1. VA/DoD and VA to VA Image Sharing
Class 755
Julian Werfel and Roger Coney

2. Cumulative Images Captured 2003-2010
This is why image sharing is important
VistA Imaging stores 1.4 billion images

3. Image Sharing
Provides more patient information to use in diagnosis and treatment
Reduces number of procedures for patient by making remote data available
Saves money by reducing procedures
Saves patient and staff time
“A picture is worth a thousand words”

4. VA Remote Image Views
Clinical Display communicates across the VA WAN to retrieve images from the VistA Imaging systems at remote VA facilities
Image sharing in the VA started with Remote Image Views in 2005 (Patch 45)
All work done by Clinical Display
Requires VistA/Image Share Access for all clients
Allows all clinicians access to the entire VA patient record

5. Full access to patient record
VA/DoD Image Sharing
NDAA (National Defense Authorization Act) El Paso pilot to share radiology images and reports with DoD
Full access to patient record
DoD provides images to VA, viewed in Clinical Display
In 2006, VistA Imaging began work to share images with the DoD
Many VA sites share facilities and hardware with DoD sites, want to be able to share data as well
Many patients (particularly polytrauma patients) move between VA and DoD facilities for care

6. VA/DoD Image Sharing Provide VA images to DoD users
Particularly important for Polytrauma patients
Transfer images in DICOM with JPEG 2000 compression
Thumbnail, Lossy, and Lossless quality
Realized as the VIX service – Imaging Patch 83

7. VIX for VA/DoD Image Sharing
VistA Imaging Exchange (VIX) Service
VIX implemented as part of VISA (VistA Imaging Service Architecture)
Encapsulates VistA Imaging behind well defined interfaces - SOA
Standards based: JPEG2000, DICOM, XCA
Clinical Display requests DoD images from site VIX
DoD images available to clinicians since Patch 72 Display client
VISA is a Service Oriented Architecture implementation for image sharing
VIX servers deployed at the local site to provide functionality for Clinical Display users

8. VA/DoD Sharing Field Testing
DoD only has access to VA images at the original 7 sites shown above
Additional test sites for Patch 83 include:
Tucson
Baltimore
Fayetteville, NC
Fayetteville, AK
Louisville
Prescott
Phoenix
Little Rock
Oklahoma City
Charleston
Muskogee
All sites with Imaging Patch 83 can see DoD images

9. View DoD Radiology Images
View DICOM Radiology images for shared patients from the 7 original DoD NDAA sites
BHIE Image Adapter (BIA) requests DoD images from site PACSi (analogous to VIX)
Compression and caching to boost performance
VA/DoD Image sharing as part of NDAA El Paso project
Get compression information – what is the percentage?

10. View VA Radiology Images in DoD
Provide DICOM radiology images for shared patients
Access images from all VA sites with a VIX Server
Available to DoD facilities with a PACSi server
Images viewable from the web based Advanced Medical Image Viewer (AMIV)
VA/DoD Image sharing as part of NDAA El Paso project

11. Imaging Patch 72 DoD images integrated with VA images
Goal to make DoD images easy to access for VA users
Did not require new training
Easy to use, it just works!

12. Enhanced Remote Image Views
We realized we can harness the functionality and abilities of the VIX to enhance remote image views
No longer requires the client to implement all functionality, work is done by servers
Client doesn’t have to be aware of all remote site information and how to access it.
Built on the functionality implemented to allow improved performance
With DoD image access through the VIX, now able to provide VA image access through VIX
Access remote VA images through VIX
Remote VA and DoD images now available to VistARad in Imaging Patch 90

13. Enhanced RIV Benefits Take advantage of VIX Caching and Compression
Image is compressed at source before transfer over WAN
Image cached at local and remote VIX
VIX handles remote connection rather than client
Fewer connections over WAN
Enhanced RIV seamless to user

14. Enhanced RIV Image Quality

15. Imaging Patch 93 Updated user interface UI updated in Patch 93
RIV Toolbar moved to list view window
Can view information in list, tree, abstracts in window, full resolution in window
DoD appears in the RIV toolbar like any other VA site
Updated user interface

16. Viewing Remote Images DoD accessible same as VA data
You can see we have connected to several remote VA sites and the DoD. The images from the remote sites are integrated with the local images and the DoD images are available just like VA images. By selecting the study from the DoD you can preview the abstract and report just like VA images.
Site column shows specific facility images from the DoD come from
Patch 93 uses enhanced remote image views for VA sites by using the local VIX. The VIX does the work of connecting to the remote site.
Seamless integration for user, does not notice anything has changed but images will be available faster because of the VIX
User doesn’t have to do anything to make enhancement RIV work, client and VIX do all the work.
When Patch 93 was installed at sites with a VIX, the VIX began to handle the remote image views without the site noticing
DoD accessible same as VA data

17. Viewing DoD Images Accessing images from DoD same as VA
Viewing DoD images is the same as viewing VA images
No special viewer or tools to use
Accessing images from DoD same as VA

18. Viewing DoD Images Users can apply measurements to DoD images
If a user wants to view all of the images in a study, the user can cache the selected study – this brings all of the images to the workstation in the background allowing the user to view other images while the images are being cached.

19. Viewing DoD Images No special tools for DoD, same as VA
Viewing DoD images is just as easy as VA images
No special tools
Same manipulation tools as for VA images
No special tools for DoD, same as VA

20. Comparing VA and DoD images
BHIE PATIENT
DoD Image
WBAMC 03/2007
VA Image
El Paso 10/2001
On the left is an image from 2007 from William Beaumont AMC, on the right is an image from 2001 in El Paso
Area of Clinical Interest

21. VistARad and the VIX View images and reports from DoD
View images, reports and requisition reports from remote VA sites
Monitor exam lists from remote sites without requiring user to login
Exams from remote sites integrated with exams from local site

22. VistARad Manager
VistARad Manager shows exams from multiple sites including the DoD

23. VistARad Displaying DoD Images
Displaying DoD images using same controls as viewing VA images

24. Monitor Remote Sites
Monitor remote sites without logging in

25. Support New DoD Architecture
HAIMS, the Healthcare Artifact and Image Management Solution, will replace the NDAA El Paso solution in the DoD enterprise
NDAA El Paso pilot will be sustained through the transition
No changes will be required to the VA architecture

26. Providing VA Images to DoD with HAIMS
No changes required by VA to continue to provide VA images to DoD
No changes will be required to the VA architecture

27. VA/DoD Artifact Sharing
Share Artifacts
Non radiology images
NCAT (Neurocognitive Assessment Test) reports from DoD
Bidirectional
Implemented with IHE profile Cross Community Access (XCA)
Development in progress

28. Expanding the VIX – the CVIX
Centralized VistA Imaging Exchange (CVIX) Service
Enterprise gateway for image sharing
Currently deployed in AITC (Austin Information Technology Center)
Highly Available, Load Balanced, Clustered Deployment
Based on the VIX design
Doing more than just site VIX servers, more sharing with enterprise services
Will be used for several image sharing initiatives
DoD Radiology access through CVIX will provide a single interface for the DoD and other communities to access VA images

29. CVIX Provides Artifacts available to VA Users Artifacts from VA to DoD
Artifacts from HAIMS
NCAT (Neurocognitive Assessment Test) reports
Artifacts from VA to DoD
Radiology sharing through CVIX
Support Future Interfaces
NHIN (National Health Information Network)
VLER (Virtual Lifetime Electronic Record)

30. View DoD Artifacts and Radiology Images
CVIX retrieves HAIMS artifact and radiology lists from the BHIE Framework for viewing by VistA Imaging client applications
CVIX retrieves HAIMS artifact lists from the BHIE Framework for viewing by VA applications
CVIX retrieves HAIMS and NCAT artifacts for viewing by VistA Imaging client applications – Imaging Patch 104 (June 2010 – Pending Approval)
With the CVIX in place, we will be able to move all DoD access behind it to make a cleaner interface for our site VIX servers. This will provide access to DoD artifacts and DoD radiology images from within Clinical Display
Working to provide DoD artifacts to VA users and provide VA artifacts to DoD
Includes viewing NCAT assessments from DoD
DoD artifacts will be listed in VistAWeb and Clinical Display
Artifact transfers go directly from CVIX to repository (NCAT or HAIMS)
Artifacts are transferred using XCA (Cross Community Access) IHE profile

31. Providing VA Artifacts and Radiology Images to DoD with CVIX
* CVIX communicates with site VIX servers or directly with the VistA system at the site
CVIX provides VA study and artifacts lists to the BHIE Framework for consumption by HAIMS
CVIX provides radiology images to the BHIE framework for consumption by HAIMS
CVIX provides artifacts directly to the HAIMS gateway

32. Image Enabling VistaWeb
VistA Imaging providing Advanced Web Image Viewer (AWIV) to VistaWeb for image viewing
View images associated with Progress Notes and Radiology Reports
VistaWeb users can view VA images within VistaWeb
Similar to CPRS/Clinical Display interface
VistaWeb version 12
One use of the CVIX is image enabling VistAWeb
Working with VistAWeb team to provide VA images to VistAWeb users
VistAWeb version 12, VistA Imaging Patch 105

33. AWIV Uses components from Clinical Display Easy access from VistaWeb
Does not show all images stored in VistA Imaging
Will view DoD Radiology and artifacts in future
AWIV uses Centralized VistA Imaging Exchange (CVIX) server
Currently in field testing (June 2010) – Imaging Patch 105

34. VistaWeb Viewing VA Images
VistAWeb passes information to the AWIV
All AWIV communication through CVIX
CVIX communicates with site VIX servers or directly to VistA systems at sites without VIX
AWIV retrieves all images from CVIX
CVIX communicates with VA sites with and without a VIX

35. VistaWeb Progress Notes
New icon indicates images are associated with note

36. AWIV Viewing VA Note Based on Clinical Display Hosted inside VistAWeb
Shows Photo ID
Abstracts of images in study
Full Resolution and Radiology viewer for images

37. AWIV Viewing VA Note

38. VistaWeb Radiology Reports
New icon indicates images are associated with report

39. AWIV Viewing VA Radiology Image

40. VistaWeb Viewing DoD Artifacts
Prototype of Artifact Sharing
Future Development

41. AWIV Viewing NCAT Report

42. AWIV Viewing DoD Artifacts
Artifacts viewed in AWIV

43. VA/DoD Radiology Sharing Today
DoD radiology images available in Clinical Display and VistARad

44. AWIV Viewing VA Images
AWIV can view VA images through VistaWeb – Field Testing June 2010

45. VA Viewing DoD Artifacts
DoD Artifacts available in Clinical Display
HAIMS providing artifacts and radiology
Field Testing December 2010

46. Server Deployment Changes - 2011
CVIX clustered and moved to Philadelphia
NDAA fully replaced by HAIMS

47. AWIV Viewing DoD Artifacts - 2011
Artifacts available in VistaWeb and AWIV

48. Image Sharing Big Picture
Sharing of images improves patient care
VA users can now view Radiology Images from VA and DoD in Clinical Display and VistARad
DoD can view VA images
VistaWeb users can view VA images with AWIV
Artifact sharing with DoD coming soon

49. VIX Makes Image Sharing Work
VIX provides access to images for VA and DoD
Improves performance within VA
VIX is reliable
Optimized for delivery of images as quickly and safely as possible
VIX encapsulates functionality with standards using VISA

50. Questions?
Julian Werfel (240) Roger Coney (240)

51. VIX Development Team Julian Werfel (julian.werfel@va.gov)
Keith Buck
Chris Beckey
Csaba Titton
Roger Coney

52. Shared Modalities CT – Computed Tomography CR – Computed Radiography
MR – Magnetic Resonance
US - Ultrasound
DX – Digital Radiography
RF – Radio Fluoroscopy
NM – Nuclear Medicine
XA – X-Ray Angiography
PT – Positron Emission Tomography
DS – Digital Subtraction Angiography