ACC, HIMSS and RSNA
Integrating the Healthcare EnterpriseIHE Cardiology Technical Framework
Supplement 2006-2007

Stress Testing Workflow Integration Profile

Published for Trial Implementation
June 8, 2006

IHE Cardiology Technical Framework Supplement – Stress Testing Workflow______________________________________________________________________________

1 Foreword
Integrating the Healthcare Enterprise (IHE) is an initiative designed to stimulate the integration of
the information systems that support modern healthcare institutions. Its fundamental objective isto ensure that in the care of patients all required information for medical decisions is both correct
and available to healthcare professionals. The IHE initiative is both a process and a forum forencouraging integration efforts. It defines a technical framework for the implementation of
established messaging standards to achieve specific clinical goals. It includes a rigorous testingprocess for the implementation of this framework. And it organizes educational sessions andexhibits at major meetings of medical professionals to demonstrate the benefits of this frameworkand encourage its adoption by industry and users.
The approach employed in the IHE initiative is not to define new integration standards, but rather
to support the use of existing standards, HL7, DICOM, IETF, and others, as appropriate in theirrespective domains in an integrated manner, defining configuration choices when necessary. IHE
maintain formal relationships with several standards bodies including HL7, DICOM and refers
recommendations to them when clarifications or extensions to existing standards are necessary.
This initiative has numerous sponsors and supporting organizations in different medical specialty
domains and geographical regions. In North America the primary sponsors are the American
College of Cardiology (ACC), the Healthcare Information and Management Systems Society(HIMSS) and the Radiological Society of North America (RSNA). IHE Canada has also been
formed. IHE Europe (IHE-EUR) is supported by a large coalition of organizations including theEuropean Association of Radiology (EAR) and European Congress of Radiologists (ECR), theCoordination Committee of the Radiological and Electromedical Industries (COCIR), Deutsche
Röntgengesellschaft (DRG), the EuroPACS Association, Groupement pour la Modernisation duSystème d'Information Hospitalier (GMSIH), Société Francaise de Radiologie (SFR), Società
Italiana di Radiologia Medica (SIRM), the European Institute for health Records (EuroRec), andthe European Society of Cardiology (ESC). In Japan IHE-J is sponsored by the Ministry of
Economy, Trade, and Industry (METI); the Ministry of Health, Labor, and Welfare; and MEDISDC; cooperating organizations include the Japan Industries Association of Radiological Systems(JIRA), the Japan Association of Healthcare Information Systems Industry (JAHIS), Japan
Radiological Society (JRS), Japan Society of Radiological Technology (JSRT), and the Japan
Association of Medical Informatics (JAMI). Other organizations representing healthcare
professionals are invited to join in the expansion of the IHE process across disciplinary andgeographic boundaries.
The IHE Technical Frameworks for the various domains (IT Infrastructure, Cardiology,
Laboratory, Radiology, etc.) define specific implementations of established standards to achieve
integration goals that promote appropriate sharing of medical information to support optimal
patient care. It is expanded annually, after a period of public review, and maintained regularly______________________________________________________________________________
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through the identification and correction of errata. The current version for these Technical
Frameworks may be found at www.ihe.net.
The IHE Technical Framework identifies a subset of the functional components of the healthcare
enterprise, called IHE Actors, and specifies their interactions in terms of a set of coordinated,
standards-based transactions. It describes this body of transactions in progressively greater depth.
The volume I provides a high-level view of IHE functionality, showing the transactions organized
into functional units called Integration Profiles that highlight their capacity to address specificclinical needs. The subsequent volumes provide detailed technical descriptions of each IHE
transaction.
This supplement to the IHE Cardiology Technical Framework v2 is submitted for Trial
Implementation through March 2006.

Comments arising from Trial Implementation should be submitted to:
http://forums.rsna.org
Under the “IHE” forum, select the“IHE Cardiology Technical Framework Supplements 2006”
sub-forum.
The IHE Cardiology Technical Committee will address these comments and expects topublish the Final Text version in June 2007.

2 Introduction to this Supplement
This Supplement adds a new Stress Testing Workflow Integration Profile to the IHE Cardiology
Technical Framework. The Stress Profile defines a means of ordering and performing cardiac
stress tests involving stress ECG, echocardiographic, and/or nuclear imaging components. The
profile is aligned with the Actors and Transactions of the Echocardiography Workflow and
Scheduled Workflow Integration Profiles, so that a common infrastructure can be used in an
integrated manner.

2.1 Selection of the Standard
The IHE Cardiology Technical Committee has selected the use of DICOM to manage workflow
for stress testing in this profile. We seriously considered the alternative of an HL7-based
workflow management environment, and devoted considerable effort to developing a profile for______________________________________________________________________________
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such. However, after comparing DICOM to HL7 for the use cases of this profile, we believe
DICOM is the best choice for the long term for the following principal reasons:•HL7 does not have a strong query model for managing diagnostic procedure worklists. It
has a general outline for queries, but each use requires a unique profile specifying query
keys, query wildcards, required and optional data elements, response messages, etc. The
effort to develop an interoperable profile is comparable to defining a major new message
exchange standard. However, the DICOM standard Modality Worklist is already fully
defined and profiled in the IHE Technical Framework.

•

Since an HL7 query profile would be new, there would be no implementation experienceavailable to draw on. In contrast, DICOM Modality Worklist has been in use in products
for almost a decade, and there is a full set of MESA test tools available to test it.

•

The ECG component of stress testing must be coordinated with the imaging (echo or
nuclear) component. This is easier accomplished if the workflow management uses
identical procedure management concepts and the same message standards. Since thestress imaging side is already managed using DICOM through defined IHE profiles,
applying that to the stress ECG side make the job of the department management systemmuch simpler.

2.2 Stress Evidence Document Content
While this profile specifies the use of DICOM Structure Report (SR) Evidence Documents toconvey stress measurements, it has not specified Templates for the content of ECG or Nuclear
stress evidence documents. The stress echocardiography Template is specified in the Echo
Evidence Option of the Evidence Documents Profile (see IHE Cardiology Technical Framework
Volume 1, Section 7.2).
It is the expectation of the IHE Cardiology Technical Committee that the necessary SR Templates
for this use will be developed by DICOM WG-01 during the course of this year, and will beavailable for profiling in IHE for Cardiology Year 4 (2007-2008). At that time, additional options
will be specified for the Evidence Documents Profile paralleling the options for Cath and Echo.

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Additions to IHE Cardiology Technical Framework
Volume 1
Add to Section 1.7
o The Stress Testing Workflow Profile provides the mechanism for ordering andcollecting multi-modality data during diagnostic Stress testing procedures.

Add to Section 2.1
Table 2-1 Integration Profile Dependencies
Stress Testing
Workflow

ITI-TF Consistent TimeThe DSS/Order Filler and theAcquisition Modality actors are
required to be grouped with Time
Client actors.

RAD-TF Nuclear Medicine

The Image Manager/Image Archive
and Image Display actors shall support
the Nuclear Medicine Profile and theCardiac NM Option.

CARD-TF Echocardiography Workflow

The Image Manager/Image Archive
and Image Display actors shall support
the Echocardiography Workflow
Profile.

Add to Section 2.2
2.2.6 Stress Testing Workflow
The Stress Testing Workflow Integration Profile describes the workflow associated with managing
cardiac stress test procedures. This profile deals with patient identifiers, orders, scheduling, status
reporting, multi-stage exams, and data storage. It specifies the scheduling and coordination ofprocedure data across a variety of imaging, ECG acquisition, measurement, and analysis systems,
and its reliable storage in an archive from where it is available to support subsequent workflow
steps, such as reporting.

Add to Section 2.3______________________________________________________________________________
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Table 2.3-1 Integration Profile Actors
Integration Profile

CATH

ECHO ECGED

StressX

X

Actor
Acquisition Modality

X

X

ADT Patient Registration

X

X

X

Department System Scheduler/Order Filler

X

X

Evidence Creator

X

X

X

X

Image Archive

X

X

X

X

Image Display

X

X

X

X

Image Manager

X

X

X

X

Order Placer

X

X

X

Performed Procedure Step Manager

X

X

X

X

Report Creator

X

X

Report Manager
Report Reader
Report Repository
Enterprise Report Repository
Time Client(note 1)

(note 1)

Display

X

Information Source

X

Notes: 1. The Time Client actor is not formally part of the Cath and Stress Workflow Profiles, but
it must be grouped with certain actors in that those Profiles.
2. …

Add to Section 2.4
Table 2.4-1. Integration Profile Transactions
Integration Profile

CATH ECHO ECGEDStressTransaction
Patient Registration [RAD-1]

X

X

X

Placer Order Management [RAD-2]

X

X

X

Filler Order Management [RAD-3]

X

X

X

Procedure Scheduled [RAD-4]

X

X

X

Query Modality Worklist [RAD-5]

X

X

X

Modality Procedure Step In Progress [CARD-1]

X

X

X

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Integration Profile

CATH ECHO ECGEDStressTransaction
Modality Procedure Step Completed [RAD-7]

X

X

Modality Images/Evidence Stored [CARD-2]

X

X

X

X

Storage Commitment [CARD-3]

X

X

X

X

Patient Update [RAD-12]

X

X

X

Procedure Update [RAD-13]

X

X

X

Query Images [RAD-14]

X

X

X

Retrieve Images/Evidence [CARD-4]

X

X

X

Instance Availability Notification [RAD-49]

X

X

X

X

Query Evidence Documents [RAD-44]

X

Maintain Time [ITI-1](note 1)

(note 1)Retrieve Specific Info for Display [ITI-11]

X

Retrieve ECG List [CARD-5]

X

Retrieve ECG Document for Display [CARD-6]

X

Encapsulated Report Submission [CARD-7]
Report Reference Submission [CARD-8]
Encapsulated Report Storage [CARD-9]
Encapsulated Report Query [CARD-10]
Encapsulated Report Retrieve [CARD-11]
Retrieve Document for Display [ITI-12]

Notes: 1. The Maintain Time transaction is not formally part of the Cath and Stress Workflow
Profiles, but it is required for the Time Client actor grouped with certain actors in thatthose Profiles.
2. …

Add to Section 2.5
In general, a product implementation may incorporate any single actor or combination of actors.
However, in the cases specified below, the implementation of one actor requires theimplementation of one or more additional actors:• The Image Archive shall be grouped with the Image Manager, and the Image Manager shall begrouped with the Image Archive.
• The Image Manager participating in Cath, Workflow or Echo, or Stress Workflow Integration
Profiles shall be grouped with a Performed Procedure Step Manager. The grouped Performed
Procedure Step Manager shall be capable of being disabled via configuration.
______________________________________________________________________________
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Copyright © 2006: ACC/HIMSS/RSNAIHE Cardiology Technical Framework Supplement – Stress Testing Workflow______________________________________________________________________________••The Department System Scheduler/Order Filler participating in Cath, Workflow or Echo, orStress Workflow shall be grouped with a Performed Procedure Step Manager. The grouped
Performed Procedure Step Manager shall be capable of being disabled via configuration.
The DSS/Order Filler and Modality Acquisition Actors participating in Cath or Stress
Workflow Integration Profiles shall be grouped with the Time Client Actor of the ConsistentTime Profile.

Add new Section 8

8 Stress Testing Workflow (Stress)
The Stress Testing Workflow Integration Profile describes the workflow associated with cardiac
stress test procedures. This profile deals with patient identifiers, orders, scheduling, status
reporting, multi-stage exams, and data storage. It specifies the scheduling and coordination ofprocedure data across a variety of imaging, ECG acquisition, measurement, and analysis systems,
and its reliable storage in an archive from where it is available to support subsequent workflow
steps, such as reporting.
This profile has much in common with the IHE Radiology Scheduled Workflow and Patient
Information Reconciliation Integration Profiles, but deals more explicitly with the multi-modality
coordination, and with stress-specific data requirements. See Rad TF-1: 3.4 for the integrated
workflow data model adopted by the IHE Technical Framework for HL7 messages and DICOM
information objects. This data model offers three major levels of control for workflow:• Order: A request for a Departmental Service• Requested Procedure: Unit of work resulting in one or more reports, with associatedcodified, billable acts.
• Scheduled and Performed Procedure Step: the smallest unit of work in the workflowthat is scheduled (work to do) or performed (work done).
A clear understanding of the workflow data model is essential to interpreting the Stress Profile.
Additional information may be found in Appendix B.
Although the major cases for stress testing workflow are described in the following subsections, it
is beneficial to also see the corresponding workflows in radiology. Rad TF-1: 3.3 has a descriptionof the “normal” scheduled workflow when all three levels of control in the data model are fully
utilized for known patients.

8.1 Actors/Transactions
Figure 8.1-1 diagrams the actors involved with this profile and the transactions between actors.
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Note that this diagram maintains the actor and transaction names specified in the Radiology
Technical Framework (RAD-TF) for consistency of definitions. In particular, note that the ImageManager / Image Archive and Image Display are required in this profile to support not just images,
but also waveforms and structured reports.

ADT

Pt. Registration [RAD-1] ↓Patient Update [RAD-12] ↓DSS/ Order Filler↓ Pt. Registration [RAD-1]↓ Patient Update [RAD-12]← Placer Order Management [RAD-2]→ Filler Order Management [RAD-3]

Time Client↑ Modality PS in Progress [CARD-1]↑ Modality PS Completed [RAD-7]

Order Placer↓ Procedure Scheduled [RAD-4]↓ Patient Update [RAD-12]↓ Procedure Updated [RAD-13]↑ Instance Availability Notification [RAD-49]
Evidence
Creator← Modality PS in Progress [CARD-1]← Modality PS Completed [RAD-7]
Storage ↓Commitment[CARD-3]

Performed
Procedure
Step Manager

Image Display↓ Modality Image/EvidenceStored [CARD-2]

Image
Manager

Report Creator↓ Query Images [RAD-14]↓ Retrieve Images/Evidence [CARD-4]

Image
Archive→ Modality PS in Progress [CARD-1]→ Modality PS Completed [RAD-7]
StorageCommitment ↑[CARD-3]↑Modality Image/EvidenceStored [CARD-2]← Modality PS in Progress [CARD-1]← Modality PS Completed [RAD-7]
Acquisition
Modality← Query Modality Worklist [RAD-5]

Report Creator

Time Client

Figure 8.1-1. Stress Testing Workflow Diagram

Table 8.1-1 lists the transactions for each actor directly involved in the Stress Profile. In order toclaim support of this Integration Profile, an implementation must perform the required transactions(labeled “R”). Transactions labeled “O” are optional. A complete list of options defined by thisIntegration Profile that implementations may choose to support is listed in Section 8.2.

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Table 8.1-1. Stress Workflow - Actors and Transactions
Optionality

Section

ADT Patient
Registration

ActorsPatient Registration [RAD-1]

R

RAD-TF 2: 4.1

Patient Update [RAD-12]

R

RAD-TF 2: 4.12

Order Placer

Patient Registration [RAD-1]

R

RAD-TF 2: 4.1

Patient Update [RAD-12]

R

RAD-TF 2: 4.12

Placer Order Management [RAD-2]

R

RAD-TF 2: 4.2

Filler Order Management [RAD-3]

R

RAD-TF 2: 4.3

Patient Registration [RAD-1]

R

RAD-TF 2: 4.1

Patient Update [RAD-12]

R

RAD-TF 2: 4.12

Placer Order Management [RAD-2]

R

RAD-TF 2: 4.2

Filler Order Management [RAD-3]

R

RAD-TF 2: 4.3

Procedure Scheduled [RAD-4]

R

RAD-TF 2: 4.4

Query Modality Worklist [RAD-5]

R

RAD-TF 2: 4.5

Modality Procedure Step In Progress [CARD-1]

R

CARD-TF 2: 4.1

Modality Procedure Step Completed [RAD-7]

R

RAD-TF 2: 4.7

Procedure Updated [RAD-13]

R

RAD-TF 2: 4.13

Instance Availability Notification [RAD-49]

O

RAD-TF 3: 4.49

Query Modality Worklist [RAD-5]

R

RAD-TF 2: 4.5

Department System
Scheduler/
Order Filler

Acquisition
Modality

Image Manager/
Image Archive

Transactions

Modality Procedure Step In Progress [CARD-1]

R

CARD-TF 2: 4.1

Modality Procedure Step Completed [RAD-7]

R

RAD-TF 2: 4.7

Modality Images/Evidence Stored [CARD-2]

R

CARD-TF 2: 4.2

Storage Commitment [CARD-3]

R

CARD-TF 2: 4.3

Procedure Scheduled [RAD-4]

R

RAD-TF 2: 4.4

Modality Procedure Step In Progress [CARD-1]

R

CARD-TF 2: 4.1

Modality Procedure Step Completed [RAD-7]

R

RAD-TF 2: 4.7

Modality Images/Evidence Stored [CARD-2]

R

CARD-TF 2: 4.2

Storage Commitment [CARD-3]

R

CARD-TF 2: 4.3

Patient Update [RAD-12]

R

RAD-TF 2: 4.12

Procedure Updated [RAD-13]

R

RAD-TF 2: 4.13

Query Images [RAD-14]

R

RAD-TF 2: 4.14

Retrieve Images/Evidence [CARD-4]

R

CARD-TF 2: 4.4

Instance Availability Notification [RAD-49]

O

RAD-TF 3: 4.49

Performed
Procedure Step
Manager

Modality Procedure Step In Progress [CARD-1]

R

CARD-TF 2: 4.1

Modality Procedure Step Completed [RAD-7]

R

RAD-TF 2: 4.7

Image Display

Query Images [RAD-14]

R

RAD-TF 2: 4.14

Retrieve Images/Evidence [CARD-4]

R

CARD-TF 2: 4.4______________________________________________________________________________
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ActorsTransactions

Evidence Creator

Report Creator

Optionality

Section

Modality Procedure Step In Progress [CARD-1]

R

CARD-TF 2: 4.1

Modality Procedure Step Completed [RAD-7]

R

RAD-TF 2: 4.7

Modality Images/Evidence Stored [CARD-2]

R

CARD-TF 2: 4.2

Storage Commitment [CARD-3]

R

CARD-TF 2: 4.3(See Text)

Refer to Table 2-1 for other profiles that may be pre-requisites for this profile.
If a Report Creator wishes to participate in this profile, it does not have to support any transactions
directly, however it is required to be grouped either with an Acquisition Modality, or with an
Image Display. This grouping enables the Report Creator to have access to the images, waveforms,
and evidence documents of the Requested Procedure. The Report Creator shall be able to referenceor transfer some contents of the created or retrieved objects into the reports it creates, and to send
those reports in accordance with another Profile.
Notes: 1. See, e.g., Report Creator in the DRPT Profile.
2. In accordance with section 2.5, there are no external transactions for the Report Creator inthis Profile. Interactions with the grouped Acquisition Modality or Image Display actor use
internal mechanisms beyond the scope of the Technical Framework.

8.2 Stress Workflow Integration Profile Options
Many Actors have Options defined in order to accommodate variations in use across domains orimplementations. Options that may be selected for this Integration Profile are listed in the table
8.2-1 along with the Actors to which they apply. Certain of these Options are required for
implementation by actors in this Profile (although they may be truly optional in other Profiles).
Table 3.2-1: Stress Workflow - Actors and Options
Actor

Option Name

Optionality

Vol & Section

ADT Patient Registration

No options defined--

Order Placer

No options defined--

Department System Scheduler/Order
FillerMulti-modality Procedure Update

R

CARD-TF 2: 4.1

PPS Exception Management

O

RAD-TF 2: 4.7

Availability of PPS-Referenced InstancesO

RAD-TF 3: 4.49

Patient Based Worklist QueryO

RAD-TF 2: 4.5

R (see note 1)

RAD-TF 2: 4.5

O

RAD-TF 2: 4.7

Acquisition Modality

Broad Worklist QueryPPS Exception Management______________________________________________________________________________
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Actor

Image Manager/ Image Archive

Option Name

Optionality

Vol & Section

Stress ECG

R (see note 2)

CARD-TF 2: 4.2

Stress Echo

R (see note 2)

CARD-TF 2: 4.2

Nuclear Medicine (see note 3)

R (see note 2)

RAD-TF 2: 4.8

PPS Exception Management

O

RAD-TF 2: 4.7

Intermittently Connected Modality

R

CARD-TF 2: 4.3

Stress ECG

R

CARD-TF 2: 4.2

Echocardiography

R

CARD-TF 2: 4.2

Nuclear Medicine (see note 3)R

RAD-TF 2: 4.8

Availability of PPS-Referenced InstancesO

RAD-TF 3: 4.49

Stress ECG

R

CARD-TF 2: 4.4

Stress EchoR

CARD-TF 2: 4.2

Cardiac NM (see notes 3, 4)

R

RAD-TF 2: 4.16

Performed Procedure Step Manager

No options defined--

Evidence Creator

No options defined--

Report Creator

No options defined--

Image Display

Note 1: The Broad Worklist Query option facilitates effective workflow in the multimodality
environment.
Note 2: An Acquisition Modality shall support one of the options Stress ECG, Stress Echo, or Nuclear
Medicine.
Note 3: Nuclear Medicine (NM) is not formally an option, but is rather a separate IHE Profile. The
Image Manager/Image Archive and the Image Display must support the NM Profile.
Note 4: The Image Display shall support the Cardiac NM Option of the NM Profile.

8.3 Stress Testing Scheduled Process Flow
The process and information flow for Stress Test procedures generally follows the same flow as
the Cath Scheduled Process Flow (see section 3.3).

8.4 Stress Testing Workflow Use Cases
Stress tests are performed to challenge the patient’s cardiovascular system in a controlled stressinducing environment.
A stress test is ordered by a physician, either inside the performing institution, or by a referral fromoutside the institution. The test is scheduled for the patient, transportation is arranged if the patientis an inpatient, equipment is scheduled, radiopharmaceuticals are ordered if the stress test is
included with nuclear imaging, a room is reserved for the test, and personnel are scheduled. The
test is performed by a physician or trained professional (such as a nurse, physician’s assistant, or
trained exercise technician).
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Copyright © 2006: ACC/HIMSS/RSNAIHE Cardiology Technical Framework Supplement – Stress Testing Workflow______________________________________________________________________________In order to stress the patient, a stress test commonly uses an exercise device such as a treadmill orbicycle ergometer. Other types of stress agents are pharmacologic and metabolic. Regardless of thestress method, the Stress Monitor measures the stress study time, obtains electrocardiograms at
discrete intervals, and reports out the performance of the patient’s cardiovascular activity at eachstage of work. The end point of the study is determined by a physician, or trained allied healthindividual, and then interpreted.
Stress testing is performed alone, or in conjunction with an imaging protocol such as a thallium
nuclear cardiology study, or stress echocardiography. The management of the test must take into
account all potential modalities.
8.4.1 Use Case S1: Cardiac Stress Test, ECG Only
A cardiac stress test is performed based on a prescribed exercise or pharmacological stressprotocol. This protocol is divided into stages of stress, where typical stages are Resting, Baseline,
Stage 1, Stage 2,…, Recovery. The patient is subjected to increasing levels of stress for each stage
while the Stress Monitor collects ECG waveforms, patient physiological parameters (stresssymptoms, heart rate, blood pressure), and equipment settings (speed, elevation, duration). A
typical stress examination goes through progressive stages until a clinical end-point is reached,such as achieving a pre-determined heart rate or emergence of symptoms preventing the patientfrom continuing (arrhythmia, hypotension, angina, fatigue, etc.). A test is typically be completed
even though the protocol did not complete, i.e., fewer than the number of planned stages werecompleted. Once the test is complete, it is interpreted by a physician, and the results are reported.
Table 8.4-1 shows a typical workflow for a cardiac stress test, showing the clinical steps and thecorresponding IHE transactions
Table 8.4-1: ECG Only Stress Use Case
Clinical Context

IHE Context

A Stress Test order is placed.

Either at the Order Placer, with a Placer OrderManagement [RAD-2] transaction, or at the
Department System Scheduler / Order Filler with aFiller Order Management [RAD-3] transaction.

The Stress Monitor equipment is scheduled, andthe type of stress protocol may be selected.

At the Department System Scheduler / Order Filler

The patient arrives for the test.
The patient demographics and order information isloaded into the Stress Monitor.

Using Query Modality Worklist [RAD-5]______________________________________________________________________________
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Selected protocol has an associated Protocol Code.
The beginning of the test is signaled with the
Modality Procedure Step In Progress [CARD-1]
transaction to the DSS/OF and Image Manager/
Image Archive.

The patient is prepared for the stress test:
The patient’s skin is prepared for the ECG
electrodes, and the electrodes are attached to theskin.
If blood pressure will be monitored, the cuff isplaced on the patient.
The patient is placed in a supine position andResting ECG waveforms are collected.

The protocol stage is selected and recorded in the
ECG object, which is sent to the Image Manager/
Image Archive using the Modality Images/
Evidence Stored [CARD-2] transaction.

If using an exercise stress protocol, the patient getson the exercise equipment at rest, and Baseline
ECG waveforms are collected.

The protocol stage is selected and recorded in the
ECG object, which is sent using the Modality
Images/Evidence Stored [CARD-2] transaction.

The stress protocol is started and ECG waveforms
are collected as the protocol is run through its
stages of increasing stress. For an exercise
protocol, this is typically done by increasing theelevation and/or speed of a treadmill or increasing
the resistance of an ergometer. For apharmacologic protocol, this is done by periodic
drug injections.

The protocol stage is selected and recorded in the
ECG object, which is sent using the Modality
Images/Evidence Stored [CARD-2] transaction.

The test is terminated when the patient reaches“maximum stress” or exhibits other adverse
symptoms.
The Recovery ECG waveforms are collected.

The protocol stage is selected and recorded in the
ECG object, which is sent using the Modality
Images/Evidence Stored [CARD-2] transaction.

The exam is ended and the patient released.

Additional stress exam data (measurements,
procedure log) is sent using the Modality Images/
Evidence Stored [CARD-2] transaction.
The end of the test is signaled with the Modality
Procedure Step Completed [RAD-7] transaction.
Storage of objects to the Image Manager/ Image
Archive is confirmed with the Storage
Commitment [CARD-3] transaction.

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the Stress Monitor, or on a reviewing workstation.

The Image Display actor uses Query Images[RAD-14] and Retrieve Images/Evidence [CARD4] to retrieve ECG objects

The physician interprets the results and creates areport.

The Report Creator actor sends a report (using
another profile).

8.4.2 Use Case S2: Cardiac Stress Test with Imaging
It is estimated that 80+ % of stress tests are done in conjunction with an Echo or Nuclear exam in
the acute care market in the United States. Therefore, there exists a clinical need to combine
clinical information from Stress Monitors and Imaging Modalities. In these cases the medical
devices involved in the exams shall be synchronized to a common time source. The
synchronization is required to correctly time align the Stress Monitor data with the Imaging data.
Table 8.4-2 shows a typical workflow for a cardiac stress test with imaging, showing the clinicalsteps and the corresponding IHE transactions
Table 8.4-2: ECG with Imaging Stress Use Case
Clinical Context

IHE Context

A Stress Test order is placed.

Either at the Order Placer, with a Placer OrderManagement [RAD-2] transaction, or at the
Department System Scheduler / Order Filler with aFiller Order Management [RAD-3] transaction.

The Stress Monitor equipment and Imaging
modality are scheduled, and the type of stressprotocol may be selected.

At the Department System Scheduler / Order Filler

The patient arrives for the test.
The patient demographics and order information isloaded into the Stress Monitor and Imaging
Modality.

Using Query Modality Worklist [RAD-5]

The stress protocol is confirmed or changed asdetermined by the person performing the test.

Selected protocol has an associated Protocol Code.
The beginning of the test is signaled with the
Modality Procedure Step In Progress [CARD-1]
transaction to the DSS/OF and Image Manager/
Image Archive.

The ECG waveform analog output from the Stress
Monitor is connected to the Imaging Modality.
This analog output provides a cardiac gating signal
for the collection of cardiac images.

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The patient’s skin is prepared for the ECG
electrodes, and the electrodes are attached to theskin.
If blood pressure will be monitored, the cuff isplaced on the patient.
The patient is placed in a supine position andResting ECG waveforms are collected.

The protocol stage is selected and recorded in the
ECG object, which is sent to the Image Manager/
Image Archive using the Modality Images/
Evidence Stored [CARD-2] transaction.

Resting, pre-stress images are collected.

The protocol stage is selected and recorded in theimage object, which is sent to the Image Manager/
Image Archive using the Modality Images/
Evidence Stored [CARD-2] transaction.

If using an exercise stress protocol, the patient getson the exercise equipment at rest, and Baseline
ECG waveforms are collected.

The protocol stage is selected and recorded in the
ECG object, which is sent using the Modality
Images/Evidence Stored [CARD-2] transaction.

The stress protocol is started and ECG waveforms
are collected as the protocol is run through its
stages of increasing stress. For an exercise
protocol, this is typically done by increasing theelevation and/or speed of a treadmill or increasing
the resistance of an ergometer. For apharmacologic protocol, this is done by periodic
drug injections.

The protocol stage is selected and recorded in the
ECG object, which is sent using the Modality
Images/Evidence Stored [CARD-2] transaction.

Mid-stress images are collected as needed. For an
exercise protocol, the patient steps off the treadmill
or ergometer for the imaging process.

The protocol stage is selected and recorded in theimage object, which is sent to the Image Manager/
Image Archive using the Modality Images/
Evidence Stored [CARD-2] transaction.

The test is terminated when the patient reaches“maximum stress” or exhibits other adverse
symptoms.
Peak stress images are collected.

The protocol stage is selected and recorded in theimage object, which is sent to the Image Manager/
Image Archive using the Modality Images/
Evidence Stored [CARD-2] transaction.

The Recovery ECG waveforms are collected.

The protocol stage is selected and recorded in the
ECG object, which is sent using the Modality
Images/Evidence Stored [CARD-2] transaction.

The exam is ended and the patient released.

Additional stress exam data (measurements,
procedure log) is sent using the Modality Images/______________________________________________________________________________
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Evidence Stored [CARD-2] transaction.
The end of the test is signaled with the Modality
Procedure Step Completed [RAD-7] transaction.
Storage of objects to the Image Manager/ Image
Archive is confirmed with the Storage
Commitment [CARD-3] transaction.
The stress test is reviewed by a physician, either on
the Stress Monitor, or on a reviewing workstation.

The Image Display actor uses Query Images[RAD-14] and Retrieve Images/Evidence [CARD4] to retrieve ECG, image, procedure log, andmeasurement objects.

The physician interprets the results and creates areport.

The Report Creator actor sends a report (using
another profile).

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Additions to IHE Cardiology Technical Framework
Volume 2
Add to Section 4.2

4.2 Modality Images/Evidence Stored [CARD-2]...
4.2.6 Stress ECG Option
Image Archives supporting the STRESS ECG option are required to support all of the SOP classes
listed in Table 4.2-1 below.
Table 4.2-10. Stress ECG SOP Classes
SOP Class UID

SOP Class Name

1.2.840.10008.5.1.4.1.1.9.1.1

12-Lead ECG Waveform Storage

1.2.840.10008.5.1.4.1.1.9.1.2

General ECG Waveform Storage

1.2.840.10008.5.1.4.1.1.88.22

Enhanced SR

1.2.840.10008.5.1.4.1.1.88.33

Comprehensive SR

1.2.840.10008.5.1.4.1.1.88.40

Procedure Log

1.2.840.10008.5.1.4.1.1.104.1

Encapsulated PDF

Acquisition Modality actors supporting the STRESS ECG option are required to support a numberof attributes in ECG Waveform objects created for a stress procedure as described in Table 4.2-11.
Many of these requirements build on attributes which are Type 2 or Type 3 in DICOM (suchattributes are indicated with R+).
Table 4.2-11. Attributes That Convey Staged Protocol Related Information
Attribute Name

Tag

Requirement

Performed Procedure Step Description(0040,0254)

R+

Protocol Name

(0018,1030)

R+

Performed Protocol Code Sequence(0040,0260)

R+

Acquisition Context Sequence(0040,0555)

R+______________________________________________________________________________
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Table 4.2-12. ECG Stress Protocol Codes
Coding Scheme
Designator(0008,0102)

Code Value(0008,0100)

Code Meaning(0008,0104)

SRT

P2-7131C

Balke protocol

SRT

P2-7131A

Bruce protocol

SRT

P2-7131D

Ellestad protocol

SRT

P2-7131B

Modified Bruce protocol

SRT

P2-713A1

Modified Naughton protocol

SRT

P2-713A0

Naughton protocol

SRT

P2-7131F

Pepper protocol

SRT

P2-7131E

Ramp protocol

SRT

P2-31102

Bicycle Ergometer Stress Test protocol

99IHE

PHARMSTRESS

Pharmacologic Stress protocol

99IHE

PERSANTINE

Persantine Stress protocol

99IHE

ADENOSINE

Adenosine Stress protocol

99IHE

DOBUTAMINE

Dobutamine Stress protocol

Adapted from DICOM PS3.16-2006
Note:

The pharmacologic stress protocol concepts have been submitted to SNOMED for assignmentof codes. Such codes are expected to be available at the time of adoption of Final Text for thisTransaction.

The Acquisition Context Sequence shall include at least the two content items shown in Table 4.213, drawn from DICOM Template 3401, and use the codes from DICOM Context Group 3262
shown in Table 4.2-14.
Table 4.2-13. Acquisition Context Items
Value
Type

Concept Code

Value

CODE

(109054, DCM, ”Patient State”)

See Table 4.2-14

NUM(109055, DCM, ”Protocol Stage”)

Numeric Value, Units of Measurementis (“{stage}”, UCUM, “stage”)

Adapted from DICOM PS3.16-2006______________________________________________________________________________
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Table 4.2-14. Patient State Codes
Coding Scheme
Designator(0008,0102)

Code Value(0008,0100)

Code Meaning(0008,0104)

SRT

F-01604

Resting state

SRT

F-01602

Baseline state

SRT

F-01606

Exercise state

SRT

F-01608

Post-exercise state

Adapted from DICOM PS3.16-2006

Add to Section 4.4

4.4 Retrieve Images/Evidence [CARD-4]...
4.4.4 Stress ECG Option
Image Display actors supporting the STRESS ECG option are required to support all of the SOPclasses listed in Table 4.4-8 below.
Table 4.4-8. Stress ECG SOP Classes
SOP Class UID

SOP Class Name

1.2.840.10008.5.1.4.1.1.9.1.1

12-Lead ECG Waveform Storage

1.2.840.10008.5.1.4.1.1.9.1.2

General ECG Waveform Storage

1.2.840.10008.5.1.4.1.1.88.22

Enhanced SR

1.2.840.10008.5.1.4.1.1.88.33

Comprehensive SR

1.2.840.10008.5.1.4.1.1.88.40

Procedure Log

1.2.840.10008.5.1.4.1.1.104.1

Encapsulated PDF

4.4.4.1 Expected Actions
The Image Display actor is expected to render the ECG waveforms in a clinically relevant way.
The actor is expected to be able to handle the display of representative beats and rhythm
waveforms. Stress ECGs are typically not more than 15 leads. Full disclosure ECG waveforms
from the entire test are typically less than 30 minutes. Each waveform must be labeled with thelead name. The following information about the waveforms shall be displayed:•

Voltage scale______________________________________________________________________________
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Time scale•

Frequency content•

Acquisition time•

Originality -- e.g., original (rhythm) or derived (representative beat)•Protocol name, protocol stage, and patient state.

The Image Display actor shall support the display of DICOM Encapsulated PDF and DICOM SRSOP Instances.
Note:

An Image Display that supports a DICOM SR SOP Class is required (by the DICOM
Standard) to unambiguously render all legal SOP Instances within that SOP Class, regardlessof the Template used to create it. See DICOM PS3.4 Annex O.

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Add new Appendix

Appendix X – Stress Test Protocol and Stage Identification
For various historical and clinical reasons, the manner in which stress test protocols and protocol
stages are identified differs across the modality information object definitions. This appendix
elucidates the requirements for such identification.

X.1 Procedure
In stress testing, the selection of the protocol is first constrained by the selection of the type ofstress test procedure, i.e., the modality or modalities to be used (stress ECG alone, ECG plus echo
or nuclear imaging, or imaging alone), and the selection of the stress induction method (exercise or
pharmacological). This top level procedure type selection must be done at test scheduling time inorder to marshal the necessary resources for the test, and is conveyed in the Requested Procedure
Code Sequence.

X.2 Protocol
Within the Requested Procedure, the specific protocol is selected. Typically this is done at theacquisition equipment when the test is set up. However, it can also be specified (or recommended)
during scheduling. In the DICOM information model, this protocol is a modality-dependent
construct associated with the scheduled and performed procedure steps.
As a modality-dependent construct, there is no need for the protocol to be identical between the
ECG and imaging modalities. In fact, the ECG modality may have a deeper understanding of therange of such protocols than the imaging modalities. The clinical requirement is for each modality
to encode its acquired data with sufficient information about the protocol so as to be able tointerpret the data.
When the protocol is selected during scheduling, its coded representation is passed to themodalities in the Scheduled Protocol Code Sequence attribute. The protocol actually used by themodality (which may differ from the scheduled protocol) is reported in the Performed Protocol
Code Sequence attribute of the composite object and the Modality Performed Procedure Step
object. The required values for this attribute are enumerated in table 4.2-3 for Echo and in table
4.2-12 for ECG. It is recommended that NM use the values in 4.2-12.
Note that the ECG Acquisition Context Template 3401 used in Stress ECG Waveform objects
allows encoding of the protocol in the Acquisition Context Sequence attribute, but that use isdeprecated by IHE in favor of the Performed Protocol Code Sequence attribute.

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X.3 Stage
Stress protocols typically have a series of stages. These stages typically increase the level ofstress. Each stage is defined by the protocol and is identified by a number. For example, theBruce protocol has 7 stages of work identified as stages 1, 2, 3, 4, 5, 6 and 7. Stage 1 has atreadmill speed of 1.7 mph with a 10% grade and stage 7 has a speed of 6.0 mph with a 22% grade.
These protocol stage identifiers are recorded with the ECG waveforms in the Acquisition Context
Sequence.
The state of the patient relative to the overall test regimen is recorded in the Acquisition Context
Sequence of ECG and NM objects as “Patient State”. These coded states are enumerated in table
4.2-14.
The echocardiography modality also records the patient state using the attribute Stage Code
Sequence. These codes are enumerated in table 4.2-4 and convey similar concepts to those in table
4.2-14. Echocardiography similarly identifies for grouping purposes all images acquired in aparticular patient state using a numeric value denoted “Stage Number”. This “Stage Number”
should not be confused with the protocol stage number; it is a sequencing number meaningful only
to the echo modality.

X.4 Attribute Summary
A summary of the attributes used for protocol and stage identification is show in Table X-1.
Table X-1. Stress Protocol and Stage Concepts and Attributes
Concept

Modality Worklist

Echo

ECG

NM

Requested
Procedure

Requested Procedure
Code Sequence(0032,1064)

Procedure Code
Sequence(0008,1032)

Procedure Code
Sequence(0008,1032)

Procedure Code
Sequence(0008,1032)

ProtocolScheduled Protocol
Code Sequence(0040,0008)

Performed Protocol
Code Sequence(0040,0260)
CID 12001*

Performed Protocol
Code Sequence(0040,0260)
CID 3261

Performed Protocol
Code Sequence(0040,0260)
CID 3261**

ProtocolStage
NumberPatient
State

Acquisition Context
Sequence(0040,0555)>(109055, DCM,
“Protocol Stage”)
Stage Number(0008,2122)
Stage Code
Sequence(0040,000A)
CID 12002*

Acquisition Context
Sequence(0040,0555)>(109054, DCM,
“Patient State”)
CID 3262

Acquisition Context
Sequence(0040,0555)>(109054, DCM,
“Patient State”)
CID 3101______________________________________________________________________________
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