Session 702 - I'm a VistA Imaging Coordinator with a New System. Now What ?

1. Session 702 - I'm a VistA Imaging Coordinator with a New System. Now What ? Presented by Jeannie Jernigan, VistA Imaging PACS Administrator, OI&T VAMC Fayetteville, NC

2. Session Outline • Terms - Contingency Plans • Configurations - Implementation Workgroup • DICOM Basics - Getting Support • DICOM Gateways - Troubleshooting • Image Quality - Patches and Testing • Adding New Devices • Preventive Maintenance

3. TERMS • VistA • Veterans Information System and Technology Architecture. • Primary system for storing and maintaining the patient electronic medical record. Text based – Not designed for Images • Imaging • Parallel system linked with VistA • Storage and Archive, Terabytes of Storage! • Management of captured data (corrections, deletions) • Retrieval • Allows the images to be linked with various parts of the patient record in VistA. • Both systems use program code written in Mumps and run in the Cache’ Database environment.

4. TERMS (continued) • PACS - Picture Archiving and Communication Systems (PACS) are computer systems dedicated to the storage, retrieval, distribution and presentation of images. • HL7 – Health Level 7 (HL7) is standard based electronic message format supporting administrative, logistical, financial as well as clinical processes. • DICOM - Digital Imaging and Communications in Medicine (DICOM) is a standard for handling, storing, printing, and transmitting information in medical imaging. • CPRS – Computerized Patient Record System. • Clinical Workstation – Software installed on workstations without any additional enhanced viewing software or monitors. • Diagnostic Workstation – Specialized workstation that allows Radiologists to interpret radiology images without film (calibratible monitors).

5. WHAT’S IN IMAGING? Scanned Documents Ultrasounds Rich Text Reports Dental Images ECG Waveforms Ophthalmic images Patient Photo Pathology Images X-Rays Digital Camera CT’s Diagram Annotations MRI’s Dermatology images And more…

8. VISTA IMAGING CONFIGURATIONS VistA Imaging can be installed in several levels • Basic Configuration - Storage only with Capture Workstation. Used for document scanning and Clinical Procedure reports image capture and re-display (includes Tele Retinal and Tele Derm images) • DICOM Configuration - Basic plus DICOM Gateways to handle DICOM modalities • VistARad – DICOM configuration plus VistARad running on Diagnostic Workstations • Image Routing – VistARad configuration using Image Routing for remote viewing. • DICOM Configuration with Commercial PACS – DICOM Configuration plus Commercial Radiology PACS

9. BASIC CONFIGURATION • Per VA requirement each facility must have VistA Imaging storage in place to handle scanned documents, Clinical Procedure reports, and PACS Archive. This is the minimum configuration. • RAID Storage - Holds Images (short term). Images are purged after a prescribed time period. • Optical Jukebox – Holds Images (Long Term/Archive) Could be centralized. • Background Processor (manages transfers to and from Jukebox, as well as other activities) • Clinical Display installed as needed • Clinical Capture installed as needed, OR interface to an approved commercial document capture system. • http://vaww.va.gov/imaging/ImgMandate12001045.pdf

10. DICOM CONFIGURATION • Adds DICOM processing to the Basic Configuration • Allows text information (worklist) transfer to and image storage from DICOM modalities. • Applications include • Computed Radiography • Dental Image capture • Ophthalmology Image Capture • Dermatology Image Capture • Transferring DICOM images to other modalities, such as DICOM Printers (via DICOM Store) • Encapsulated PDF’s

11. MORE DEFINITIONS • SCU(Service Class User) – Device taking a client role (example: device that sends print jobs) • SCP(Service Class Provider) – Device that takes a host role (Example: DICOM print server). • DICOM Images are a Composite Format • Image Data for the actual picture • A “Header” area at the beginning of the file that contains the “DICOM Header”. This area is for text data associated with the image, containing • Patient Identifying information • Exam information (date of exam, accession number, case number) • Information about acquisition modality (manufacturer, model) • Image information (geometry, attributes) • And lots of other stuff…

12. Worklist Image Capture QA/Storage Patient Two X:2056 Y:1998 ? Patient One Patient Two DICOM Patient Two 000-28-1665 X:2056 Y:1998 Patient, Two 000-28-1665 X:2056 Y:1998 DICOM Text Gateway DICOM Image Gateway Background Processor Patient Two Image Storage (RAID - Magnetic) VistA Patient Two X:2056 Y:1998 HL7 Patient Two Optical Archive

13. Configuration 3: DICOM with VistARad • Adds VistARad diagnostic workstations to the DICOM configuration • Allows radiologists to interpret radiology images on computer (soft-copy interpretation) • VistARad is simply Image viewing software with tools helpful to a radiologist • Runs on select workstations equipped with Diagnostic monitors • Communicates with VistA to update exam status when interpreted • Currently Patch 101 • Free software

14. VistARad Diagnostic WS Background Processor Image Storage (RAID - Magnetic) VistA Optical Archive Radiology Status Waiting for Exam Examined Interpreted Transcribed Complete

15. Configuration 5: VistaRad with Image Routing • Image Routing – Allows VistaRad workstations to be used across slower WAN (Wide Area Network) connections. • Text Data Stream – Used to display the Unread list and patient text reports. Since the text data stream is so small it still comes directly from Vista. • Image Data Stream – Which is much larger, gets pushed to the workstation in advance of reading. • Dicom Gateways – Are used to push the images to the appropriate workstation. • Images can be routed “on demand” or “Autorouted”.

16. Configuration 6: DICOM with Commercial PACS • PACS – Picture Archival and Communication System • Self contained patient management system for radiology • Includes separate • Patient Management and Worklist • Image Acquisition and QA • Storage • Diagnostic Interpretation • VistA Imaging sees a PACS simply as a modality • Sends it DICOM worklist and receives images • Required to store PACS images simultaneously in VistA Imaging - Portability

17. Image Capture Worklist QA/Storage IMAGPAT, 1 RIS Image Storage PACS Diagnostic WS COMMERCIAL PACS

18. Commercial PACS Continued Pros Self Contained – not solely dependent on VistA or other external systems. Robust Feature Set – Watch for dependencies Cons Self Contained – If integrated with another system like Vista or other HIS, data must be kept synchronized, and QA’d on both systems. Expensive to Buy and Maintain Data Stored in Proprietary Format

19. DICOM Text Gateway • Used to run Micronetics Mumps (MSM) on Windows 2000/XP, now run on Cache instead of MSM, and Windows 2003 Server instead of 2000/XP • Is a Worklist SCP Modality (since it responds to query requests from clients) • Queries HL7 messages from VistA to fetch data • Vista builds HL7 messages from exam orders into a global called MAGDHL7. The text Gateway pulls the messages from that global and stores in it’s internal database. • Converts data to DICOM and sends to the requesting modality.

20. DICOM Image Gateway Up Close • Like the Text Gateway, also runs MSM on Windows 2000/XP, now on Cache instead of MSM, and Windows 2003 Server instead of 2000/XP • Storage SCP Modality (among others!) • Receives DICOM Images from modalities and… • Examines Patient and exam information in the DICOM Header • Queries VistA to verify a match on Name, SSN, and Accession Number. • If no match, image is held and flagged for correction • If matched, the Image Gateway • Queries VistA for an IEN (Internal Entry Number) • Splits the DICOM file appropriately • Stores/copies the image(s) to the RAID • Notifies VistA of the file locations on RAID for later retrieval • Queues a BGP entry for copy to Jukebox

21. DICOM Image Gateway Up CloseSaving DICOM Files as TGA • Targa conversion is a legacy method of converting the DICOM image data to Targa format. The conversion involves splitting the DICOM image file as follows… • BIG File– An exact TGA version of the Image data in larger DICOM files (such as X-Rays). Non-existent for smaller images. • TGA File – A second version of the TGA file. • For large images like X-Rays, this is generally 1:8 reduced. • For smaller images (CT slices, ultrasounds) this is the whole Image. • TXT File – Contents of DICOM Header • ABS File – Abstract Image or thumbnail of the image. • Once beneficial, now being replaced by native DICOM Storage. • Native DICOM storage simply copies the DCM (DICOM) file into storage with it’s associated TXT and ABS file.

22. VistA RAD • Terms of Use • Use of the VistARad diagnostic workstation is subject to the following provisions: Caution: Federal law restricts this device to use by or on the order of either a licensed practitioner or persons lawfully engaged in the manufacture or distribution of the product. • No modifications may be made to this software without the express written consent of the VistA Imaging National Project Manager. • The Food and Drug Administration classifies the VistARad software as a medical device. Modifications to the VistARad diagnostic workstation, such as the installation of unapproved software, will adulterate the medical device. The use of an adulterated medical device violates US federal law (21CFR820). • Image presentation quality depends on monitor resolution, and on regular monitor testing and calibration to correct for display degradation over time. It is the responsibility of the clinical practitioner to determine if images presented on a VistARad workstation are of sufficient quality for clinical interpretation. Any concerns regarding monitor resolution or calibration should be reported immediately to the Imaging Coordinator before interpretation is performed.

23. Image Quality Basics • Image Quality is Everything • Good, Working, Appropriate Equipment • Appropriate Resolution (aka Image Matrix) • 1:1 Pixel Ratio – The Ideal Scenario • Image Type Requirements • Larger display matrices are in “Megapixels”, ie 5mp is 2500x2000 pixels. • Intended Use (Clinical Review vs. Diagnostic Review) • Proper Grayscale • 0 to 100 in 1/60 of a Second • What Affects Perceived Grayscale? • Hardware Limitations, Setup, Environment • Appropriate and Calibrated Resolution/Grayscale is at the Heart of a Diagnostic Display System

24. Image Quality and Grayscale CalibrationProducing a Good Curve

25. Adding New DICOM Modalities Tools to Help Ensure Successful Interface • DICOM Conformance Statement – Should be required BEFORE procurement. • Vendor Survey – Required component of Directive 6550 • Networking/Security specifics (no external modems required, etc) • Users do not require administrative privilege to function • Physical characteristics (electrical, floor loading, environmental) • Any items you wish you knew from prior procurements • Contact Silver Spring (VHA VI DICOM Validation mail group) to verify that the device is approved for interface if not on the approved list on the web site (yes it MUST be approved). • If the device is not approved instruct the vendor to contact Silver Spring for validation. Do not back down on this! Approved list http://vaww.va.gov/imaging/VistA_Imaging_DICOM_Modality_Interfaces.pdf

26. Documentation • Image Acquisition Technical Data Sheets • 2 Different forms – DICOM and Clinical Capture • Need to submit a form for each new modality and/or Clinical Capture device • Image Quality Certification Form • Submitted after interface is in use • Completed by end user • Latest forms on Imaging/Clinical Procedures Web Site • http://vaww4.va.gov/imaging/IMGplanproc.htm • http://vista.med.va.gov/ClinicalSpecialties/clinproc/

27. Preventive MaintenanceNot official OR comprehensive! • Each Morning • Review basic operation, DICOM Gateways, BGP, Jukebox, etc. • Review System logs for events • Review VistA error trap • Review prior night’s Backups • Remove any completed Jukebox copy media to secure location • Walk through key areas as time permits • Keep a log of any anomalies • Monthly • Monthly backup operations (remove media to offsite, etc) • Purge DICOM Gateways • Check RAID free space

28. Disaster/Contingency Plans • PLAN for Disasters • Make a point to make your disaster guide easy to follow in urgent situations • Label key information on critical equipment for quick access (where appropriate. Be discrete with public equipment) • Document Formula (Again, NOT Official) Consult with your ISO • Accurate Table of Contents • Emergency Contacts • System overview with good diagrams • Key information for each piece of equipment. Give complex devices (Imaging SAN) an overview section AND component sections • Function • Effect of Outage • Startup/Shutdown procedure • Contingency Plan • Notes

29. Implementation Workgroup • Group comprised of key individuals representing key disciplines (Required by Directive 6550) • Integrating Service (Radiology, Cardiology, etc) • Imaging Coordinator (YOU!) • IRM • Biomedical Engineering • Procurement (If considering major purchases) • Your Implementation Manager for larger projects • Helps keep the Devil OUT of the details • Should be involved on EVERY medical device purchase that hopes to integrate with VA network.

30. Getting Support • National Helpdesk 888-596-4357 • Will help you identify who to contact • Will page support personnel and enter Remedy tickets for urgent issues • Remedy for VA Package Issues (VistA Imaging) • Use Remedy to track the status of your support calls and update support staff • HP Expertise Center – 800-299-7282 • Will help with server hardware issues

31. Weekly Imaging Conference Call • Held each Thursday from 12:00 – 1:00 PM Eastern Time • Forum for announcing new developments • Forum for addressing the group on issues your site/VISN may be experiencing • Call in number – 800-767-1750, code - 18449 • Monthly HP Imaging Conference Call • Held 3rd Tuesday of the month from 2:00 – 3:00 PM Eastern Time (1-877-675-4345, Passcode: 2102543262) • Forum for hardware issues • Get on the ListServe to receive critical updates and requests.

32. TROUBLESHOOTING • I’m still getting an “ID Mismatch” Why? Answer: If BOTH the ICN and the SSN have been changed, the images will be non-viewable. • No images on a patient, but the case says it’s complete. a. Did the images really get sent from the modality/device? b. Are they a DICOM correct? • Image is there but non-viewable. Answer: Patch 93 introduced the TIU Business rule association. If an image is associated to a progress note that is non-viewable, you will no longer be able to view that image.

33. Keys/Menu Options • IMAG Imaging System Manager Menu ... [MAG SYS MENU] **> Locked with MAG SYSTEM • MAG WINDOWS • MAG DELETE • MAGDISP Clin/MAGDISP Admin • MAG CAPTURE, MAGCAP TIU, MAGCAPMAGJ VISTARAD • MAGJ VISTARAD WINDOWS • WINDOWSVRAD Keys: MAGJ

34. Patches • Patch 94 Clinical Capture/Display Client • Patch 90 VistARAD • Patch 83 VistA Imaging Exchange (VIX support • Patch 39 BGP Enhancements • 66 DICOM Query/Retrieve • Others

35. Patch 90 is a VistARad enhancement patch that also has BSE and includes remote image views in the patient exams list, the capability to remotely read/interpret studies; and provides a single sign-on to a group of selected remote sites and the local site. • Patch 83 allows remote image viewing of VA/DoD and VA-to VA Image Sharing (using the VIX environment). It allows access to DoD radiology images using existing Clinical Display remote image views functions. And, in conjunction with 90, allows new VA-to-VA remote image access and remote exam list monitoring for VistARad (enhanced remote reading capabilities). • Patch 39 is the Background Processor Enhancement patch that allows for automatic restart of the BGP upon disconnection, PGP system monitor status failure email user notifications (set frequency intervals and recipients); and an improved GUI interface for managing the BGP settings (BGP queues, etc) in addition to improved purge options (manual purge by selected shares, purge by Date Modified, purge by Date Created). (VEHU Imaging Session 760) • Patch 66 DICOM Query/Retrieve provides the ability for DICOM to serve as a Service Class Provider (SCP) to enable current specialty workstations, PACS, and teleradiology systems to query and retrieve images stored in VistA Imaging. • Some other improvements in field testing include (not a complete listing): • 98 Storage Utilities (MagDexter, MagUtility, MagKat) – to backfill specific fields in Image file #2005 to address discrepancies that may appear in displaying older images; new storage mgmt utilities with GUI’s. • 99 DICOM Object Storage – Allow the option to store all currently supported DICOM modalities images in native DICOM format that would otherwise be stored in Targa formate (e.g. CR & DX modalities) WITHOUT changing or transforming the presentation. • 105 Advanced Web Image Viewer (AWIV) Development – will let VistAWeb users locate and display VA images associated with progress notes (supports display of images associated with Radiology reports as well) • Some others to mention that are in Development: • 34 Storing DICOM objects Phase 3 – takes patch 99 further in that it allows storage of all composite DICOM objects that are transmitted to VistA Imaging for currently supported and unsupported SOP class images regardless of modality. The images are retained in DICOM format without alteration. The storage of DICOM objects in DICOM format will be mandatory in Patch 34. • 106 Teledermatology – includes DICOM image capture via the VistA Imaging Clinical Capture/Display client; controlled use of Telereader with Thin Clients; and limited annotation when reviewing images in Telereader/display. (currently specialized software is utilized to capture TeleDerm images). • 115 – VistA Rad Enhancements – Includes a process for automatically updating the VistARad client software; CCOW integration, provides management functions including remove or disable a user from the settings file (e.g. residents who leave). Also provides a default profile to copy settings/hanging protocols to new users. • 117 Maintenance for Display and capture – (improve QA reporting features, ability to print multiple images, deleted image placeholder, to name a few) • There are several other maintenance and enhancement patches for VistARad, Display and Capture and the gateways that are underway. Each will improve the current products being used and address Remedy ticket issues that have been reported.

36. Becoming a Test Site • Why should I? • Helps the project • Helps your site (help shape new software) • Test Phases • E3R/NSR • Concept and Development • Internal Testing • Alpha Testing – Design refinement and bug squashing • Beta Testing – Small bug squashing • Release • Test Documentation • Testing Scenarios • Site Feedback Forms

37. Questions…