Order RAD 7 Modality
Placer
Pt Reconciliation

Order Report
RAD 12
Filler / DSS Manager

RAD 3 RAD 12

Order Image
Placer Manager

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 Case 5:Image Acquisition Completed Without Scheduling at Department
System Scheduler/Order Filler
• No valid Patient ID is available to the Department System Scheduler/Order Filler
and no scheduling is done before the procedure is performed.
• A temporary ID and name are entered by the technologist at the Modality and
conveyed to the Department System Scheduler/Order Filler and to the Image
Manager.
• The Patient ID and name are selected by the technologist according to the locally
defined rules; for example, selected from the predefined pool of “Patient ID–patient
name” pairs.
• The rules for selecting temporary Patient ID shall guarantee its uniqueness within
the scope of Department System Scheduler/Order Filler.
• Upon receiving the Modality Procedure Step Completed message, the DSS/Order
Filler and Image Manager recognize an unscheduled case based on the content of the
message
• When patient information becomes known, the ADT sends the new patient
information to both the Order Placer and Department System Scheduler/Order Filler.
• The Department System Scheduler/Order Filler performs a merge of the permanent
patient record with the temporary one and sends a Patient Update to the Image
Manager and the Report Manager.

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 • At the same time, Department System Scheduler/Order Filler generates and submits
an order to the Order Placer using a valid Patient ID.
• Significant Transactions:
• On receiving a Procedure Step Completed transaction, the Department System
Scheduler/Order Filler recognizes it as an unscheduled case.
• Patient information is reconciled internally by the Department System
Scheduler/Order Filler using the Patient Registration from the ADT.
• The Department System Scheduler/Order Filler sends a Patient Update (Merge)
transaction to the Image Manager and to the Report Manager.
• The Department System Scheduler/Order Filler sends a Filler Order Management
(New Order) transaction [RAD-3] to the Order Placer.
• Using the information from the Procedure Step Completed transaction and placed
order, the Department System Scheduler/Order Filler creates a new Requested
Procedure record and sends a Procedure Scheduled [RAD-4] transaction to the
Image Manager and Report Manager.

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 Case 5:Image Acquisition Completed Without Scheduling at Department
System Scheduler/Order Filler

DSS recognizes it
as Unscheduled
Case
Acquisition MPS Compl Order
Modality RAD 7 Filler / DSS
Reconciliation done
internally
MPS Compl Patient Reconciliation
RAD 7

RAD 1

Image
Manager DSS /
ADT RAD 1
Order Filler

RAD 12
RAD 12

Image Report
Mgr Mgr

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 Case 6: Patient Information Reconciliation During Image Acquisition

• The Modality may have requested information from the Department System
Scheduler before the update has occurred and continue to send the images with the
original Patient Registration and Order information.
• The Image Manager will need to continue updating the patient information from
items retrieved from the Image Archive.
• Significant Transactions:
• The Modality may continue to send information using the original patient
information even after the patient update has occurred.
• The Image Manager must continue reconciling Patient Information even after the
Patient Update transaction has been completed.

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