VistA Imaging: An Update on IHS Activity and Directions Mark Carroll, MD; Janis Sollenbarger

Objectives Overview of VistA Imaging Current experience with VistA Imaging in Indian Health Next steps/planning

Why VistA Imaging? RPMS has no image storage capability Critical implications for the IHS EHR and for diverse Telehealth activities

EHR “Image” Needs Reports Consults from Outside Specialists Consents Advance Directives Patient Photos Non-DICOM images DICOM type images

VistA Imaging Functionality Multi-faceted software program developed in federal sector for image capture, display, and storage of: Scanned documents Non-DICOM images DICOM images

DICOM VistA Imaging can serve as a PACS Fully integrated solution Can interface to existing PACS Able to capture, display, route, and store DICOM image files

Tele-Radiology

Strategic Direction VistA Imaging is the multimedia component of the Veteran’s Administration Electronic Health Record VI is being offered as the multimedia component of IHS Electronic Health Record

Is VI a mandate? VistA Imaging is not a mandate Aside from project oversight and VHA support, it is not a funded agency activity But Imaging is a necessary part of a comprehensive EHR, and - No other solution is available or being supported at present by OIT It is part of OIT, ISAC, and ISC strategic planning

VistA Imaging in Indian Health Permission to use VI Configurations and Models Proprietary license review IT/IHS EHR integration issues Early implementations Planning and roll-out

IHS-VHA Project Agreement

Support from VHA For: Planning and Implementation Assistance from VistA Imaging Program Office Training support VHA Enterprise support i.e. application help desk

IHS-VHA Distribution Agreement VHA is manufacturer of FDA regulated device IHS cannot modify VistA Imaging code Software is free (except for some embedded proprietary software) IHS must install VistA Imaging on hardware configuration certified by VHA Hardware configuration is “robust” HP is only vendor currently certified by the VHA for full configuration – on-line storage and permanent storage

Hardware Configuration Storage redundancy and security Image data is stored in 3 places – RAID Tape Magneto optical discs (Jukebox) Note: Any database IT configuration should have similar redundancy and hence similar costs

VistA Imaging is not CPRS VistA Imaging is a separate application to CPRS (the VA EHR) It runs on separate hardware Some proprietary software embedded within application

Possible Models Different models are possible: A hardware “cluster” at every site(!) Regional cluster approach Option 1: Regional solution to both on- line and permanent storage (i.e. “jukebox”) Option 2: Local on-line cluster with regional permanent storage Note re: PACS VI can blend with commercial PACS solns Or – VI can be used as a PACS system

Regional Approaches to Hardware Pros Cost-effective Opportunity for image sharing Facilitates technical support Capable of supporting teleradiology Cons Relies on Wide Area Network

Regional Hardware in the VHA? Some VISNs are consolidating their Jukebox/permanent storage The current trend is to provide approx 7 years of on-line storage so that the JB is accessed less and less Some VISNs have consolidated or are consolidating VistA databases Many VA Community-Based Outpatient Clinics (CBOCs) use VI via WAN access

VI – EHR Integration VI Launches from EHR Maintains patient context Presently requires a separate enduser log-on Other customization work under review Annotation tool Patient photo addition, etc.

Proprietary Licenses VistA Imaging is free to IHS and Tribal facilities Some embedded software though must be licensed: Accusoft Image Gear run-time license Other as may be needed: DICOM query and retrieve DICOM compression

VistA Imaging in the IHS Extensive work on Distribution and Project Agreements Phase 1 testing and implementation Phase 2 planning

Possible Deployment Model – circa 2005 FY05FY06FY07FY08FY09FY10 Proof of Concept Sites 4 FY05 EHR Sites 24 FY06 EHR Sites 40 FY07 EHR Sites 40 FY08 EHR Sites 40 FY09 EHR Sites 37

Phase 1: Proof-of-Concept/Pilots Wind River as initial local facility installation in 2004/05 Earlier software version of VI Portland Area regional installation in 2005 To support all Portland Area sites Warm Springs as initial site accessing VI via the IHS WAN “Live” in January, 2006

Phase 2 Implementations Nashville Area October 2006 Installation Navajo Area Underway for 6 NAIHS Service Units Most other IHS Areas in planning Some individual facilities also in planning Cherokee, NC. 2-3 Tribal facilities in Oklahoma Area

EHR Sites as of 6/6/06 Federal Hospital15 Federal Health Ctr/Stn20 Tribal Hospital5 Tribal Health Ctr/Stn13

VistA Imaging as of Ordered Under Review Installed

VistA Imaging in the VHA First version developed in 1987 National rollout began in 1998 “Core Imaging” mandated in 2001 VistA Rad (PACS) is optional Copies of all Rad images from commercial PACS systems mandated to be sent to VI as of 2006

VistA Imaging in Indian Health First facility pilot in 2004/5 First regional installation in 2006 Additional implementations in process Roll-out as guided by IHS Areas and IHS/Tribal facilities in To be determined by local and regional Area needs, funding, and priorities

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