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.
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,
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
"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
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
"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."