701H The PACS Paradigm

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701HThe PACS Paradigm

• Introduction to PACS and VistARad
• Presenters Peter A Rosenthal MD
• John H Christensen, Lead Developer VistARad

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Order of program

• Welcome and introduction of speakers
• Presentations
• Thinking about PACS
• General principles for configuring PACS stations
• VistARad and PACS
• Experience from the field
• Efficiency, cost, other issues
• VistARad The National Perspective
• VistARad New Horizons

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Aims Attendees will understand

• Principles for planning and designing protocols
  for reading all diagnostic imaging modalities
• Monitors type, number, display divisions
• Arrangement of reading environment display
  functions and monitor division
• Key parameters exam resolution, number of
  images, number of series, comparison exams,
  other IT resources
• VistARad performance by the case and nationally

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Replicate the film auto-alternator?
Thinking about PACS
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Set-up Consensus Model
Voice recogn
Minimum 17 color pc monitor for controls (
Color US)
Dedicated High res diagnostic reading monitors
How did we get here?
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Charleston, SC
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Ralph H Johnson VAMC

• Charleston SC
• 4 6 Attending radiologists
• All modalities except
• mammography, PET
• high-end interventional
• 10 years plus transition from film to filmless
  and now almost paperless
• VistARad since 2003
• VistARad 65 and Voice since 2005

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The road to VeHU

• Siegel et al /
• Ergonomics
• VistARad 16-32
• Alpha user 18-65
• Site visits

PACS SYSTEMS CAN BE FULLY CUSTOMIZED!
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Ergonomics RSNA Web Links
RSNA / Baltimore VA Elliot Siegel, MD

• Reading room makeover
• http//www.rsna.org/Publications/rsnanews/july06/r
  ead_july06.cfm
• Virtual tour of reading room (collaboration
  with GE)
• http//www.rsna.org/Publications/rsnanews/upload/G
  E_Reading_Room.swf
• Digital eye for the analogue guy
• http//www.rsna.org/Publications/rsnanews/upload/D
  igital-Eye-for-the-Analog-Guy.html
• Research, Experience and Advice - Presentation
  by Eliot Siegel, M.D. (of Baltimore VA) to the UK
  Radiological Congress, details the facility's
  experience renovating the reading room. Dr.
  Siegel explains the research that preceded the
  design and continues today in what has become an
  ergonomics research laboratory. (PPT file
  http//www.rsna.org/Publications/rsnanews/upload/U
  KRC_2006_Designing_the_Radiology_Reporting_Room.pp
  t)

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Ergonomics RSNA Web Links
RSNA / Baltimore VA / Elliot Siegel, MD

• Reading room makeover
• Reading Room
• Virtual tour of reading room (collaboration
  with GE)
• Innovations in Reading Room Design
• Digital eye for the analogue guy
• Digital-Eye-for-the-Analog-Guy
• Research, Experience and Advice This
  presentation, made by Baltimore VA radiologist
  Eliot Siegel, M.D. at the UK Radiological
  Congress, details the facility's experience
  renovating the reading room. Dr. Siegel explains
  the research that preceded the design and
  continues today in what has become an ergonomics
  research laboratory. (PPT file)

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Consensus Model Standard
MR station has 3 hi res monitors
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Thinking about PACS But Why?

• Why optimize the radiologists use of the
  systems capabilities?
• Why not just make the PACS system do what
  everyone is used to?

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Technology and the American Civil War
Lessons from Gettysburg
The battle of Gettysburg, Pa. July 3d.
1863CREATED/PUBLISHED New York  Published by
Currier Ives, 1863? Wikipedia
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Technology and the American Civil War
two armed mobs chasing each other around the
country, from which nothing can be learned
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Technology and the American Civil War

• MILITARY REVIEW,  May-June, 2004  by Richard D.
  Moorehead
• The conduct of war changed as a result of three
  technological advances during the Civil War the
  rifled musket, the electric telegraph, and the
  railroad.

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Napoleonic Tactics

• Napoleonic tactics of linear frontal assault of
  massed forces, supported by direct-fire artillery
  and quick cavalry charges, was the recipe for
  battlefield success.

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Napoleonic Tactics

• smoothbore muskets - effective range of 100 yards
  
• canister artillery - max range of
  400 yards

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The Rifled Musket

• Civil War rifled musket had an effective range of
  over 500 yards when firing the conical Minie
  ball.

• smoothbore muskets - effective range of 100 yards
  
• canister artillery - maximum range of 400 yards

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American Civil War The Rifled Musket

• The Civil War infantryman, using a rifled musket
  could target artillerymen before they were within
  range of canister fire
• Rifled musket also allowed the infantryman to
  attack cavalry soldiers from a much greater
  distance
• The change in infantry firepower shifted the
  tactical strength of armies from offense to
  defense by making frontal infantry assaults too
  costly

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Lees Plan Day 2
Given the state of technology, the best answer
was to avoid massed frontal assaults. One obvious
method was to attack an enemy's flanks.
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Gettysburg
Day 3
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The Lessons of Gettysburg

• Understand the operational aspects of a new
  technology to put it to most effective use.

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Replicate the film auto-alternator?
Thinking about PACS
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In PACS Key elements
Scrolling through stacks beats Scanning
over layouts In VistARad The value of variable
size view ports and the Double click zoom
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Scrolling beats scanning

• Re-inventing the Wheel
• The wheel on the mouse!
• Other variations
• Mouse on wheel
• Re-inventing the frog

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Riding beats swimming
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Patch 32
Layout

• Ye olde auto-changer
• 4 monitor VistARad 32
• Layout and stack views

Modeled on -
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Patch 32
Ct examples

• Where and when the rubber met the road!

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Zooming in!
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Zooming in!
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Zooming in!
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Zooming out! Double click
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Zooming on!
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View Full screen
Getting started
General radiology
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View segmented
Getting fancy
Body CT / MR
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View segmented
Even more
MR Spine CT/ MR Brain
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Flexibility
MR spine Sagittals Axials Free spaces
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Anything goes?
Current Comparison Free
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At any time Double click
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Getting started

• Open VistARad
• The KISS principle
• Use 80 20 rule
• Stuff happens
• Avoid over choice
• For user
• For the computer

Limit the number of protocols initially Choose
protocols with free space for flexibility
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Control Functions HUD!
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Control Functions HUD!

• Where the rubber meets the road!

• Hi resolution viewports

PC resolution Color monitor
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Control Functions HUD!

• Where the rubber meets the road!

• Hi resolution viewports

PC resolution Color monitor
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What space do you need?

• Control done!
• Current exam
• Comparison/s?
• Scouts?
• Resolution issues

• Modality
• Image sizing
• Optimum
• previewing
• comparison
• Spare space
• Reading with residents

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1
9
12
2
4
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The viewport as sub-unit of space
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The monitor as the Unit of Space
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Pre-built / System HPs

• What about hanging protocols that come with the
  system?
• Try some to see if they meet your needs?
• But, be ready to
• Build your own!
• and help others do the same

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GO!

• Two monitors for solo work General Radiology

All ports are stacks
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General radiology HP

• Preview the comparisons, then
• Double click on preferred comp

All ports are stacks
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General radiology HP

• Read exam

All ports are stacks
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General radiology HP

• 3 monitors for working with residents

All ports are stacks
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US layout, 6L 6R
current comparison
Basic layout scroll by 6 using page up / page
down - can change to more or fewer images, or
view as single stack at full screen after double
click
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CT all stack, 9L 2R
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MR all stack, 9L 4R
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Summary

• Consensus workstation parameters
• Modality-based sample hanging protocols
• General rad 1L 4R
• US layout 6L 6R
• CT stack 6 or 9 L 2R
• MR
• 3 monitors ideal - 4x4x4
• Horizontal monitors - 6x6

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The PACS Paradigm

• Evaluating VistARad

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Evaluating VistARad

• Experience from the field
• Efficiency impact on productivity

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Evaluating VistARad

• Experience from the field
• Ralph H Johnson VAMC Radiology
• 10 year caseload
• All modalities excl mammo, nuc med, high-end
  interventional
• 4 staff radiologists, increased to 5 in 2005
• Almost level tech staffing for duration
• Resident staffing from 3 5

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Productivity 1997 - 2006
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Productivity 1997 - 2006
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Voice recognition

• Slows down reading of studies
• Increases typographical errors
• Improves report turn around time
• VA mandate 90 in 48 hours
• Actual 24 hr turn-around ?
• Most important rate-limiting factor to
  radiologist productivity

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Thinking about PACS
PACS system characteristics

• Speed
• Flexibility
• Efficiency
• Easy to use
• adopt and adapt
• Easy to customize
• Interfaces well with other systems

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Evaluating VistARad

• Our experience has been favorable
• How else can one evaluate VistaRad?
• What are the key issues?
• Impact on productivity
• Proficient users
• Early adoption
• maintain productivity while transitioning
• Cost issues
• Acquisition
• Maintenance
• Upgrades and continuity
• System integration

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VistARad and productivity

• Timed test reading
• System process analysis
• Other sources
• Residents opinions
• Other feed back from the field
• Site visits
• Teaching hospital
• Community hospital

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Timed sample test

• I read a batch of 11 cases in Gen radiology in 20
  minutes, including one phone call to provider
• Estimate can read 30 Gen radiology exams per
  hour
• General radiology is 63 of exam caseload

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Residents Reviews

• Residents use Comm. system at MUSC
• 4 out of 24 residents at VAMC
• Comm. system is more user-friendly
• Loads large volumes faster
• Handles larger volumes for check out
• large volume exams MR / CT
• high caseload General radiology

Comments User friendliness vs. frequency of
use Solo work vs. working with residents Volume
load rate vs. of read-time Residents
resistant to using other approaches such as
read-list, or viewing history
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Processing cycle
Load Time
Read time

• Short load times are optimal
• For studies with long read times, load time
  factor is reduced.
• Workstation preloading is helpful
• (readlist functions)

Load Time time for case to be pulled from
server and displayed on monitors
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The big picture

• Pace of change
• VA record of cost-effective care
• Shift to outpatient-centered care Preventive
  screening, patient education, risk reduction and
  improved outcomes
• CPRS industry leader, saving up to 30 on lab
  and imaging costs disaster-ready IS
• VistARad 76 offers functionality comparable with
  commercial systems, at a fraction of the cost
• Key advantages System Integration, Continuity
  and user involvement in system refinements

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VistARad / VistA ImagingStatistics

• Data acquired from June 2003 through April 2008

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Imaging / VistARad StatisticsTotal Images
Archived VA-wide
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Imaging / VistARad StatisticsMonthly DICOM
Captures by VISN
Some VISNs do not forward images from
commercial PACS to the Vista Imaging archive
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Imaging / VistARad Statistics
Year by year images acquired per month
21,501,652 April 08
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Imaging / VistARad Statistics
VistARadTotal Images Interpreted by
Month 7,753,000 in April 2008
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Imaging / VistARad Statistics
VistARadTotal Images Viewed by Month 28,000,000
in April 2008
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Imaging / VistARad Statistics
200,041 Studies Interpreted in April
2008 2,242,912 for the calendar year ending
April 2008
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Imaging / VistARad Statistics
19,400 in Feb 2007!
9,900 in April 2008
Studies are auto-routed to remote locations, e.g.
remote VAMC or Radiologists home, etc.
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VistARad DevelopmentActivities

• Patches underway
• Patch 101Maintenance
• Patch 90Enhancement

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VistARad Patch 101

• Dictation changes
• New user preferences
• Default YES for one/all locked exams
• Dictation dialog list only the Current exam
• Prompt earlier in load sequence

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VistARad Patch 101

• Long accession number option (VR integrations)
• Scrapbook Previewmouse wheel the scroll bar
• Image Info tab to display the full Dicom
  header
• Fix invisible dialogs problem
• User preference defaults for 1st time user
  Based on user type (Radiologist / Other)

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VistARad Patch 101

• Annotations / measurements
• Make more interactive/editable and precise
• New elements (arrow, ellipse, freehand)
• Options to manage saving/not saving
• Audit trail capability

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VistARad Patch 101

• Large study management (CT/MR)
• Speed up ad hoc retrieval times
• Follow user priority for series
• Improve management of very large studies
  (data 1.7 gigabytes / memory
  constraints )
• Open selected image series of interest

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VistARad Patch 101

• Display Reserved exams (Readlist mode)
• Teaching file support
• MIRC service
• IHE TCE protocol
• (Teaching file Clinical trial Export )

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VistARad Patch 90

• VistARad-native 3D navigation
• Multi-planar Reconstruction
• (orthogonalsaxial, coronal, sagittal)
• Maximum/ Minimum/ Average Intensity
  Projection
• Store selected reconstructed images

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VistARad Patch 90

• Remote Image Views, Phase 1
• Similar to Display Client functionality -
  System notification of remote exams - User
  initiates retrieval
• Hanging protocol retrieve remote priors
• ? Employ ViX technology as available - Image
  file compression - Local caching of remote
  images

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VistARad Patch 90

• Remote Reading Single sign-on , Phase 1 ?
  Enhances routing / teleradiology features
• Auto sign-on to all reading sites
• Read for one site at a time
• Dashboard view of other sites worklists
• Rapid context-switching between sites

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VistARad Patch 90

• Hold status management of Unread exams
• Resident preliminary interpreted
• Problem exams research
• Bookmark an interpretation in progress
• Exams routed to a non-VistARad site
• ? Remove from the Unread list, but not
  mark Interpreted

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VistARad Patch 90

• Hanging Protocol enhancements
• HP Logic "within CPT code" differentiation
• HP "manager" function
• HP feature having Browser-like functionality
• Process successive studies for one
  patient in turn
• Export/import HP definitions

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VistARad Patch 90

• Spine labeling enhancement
• Cross referencing slice indicators on
  orthogonal series
• CCOW for integration, especially with CPRS
• User preference settings management functions
• Remove or disable a user from the settings file
• Default profiles copy settings to brand new
  users

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Summation

• How we got here !
• Where were going . . .

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Cost issues VistARad vs. Commercial
PACS

• Questions, questions, questions . . . .
• How much does a computer cost?
• How quickly do prices change?
• How fast does technology change?
• Where is vendor in business trajectory?
• What are the right choices in a massive
  government system already spending unimaginable
  sums of money?

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Cost issues VistARad vs. Commercial
PACS

• An attempt to answer the question!
• Model built around VAMC Charleston
• 60 k exams per year
• All modalities except Mammo
• Parameters
• 1 VistAImaging is a VA mandate
• 2 VistARad dovetails with VistAImaging
• 3 Commercial PACS is an add-on

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Model department

• Consensus model
• 1 MR station with 3 hi res monitors
• 5 standard stations with 2 hi-res monitors
• Hi res monitors on all stations to allow for
  interchangeable staffing and comparison review /
  correlative imaging

Serving 60k caseload per year Extrapolate from
this?
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Consensus Model Standard workstation
Dedicated High res diagnostic reading monitors
17 color pc monitor for controls ( Color US)
MR station has 3 hi res monitors
Tower
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VistARad Model
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Commercial Model
VistARad 137k
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System diagram VistARad
CT scan
Imaging gateway
PACS work station/s
Other modal/s
Background processor
RAID 8.8 t-byte
VistA-Imaging on PC
Server 2 stack
Juke box long-term storage
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System diagram Comm. PACS
Replaces
Duplicates
The rest is kept to serve VistA-Imaging
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Commercial model Server/s
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Commercial Model
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Commercial Model
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Commercial PACS

• Not included in the analysis
• Tech workstations (5 basic, 2 hybrid) 125k
• (VA - functions imbedded in CPRS)
• Maintenance costs 150k 250K
• Upgrade cost/frequency? 300k 1
  mill q 4 years?
• Other gross estimates from field 900K - 2.5M
• Other issues
• Lease vs. purchase
• Volume paradigm
• Data migration
• Vendor changes
• Interfacing with other systems
• Web access vs. routing

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System savings from VistARad 2007

• Exams interpreted / month 180,000
• Exams annualized 2.16 M
• Model dept annual cases 60k
• 2.16 M / 60 k 36
• Savings per model dept 950,000
• VistARad Savings - X 36
• Total 34,200,000

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The big picture

• Pace of change
• VA record of cost-effective care
• Shift to outpatient-centered care Preventive
  screening, patient education, risk reduction and
  improved outcomes
• CPRS industry leader, saving up to 30 on lab
  and imaging costs disaster-ready IS
• VistARad 76 offers functionality comparable with
  commercial systems, at a fraction of the cost
• Key advantages System Integration, Continuity
  and user involvement in system refinements

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End

• Acknowledgements and thanks