DOI: 10.1148/rg.284075210
RadioGraphics 2008;28:933-945
© RSNA, 2008
Informatics in Radiology
IHE Teaching File and Clinical Trial Export Integration Profile: Functional Examples1
Aaron W. C. Kamauu, MD, MS, MPH,
Jeffrey J. Whipple, BS, MS,
Scott L DuVall, BS,
Khan M. Siddiqui, MD,
Eliot L. Siegel, MD, and
David Avrin, MD, PhD
1 From the Department of Methodology and Innovation, Roche Palo Alto, 3431 Hillview Ave, Palo Alto, CA 94304 (A.W.C.K.); Department of Radiology, VA Maryland Healthcare System, Baltimore, Md (J.J.W., E.L.S.); Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah (S.L.D.); Department of Radiology, University of Maryland School of Medicine, Baltimore, Md (K.M.S., E.L.S.); and Department of Radiology, University of California San Francisco, San Francisco, Calif (D.E.A.). Presented as an Informatics exhibit at the 2006 RSNA Annual Meeting. Received November 8, 2007; revision requested January 15, 2008, and received February 27; accepted March 3. A.W.C.K. is an employee of Hoffmann-La Roche (Roche Pharmaceuticals) and a former employee of RemedyMD; J.J.W. is an employee of General Electric; S.L.D. is a partner of Scottwares Consulting and founder of Health Data Security; K.M.S. is a co-founder of iVirtuoso and member of the advisory boards of GE Healthcare and Visage Imaging; E.L.S. has received research funding from General Electric, Siemens, Xybix Systems, Steelcase, Anthro, RedRick Technologies, Evolved Technologies, Barco, Intel, Herman Miller, and Anatomical Travelogue and is a spokesperson for TeraRecon, a member of the advisory board of Mercury Computer Systems, and a member of the board of directors of Onex (Carestream Health); D.E.A. is an Amirsys stockholder and consultant.
Address correspondence to A.W.C.K. (e-mail: aaron{at}akamauu.com).
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Abstract
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The digital revolution in radiology introduced the need for electronic export of medical images. However, the current export process is complicated and time consuming. In response to this continued difficulty, the Integrating the Healthcare Enterprise (IHE) initiative published the Teaching File and Clinical Trial Export (TCE) integration profile. The IHE TCE profile describes a method for using existing standards to simplify the export of key medical images for education, research, and publication. This article reviews the authors’ experience in implementing the TCE profile in the following three processes: (a) the retrieval of images for a typical teaching file application within a TCE-compliant picture archiving and communication system (PACS); (b) the export of images, independent of TCE compliance of the PACS, to a typical teaching file application; and (c) the TCE-compliant transfer of images for publication. These examples demonstrate methods with which the TCE profile can be implemented to ease the burden of collecting key medical images from the PACS.
© RSNA, 2008
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Introduction
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The transition from film-based to filmless imaging has encouraged corresponding changes in the collection and management of images used in teaching. Before, radiologists made physical (film-based) copies of images that were useful for teaching or borrowed the original images from medical records or departmental film libraries. Notes describing the images were written directly on the film storage jackets. The adoption of the picture archiving and communication system (PACS) eliminated the use of original film-based images from which teaching file copies traditionally were made. At the same time, the emergence of cross-sectional imaging modalities such as computed tomography (CT) and magnetic resonance (MR) imaging led to an increased number of images per study, which made the production of film-based copies impractical. Moreover, the impossibility of using digital tools such as window and level settings, scrolling, and zooming to enhance the display of film-based images made film a relatively poor medium for use in training.
The management of film-based teaching files also is difficult and time consuming. Film images must be sorted and filed in a manner that makes them easily retrievable. If the same images are suitable for filing under multiple headings, a cross-referenced index must be created and maintained. Older images must be replaced as better examples become available. Film images may be misfiled or lost, and they must be duplicated for sharing.
Several digital teaching file systems have been developed to address these issues and make it possible to electronically store and manage large quantities of digital images (1–4). Digital image databases can be searched quickly for images of interest. Not only are the images easily accessible to both faculty and trainees, but searches for relevant images can be performed at the workstation during the normal image interpretation workflow.
One such digital teaching file system is the Medical Imaging Resource Center (MIRC) developed by the RSNA (http://www.rsna.org/mirc). MIRC provides tools that support the sharing of radiologic imaging data such as teaching files for academic, research, or clinical purposes. MIRC allows individual and institutional users to query and download or upload radiology teaching files to teaching file servers. The defined exchange mechanism allows MIRC-compliant teaching file servers to easily share content. As described on the RSNA Web site, MIRC offers the following aids: (a) a simple way to identify, index, and retrieve images, teaching files, and other radiology-related information, (b) the ability to search multiple imaging libraries as if they were a single library organized by medically relevant categories, (c) an authoring tool that makes it easy to create radiology teaching files and other electronic documents in flexible formats with a common underlying structure, and (d) tools to enable clinical trial sites to manage and exchange images and research data sets.
Early digital teaching file systems had many of the same flaws as other applications during the transition to filmless imaging: differences between film-based and filmless workflows, a lack of standard interfaces to external systems, designs that did not scale easily, and so on. To address these issues, the Teaching File and Clinical Trial Export (TCE) integration profile was developed by participants in the Integrating the Healthcare Enterprise (IHE) initiative under the joint aegis of the RSNA, the Healthcare Information and Management Systems Society, and the American College of Cardiology (5,6). The TCE profile defines a common method for selecting images and related documents, entering additional information, and then transferring the collection of images and information to a teaching file, clinical trial, or publication application.
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TCE Profile
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The IHE TCE export integration profile defines the roles of three functional entities: the Export Selector, Export Manager, and Receiver (Fig 1). The Export Selector provides the means for selecting key images and inputting additional case information. The Export Manager removes protected health information from the images and from any supporting data and then exports the case to the Receiver. The Receiver is a system capable of receiving DICOM files. The Export Selector and Export Manager may be independent, integrated, or components of a single system.
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Figure 1. Schema shows the three functional entities involved in radiologic image data transfer according to the IHE TCE profile: the Export Selector, Export Manager, and Receiver. ATFI = Additional Teaching File Information, DICOM = Digital Imaging and Communications in Medicine.
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The TCE profile also delineates roles for two DICOM structured reports: the Manifest and the ATFI report. The Manifest contains a list of the key images associated with the case. The ATFI report contains additional information about the case, including the diagnosis, pathologic findings, anatomic location, and more.
The TCE profile was created to describe a nonproprietary approach for exporting images and supporting data to teaching file, research, and publication applications. It outlines methods by which users can select relevant images, notes, reports, evidence documents, and presentation states on the acquisition modality or image display, enter additional information at the same time, and transmit the data to a TCE Receiver.
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Electronic Teaching File Creation with and without TCE Profile Implementation
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Implementation of the TCE profile helps simplify the workflow when creating electronic teaching files (Fig 2). Without TCE profile implementation, as teaching file images are identified and selected during image interpretation, the radiologist must capture each image from the PACS and transfer it to a computer storage system (Fig 2a). If the radiologist cannot take the time to export images during the initial image interpretation, then image- and case-related information must be manually recorded so that the images can be retrieved and exported later. After the images are exported, protected health information must still be manually removed from the images, and the image files must be renamed. The removal of protected health information often requires the use of third-party software. The radiologist then records notes (either electronically or on paper, depending on individual preference) for later incorporation into the teaching file. If a delay occurs between the identification of images of interest and their export to the storage system, the radiologist often must retrace his or her thoughts about the specific case to create notes.
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Figure 2a. Flowcharts show the steps typically required to create an electronic teaching file on a centralized teaching file server without (a) and with (b) implementation of the IHE TCE profile. Use of a TCE-enabled PACS and teaching file server allows the elimination of many steps. PHI = protected health information, TF = teaching file.
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Figure 2b. Flowcharts show the steps typically required to create an electronic teaching file on a centralized teaching file server without (a) and with (b) implementation of the IHE TCE profile. Use of a TCE-enabled PACS and teaching file server allows the elimination of many steps. PHI = protected health information, TF = teaching file.
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Image files residing in the local file system must be moved to the teaching file server. If the system to which the images were exported and the teaching file server are on the same network, images may be moved electronically by using File Transfer Protocol software or shared directories. If the systems are not connected, images must be transferred to a removable medium such as a memory stick or CD-ROM. The removable medium is then taken to the teaching file server, and images are loaded manually onto the server. At some institutions, the two systems are not in the same building, a situation that makes the manual transfer of images time consuming.
Only after the images arrive on the teaching file server does the actual teaching file authoring process begin. The radiologist logs on to the system, opens the teaching file template, and populates the data fields with information from previously recorded notes. After all the supporting data are entered, the images must be located on the teaching file server and associated with the teaching file. The file then can be saved and published. This process is manually intensive, time consuming, and prone to error. Radiologists might often forego the authoring of teaching files because of a lack of time or an inability to complete one or more steps in the process.
The TCE profile facilitates the automation of many steps in teaching file creation (Fig 2b). A radiologist using a TCE-enabled PACS can mark key images during routine image interpretation and can initiate the teaching file authoring process whenever it is convenient. The system automatically populates the teaching file template with the key images for the study currently open. The system also populates as many template fields as possible with data from the study. The radiologist can complete the process by entering additional data and modifying existing data in prepopulated fields. These combined data then are used to generate an ATFI report. The completed template can be forwarded by using the standard DICOM Send protocol to any teaching file server with TCE Receiver capability that is either internal or external to the PACS network. The TCE Export Manager automatically removes or replaces all protected health information before sending the teaching file data to the server.
This entire process is designed to take place within the PACS and teaching file system, obviate the manual transfer of data from the PACS to the teaching file server, and thus reduce the potential for associated data entry errors. It eliminates the need to have knowledge of and access to systems and processes between the PACS and the teaching file server. If the teaching file server is capable of automatic teaching file creation, this approach also eliminates the need to log on to the teaching file server to complete the authoring process. Security is improved in this process by removing or pseudonymizing protected health information before it leaves the PACS. Most important, the process takes place within the normal image interpretation workflow with minimal additional effort. It is anticipated that these economies of time and expertise, as well as security and other enhanced applications, will result in increased participation by radiologists and trainees in the creation and creative application of electronic teaching files.
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Functional Examples of TCE Profile Implementation
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Although the TCE profile describes a common method of using existing standards to retrieve and export key images, the PACS and the TCE profile implementation may vary significantly across institutions. Moreover, the number of potential TCE Receivers is unlimited. Therefore, we present the following three illustrative examples from our experience: (a) the retrieval of images for a typical teaching file application within a TCE-compliant PACS, (b) the export of images, independent of TCE compliance of the PACS, to a typical teaching file application, and (c) the TCE-compliant transfer of images for publication.
Example 1: Teaching File Creation within a TCE-Compliant PACS
The following example is based on a prototype developed in research at the Baltimore VA Medical Center by using a modified commercially available PACS and the MIRC software suite. For the prototype, a TCE-compliant PACS was combined with a TCE-compliant Receiver (the MIRC repository) to create an easy-to-use, standards-based, intuitive environment in which radiologists could select teaching file images, capture relevant notes, and forward them to a TCE-compliant teaching file server—all within the setting of normal clinical workflow. A MIRC teaching file storage service was used as the TCE-compliant Receiver. The goal was to test MIRC’s ability to create teaching files from data received through direct implementation of the TCE profile without user intervention and, thus, to automate the teaching file authoring process.
The creation of a teaching file in this integrated environment begins when a radiologist identifies one or more images of interest on the clinical PACS (Fig 3). These images of interest or key images are marked within the system by associating them with a Key Image Note (KIN). As defined by the IHE TCE integration profile, a KIN is a note that contains a title indicating the purpose of the teaching file and may contain a user comment (7). The radiologist uses the Key Image Selection Tool (Fig 3), a combined pointer and key icon, to mark key images and regions of interest. Key images are identifiable by a key icon that appears on the left side of the display console (Fig 3b). The PACS console used in this test allowed the user to toggle the Key Image Selection Tool on and off during the interpretation process so that key images could be marked for teaching file use as they were encountered while deferring the addition of supplemental information, thereby minimizing disruption of the routine workflow.
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Figure 3a. Screen captures show the first steps in the creation of a teaching file by using a TCE-enabled PACS: the selection of a lesion or a region of interest on the key image by using a pointer (a) and a key icon (b).
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Figure 3b. Screen captures show the first steps in the creation of a teaching file by using a TCE-enabled PACS: the selection of a lesion or a region of interest on the key image by using a pointer (a) and a key icon (b).
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After marking key images to be included in the teaching file, the radiologist creates a KIN to capture supporting information related to each selected key image. The radiologist opens the KIN Editor by clicking on the teaching file folder icon on the TCE-compliant PACS console (Fig 4a). The KIN Editor dialog box, preconfigured for teaching file creation, then is displayed (4b) along with the Document title (preset to "For Teaching File Export") and the teaching file data entry fields.
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Figure 4a. Screen captures show the creation of a KIN. After a key image is selected for the teaching file, the annotation window may be opened to record additional information about the image or case by clicking on the teaching file folder button in a. When the KIN is completed, it may be saved along with the image selections by clicking on the Send button shown in b.
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Figure 4b. Screen captures show the creation of a KIN. After a key image is selected for the teaching file, the annotation window may be opened to record additional information about the image or case by clicking on the teaching file folder button in a. When the KIN is completed, it may be saved along with the image selections by clicking on the Send button shown in b.
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After entering the desired information, the radiologist clicks on the Send button, which saves the image selections and the completed KIN and opens the Exam Export dialog box (Fig 5). Like the KIN Editor dialog box, the Exam Export dialog box is preconfigured with teaching file selections; the KIN automatically selected is the one just created. Clicking on the OK button initiates the creation of both an ATFI structured report, which incorporates the teaching file supporting information stored in the KIN, and a TCE manifest, which lists the images and ATFI reports to be included in the TCE transmission. Once the ATFI report and TCE Manifest are completed, the system sends the Manifest, ATFI report, and images listed in the Manifest to the TCE-compliant Receiver selected in the drop-down list of potential destinations. The use of the Exam Export dialog box to select the TCE-compliant Receiver is necessitated by the configuration of the PACS in our prototype. In other implementations of the TCE integration profile, the destination selection step might be incorporated directly into the teaching file authoring workflow, thus eliminating the need for a second dialog box.
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Figure 5. Screen capture shows the Exam Export dialog box with the newly created KIN and the default TCE-compliant Receiver preselected. Clicking on the OK button causes the system to create an ATFI structured report based on the supporting information stored in the KIN. A Manifest is then created that lists the images selected and the ATFI report. When the Manifest is complete, it is sent to the selected TCE-compliant Receiver along with the ATFI report and the selected images.
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When the TCE-compliant Receiver (in this case, the MIRC teaching file storage service) receives the Manifest, ATFI structured report, and images from the PACS, it uses them to create a new teaching file. The radiologist subsequently may log on to MIRC via a Web browser to verify that the teaching file was created, make any necessary modifications to the file, and, finally, publish the file, making it available to others (Fig 6).
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Figure 6. Screen capture shows the teaching file created by the TCE-compliant Receiver (in this example, the MIRC Teaching File Storage Service) on the basis of the Manifest, ATFI structured report, and images exported from the PACS.
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Example 2: TCE-Compliant Image Export Independent of PACS Functionality
Some radiologists have only a minimal ability to configure their PACS for additional functionality. However, without the benefit of a TCE-compliant Export Selector built in to the PACS, another mechanism is necessary to extract key images. The system described in this section is a vendor-neutral approach to harvesting interesting cases that complies with the TCE integration profile and that may be used at institutions that do not have the capability of modifying the PACS to directly incorporate image export functionality (Fig 7). The target destination is arbitrary, requiring only a TCE-compliant Receiver. Therefore, the Receiver in this scenario could be a teaching file, clinical trial application, publication application, or any other potential recipient of DICOM files.
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Figure 7. Diagram shows the workflow with implementation of a TCE Export Selector independently of a PACS. First the radiologist selects the key images. Then data are automatically extracted from the selected images. The radiologist manually inputs additional information, which is coupled with the automatically extracted data to generate a Manifest and an ATFI structured report. The key images and structured reports are exported to the Receiver of choice by using an Export Manager.
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After the radiologist identifies the images of interest, he or she sends them from the PACS to a Web-based TCE Export Selector. The Export Selector automatically processes the DICOM images, converting them into Web-viewable images, and displays them on the computer monitor (8). The radiologist then selects the key images from the examination (Fig 8).
After selecting the key images, the radiologist is presented with a Web-based form that allows the input of relevant case information (eg, title, diagnosis, pathologic findings, anatomic location, keywords, clinical history, or case description) (Fig 9). The terms used to describe the diagnosis, pathologic findings, anatomic location, and organ system involved are based on RadLex, the RSNA-sponsored radiology lexicon (9,10). The diagnosis and the descriptions of pathologic findings, anatomic location, and organ system are stored in the ATFI report. The system also automatically generates the Manifest, which references the selected key images and the ATFI report.
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Figure 9. Screen capture shows the display during manual inputting of additional information about a teaching case. This information, coupled with data automatically extracted from the selected key images, will be used to generate the Manifest and ATFI structured reports.
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At this point the case comprises selected key images, the Manifest, and the ATFI report. Using the Export Selector, the radiologist exports the case to one or more Receivers. The case is routed through the MIRC Export Manager for pseudonymization and de-identification of protected health information before being sent to the Receivers (11).
This system is currently undergoing beta testing at a large academic institution, where it is being used to export cases to a teaching file application and a third-party publication application (Fig 10). The institutional teaching file application is in regular use by residents and attending radiologists, with an average of 5.5 cases created per week since implementation and up to 35 cases per week at maximum use to date.
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Figure 10. Flowchart shows the export of image data and related information from a PACS to one (actual) or more (hypothetical) Receivers for publication. The widespread adoption of the TCE profile would allow authors to export de-identified images directly from their institutional PACS to professional journals and other publication media.
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Although effective, the process described still requires two steps performed with two different systems: the use of the PACS to select interesting cases, and the use of a Web-based form to enter relevant case information. As new PACS systems are released and existing systems are updated, it will be possible to incorporate teaching file and clinical trial case creation into PACS interpretation workflow by implementing the TCE profile as described in the first example.
Example 3: Export of Cases for Publication
This example involves the unique implementation of a TCE-compliant Receiver designed exclusively for the electronic submission of educational cases for publication. Traditional authoring of a radiology manuscript requires access to the proprietary publication application, manual export and anonymization of images, and manual upload of images in the prescribed format with supplemental information. The Receiver described in this section accepts publishable cases from any TCE Export Manager, and the process of transferring cases from the PACS to the publisher is simplified to a few clicks.
Cases that are created by using the process described in the previous section (example 2) are exported through the TCE Export Manager and received by the Web-based Receiver. Although the functionality of a Receiver is largely undefined, it must be able to receive a Manifest and the instances to which the Manifest refers. Receivers also may receive ATFI reports. This Receiver implements TCE functionality and then performs additional tasks to create and populate a case file in a proprietary publishing system. To do this, the Receiver creates a unique case for each new Manifest it receives. As key images are received, they are compared with the known Manifests and assigned to corresponding cases or put in a queue to await the arrival of a Manifest that references them. When all key images of a case and their Manifest are received, the Receiver automatically converts the DICOM images to fit the format, size, and quality specifications of the publication application. Because the ATFI report is a DICOM structured report, the data are encoded in a template. Mapping from this template allows information extracted from the ATFI report to populate specified fields in the publisher’s proprietary data model. The case information and the key images are automatically inserted into the publication application and stored in Draft mode for additional authoring or editing by the radiologist. ACRES Console, the publication application tool used in this example, was developed by Amirsys (Salt Lake City, Utah) and is not commercially available. When the radiologist accesses this tool, all cases stored in Draft mode are listed. The tool provides the ability to complete and submit any of those cases for publication (Fig 11).
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Figure 11. Screen capture shows a case exported from the PACS to a commercial console. Mapping by the Receiver results in the prepopulation of data fields in the publishing application and in reformatting of images according to the publisher’s specifications.
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This process allows the integration of publication tasks into the routine clinical workflow. Radiologists who are also authors for a third-party publisher can export key images by using the methods described. At their convenience, they then can access the publication authoring tool to complete a case or cases and submit them to the publisher. The Receiver is undergoing final testing before its release. The system so far has been well received by authors because it automates the tasks of retrieving publishable cases from the PACS and transferring them to a third-party publishing application.
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Future Prospects for the TCE Profile
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The correction of several existing shortcomings in the TCE integration profile could substantially enhance its functionality and user satisfaction. First, the profile does not currently provide a method for transferring a teaching file title from the Export Selector to the Receiver. This information is essential for most teaching file applications. Without this information, searches for a particular case are difficult, and extra steps are required for authors to locate and edit their contributions on the server. During testing of the first TCE implementation (example 1), new teaching files in the MIRC repository were assigned the default title ("Untitled"). The lack of a meaningful and specific title made it difficult to quickly identify new teaching files. Each file had to be opened to be identified before the title could be appropriately amended. These extra steps in the editing of titles may run counter to the goal of minimizing or eliminating the need to edit new teaching files after their creation. Although the problem was observed when using MIRC, it would likely occur with any TCE-compliant teaching file server. The addition of a title concept to the template for the ATFI structured report would provide a vendor-neutral solution to this problem.
Second, many teaching file applications, including MIRC, provide the capability to specify both an author and an owner of a teaching file. The author is the person who created the file. The owner manages it and has the ability to modify, publish, or delete it. The author and the owner usually are the same person. However, this may not always be the case. For example, an author may use his or her full name in the author field while the owner field is populated by a preassigned teaching file server user name. During testing of the system described in example 1, several authors were unable to access a teaching file because the owner name field was left blank or was populated with something other than the author’s MIRC user name. Although this problem was observed with the MIRC software, it is likely also to occur with other teaching file systems. We recommend that this issue be evaluated and that a vendor-neutral solution be incorporated into the TCE profile.
Third, the TCE profile does not currently support the insertion of hyperlinks to online Web content within the Manifest. Therefore, a teaching file author is limited to using static text alone during the initial authoring process. However, the retrospective addition of hyperlinks may be possible if the teaching file repository allows this capability during editing.
Because the role of the Receiver is not strictly defined by the TCE profile, there are many possibilities for the innovative use of images and metadata exported with TCE-compliant methods. Although the TCE profile explicitly names teaching file and clinical trial applications as potential TCE Receivers, any application in which DICOM images are needed would benefit from the standard image retrieval methods defined by the TCE profile. One such application (described in example 3) is publication. We believe that the use of the TCE profile provides significant benefits in facilitating publication submissions and authoring. It allows the publishing organization (corporation or journal) to receive the original de-identified DICOM images that can be converted into any image file format, spatial resolution, and contrast resolution specified by the publishing application; thus, the publisher has greater control of image quality. In addition to publishers, many other potential Receivers in academic, research, and clinical settings also could benefit from the TCE-enabled transfer of medical images and related data.
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Summary
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For most radiologists, the extraction of key images from a PACS for education, research, or publication is a complicated process. Although many teaching file authoring solutions are available, the methods used to transfer images and case information vary significantly from one system to the next. The efficient export of key images during clinical image interpretation is perhaps the greatest challenge. PACS vendor compliance with the TCE integration profile would facilitate the creation and exchange of radiologic case files without interrupting the clinical workflow. However, the methods described in this article may be used even in the absence of such compliance (ie, with a PACS that does not have an Export Selector or Manager).
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TAKE-HOME POINTS
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The TCE profile defines a common method for selecting images and related documents, entering additional information, and then transferring the collection of images and information to a teaching file, clinical trial, or publication application.
- A radiologist using a TCE-enabled PACS can mark key images during routine image interpretation and can initiate the teaching file authoring process whenever it is convenient.
- The entire process is designed to take place within the PACS and teaching file system, obviating the manual transfer of data from the PACS to the teaching file server and thus reducing the potential for associated data entry errors.
- Although the TCE profile describes a common method of using existing standards to retrieve and export key images, the PACS and the TCE profile implementation may vary significantly across institutions.
- PACS vendor compliance with the TCE profile would facilitate the creation and exchange of radiologic case files without interrupting the clinical workflow.
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Acknowledgments
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We thank Andrew P. Liimatta and Richard H. Wiggins III, MD, for their contributions to the research project, and Denny W. Lau, Krishna Juluru, MD, John Perry, and Christopher F. Beaulieu, MD, for their help in preparing the exhibit, on which this article is based.
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Footnotes
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Abbreviations: ATFI = Additional Teaching File Information, DICOM = Digital Imaging and Communications in Medicine, IHE = Integrating the Healthcare Enterprise, KIN = Key Image Note, MIRC = Medical Imaging Resource Center, PACS = picture archiving and communication system, TCE = Teaching File and Clinical Trial Export
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Abstract
Introduction
