Brent Fugett Huntington, WV

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Session 130 Imaging Coordinators Getting
Started!

• Presented By
• Brent Fugett - Huntington, WV
• Michele Krajewski Philadelphia, PA

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Introduction

• My Background
• VistA Imaging from YOUR perspective
• Session Outline
• Terms - Contingency Plans
• Configurations - Implementation Workgroup
• DICOM Basics - Getting Support
• DICOM Gateways - Becoming a Test Site
• Image Quality - Customer Support
• Adding New Devices
• Preventive Maintenance

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What is VistA Imaging?

• 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.

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What is VistA Imaging?

• Data that can be stored in VistA Imaging include
  the following.
• Scanned Documents Ultrasounds
• Rich Text Reports Dental Images
• ECG Waveforms Ophthalmic images
• Patient Photo Pathology Images
• X-Rays Digital Camera
• CTs Diagram Annotations
• MRIs And more

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VistA Imaging 510(k) FDA Classification

• Property of the US Government.
• No permission to copy or redistribute this
  software is given. Use of unreleased versions of
  this software requires the user to execute a
  written test agreement with the VistA Imaging
  Development Office of the Department of Veterans
  Affairs
• The Food and Drug Administration classifies this
  software as a medical device. As such, it may
  not be changed in any way. Modifications to this
  software may result in an
• adulterated medical device under 21CFR820, the
  use of which is considered to be a violation of
  US Federal Statutes.

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Some Terms to Know

• PACS Picture Archival and Communication System.
  System designed to store and retrieve a
  patients medical Images. Historically
  Radiology-centered.
• DICOM Digital Imaging and Communication in
  Medicine.
• HL7 Medical text communication protocol.
  (Health Level 7)
• Modality per the dictionary means Conforming
  to a Standard. In Imaging it is simply an image
  capture/processing device that complies with
  DICOM.
• CPRS Computerized Patient Record System (GUI
  for VistA)
• Clinical Workstation Software that is installed
  on generic workstations deployed throughout the
  medical center that allow users to see images.
  Runs parallel with CPRS.
• Diagnostic Workstation Specialized workstations
  that allow Radiologists to interpret radiology
  images without film.
• Hard Copy versus Soft Copy Interpretation
• Soft Copy Radiologist interprets images on
  computer
• Hard Copy Radiologist uses film and light boxes
  to interpret

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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.
• 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

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Configuration 1 Basic

• 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

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Background Processor
Image Storage (RAID - Magnetic)
VistA
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Configuration 2 DICOM

• 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
• Transferring DICOM images to other modalities,
  such as DICOM Printers (via DICOM Store)

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A Bit More About DICOM

• 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

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Worklist
Image Capture
QA/Storage
Patient Two 000-28-1665 X2056 Y1998
?
Patient Two
Patient, Two 000-28-1665 X2056 Y1998
Patient Two 000-28-1665 X2056 Y1998
DICOM Text Gateway
DICOM Image Gateway
Background Processor
Patient Two
Image Storage (RAID - Magnetic)
VistA
Patient Two 000-28-1665 X2056 Y1998
Patient Two
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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
• Patch 65 introduces many commercial features
• Free software

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

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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

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Commercial PACS
Image Capture
Worklist
QA/Storage
RIS
Image Storage
PACS Diagnostic WS
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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.
• Expensive to Buy and Maintain
• Data Stored in Proprietary Format

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DICOM Text Gateway Up Close

• Runs Micronetics Mumps (MSM) on Windows 2000/XP,
  soon to 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 its
  internal database.
• Converts data to DICOM and sends to the
  requesting modality.

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DICOM Image Gateway Up Close

• Like the Text Gateway, also runs MSM on Windows
  2000/XP, soon to run 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

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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
  18 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 its associated
  TXT and ABS file.

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Image Quality Basics

• Image Quality is Everything
• Good, Working, Appropriate Equipment
• Appropriate Resolution (aka Image Matrix)
• 11 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

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Image Quality and Grayscale CalibrationProducing
a Good Curve

• SMPTE Pattern
• At a minimum, you should be able to discern 5
  and 95 grayscale simultaneously.
• http//www.smpte.org/engineering_committees/medica
  l.cfm
• Hardware/Software
• If the video card supports lookup tables (LUT)
  then the card can be calibrated for the attached
  monitor.
• Called Gamma Correction (DICOM Part 14)
• Must be re-calibrated periodically or if the
  monitor is changed
• Calibration is a good idea for clinical displays
• Calibration is a requirement for diagnostic
  displays.

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Adding New DICOM Modalities

• Tools to Help Ensure Successful Interface
• DICOM Conformance Statement Should be required
  BEFORE procurement.
• Vendor Survey
• 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 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/imagin
  terface.pdf

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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 Web Site
• http//vaww.va.gov/imaging/IMGNewHardwr_OpSys.htm

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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 nights 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
• Session 169 VistA Imaging Countdown to
  Performance

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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

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Implementation Workgroup

• Group comprised of key individuals representing
  key disciplines
• 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 VistA
  Imaging.

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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 Support
• Will help with server hardware issues

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Getting Support

• Weekly Imaging Conference Call
• Held each Thursday from 1200 100 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 200 300 PM
  Eastern Time
• Forum for hardware issues
• Get on the ListServe to receive critical updates
  and requests.

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Becoming a Test Site

• Why should I?
• Helps the project
• Helps your site (help shape new software)
• Test Phases
• E3R
• 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

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A Word on Customer Support

• How Technical People Tend to Approach Support
• Your problem is yours and I have to fix it
• Gets in my way of a happy day
• Use techno-speak to protect the black box
• How Clinicians Perceive that Approach
• Hesitate to call unless there is smoke
• The Correct Approach Support
• Your problem is my problem and I will work with
  you to fix it
• Your problems are part of why I am here
• Speak in terms the user will understand
• How Clinicians Perceive THIS approach
• More willing to communicate
• More confident in the system
• MUCH more forgiving!

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VistA Imaging
Questions