2. 1 VA IHE Success Story – DICOM Image Acquisition in and beyond Radiology Peter Kuzmak, VistA Imaging Project DICOM Team Leader Dr. Ruth Dayhoff, National Director, VistA Imaging Project

3. 2 VA Healthcare Enterprise 158 Medical Centers & 850+ Outpatient Clinics Serves an active patient population of 5 million veterans All sites acquire DICOM images 500 million DICOM images online DICOM now used for Clinical Specialties besides Radiology

4. 3 VistA & Computerized Patient Record System

5. 4 Multimedia Patient Record Combines Computerized Patient Record and VistA Imaging Chart Data –Textual chart data –Computable data –Handwritten and non-electronic chart data Multimedia Data –Images, graphics, waveforms, audio, etc.

6. 5 Wide Variety of Images Integrated with the Online Patient Record Cardiology Bronchoscopy Gastrointestinal Endoscopy Hematology Pathology Surgery Nuclear Medicine Dental Radiology Dermatology Ophthalmology Podiatry Vascular Urology Nursing Electrocardiography Scanned Documents

7. 6 Main hospital backbone Switch NT File Servers NT File Server Jukebox Image File Servers Commercial EKG System Background Processor CWS Fast Ethernet DICOM Device DxWS DICOM Gateway(s) DxWS Main VistA HIS VistA Imaging Network Topology Gigabit Ethernet Switch

8. 7 VA IHE Success Story All VA DICOM image acquisition uses IHE Radiology Transactions to interface modalities to PACS: –#5 - Modality Worklist Provided - download patient and study –#8 - Modality Images Stored - send images to the PACS. 200 different models of radiology instruments interfaced Exactly the same IHE DICOM interface to Consults for ophthalmology, dentistry, endoscopy, pathology, cardiology. The VA will not purchase a new modality unless it supports both of these capabilities.

9. 8 VAs Role in Advancement of DICOM in Radiology 1997 - required modality worklist + accession number 1999 – IHE initiative 2004 - 200 million radiology images acquired have been acquired from 200 different models of instruments

10. 9 Using DICOM to Acquire Images in the Clinical Specialties Dentistry Ophthalmology Endoscopy Cardiology Pathology

11. 10 Goal of Project Interface the VistA HIS Consult package to new DICOM-based image acquisition devices used in the clinical specialties Panoramic Image 3064x1536 16-bits

12. 11 Using Consults for Clinical Specialties (Simplified Workflow) 1.Consult Ordered 2.Schedule Appointment 3.Patient Arrives 4.Images Acquired 5.Patient Leaves 6.Diagnostic Reporting 7.Follow up Visits 369x359 24-bit

13. 12 Workflow Messages CPRS Order EntryVistA Appointment Management Order entered for a Consult or Procedure or Clinical Procedure

14. 13 Workflow Messages CPRS Order EntryVistA Appointment Management DICOM Gateway Order signed

15. 14 Workflow Messages CPRS Order EntryVistA Appointment Management DICOM Gateway

16. 15 Workflow Messages CPRS Consult Request TrackingVistA Appointment Management DICOM Gateway Patient scheduled for appointment

17. 16 Workflow Messages CPRS Consult Request TrackingVistA Appointment Management DICOM Gateway Patient arrives at image acquisition modality Imaging Modality

18. 17 Workflow Messages CPRS Consult Request TrackingVistA Appointment Management DICOM Gateway Modality obtains patient demographics and study information Imaging Modality

19. 18 Workflow Messages CPRS Consult Request TrackingVistA Appointment Management DICOM Gateway Images acquired and sent to VistA Imaging Modality

20. 19 Workflow Messages CPRS Consult Request TrackingVistA Appointment Management DICOM Gateway Images acquired and sent to VistA Imaging Modality

21. 20 Workflow Messages CPRS Consult Request TrackingVistA Appointment Management DICOM Gateway Images verified on VistA Imaging Modality

22. 21 Workflow Messages CPRS Consult Request TrackingVistA Appointment Management DICOM Gateway Patient leaves image acquisition modality Imaging Modality

23. 22 Workflow Messages CPRS Consult Request TrackingVistA Appointment Management DICOM Gateway Patient checked out Imaging Modality

24. 23 Workflow Messages CPRS Consult Request Tracking DICOM Gateway Patient checked out Imaging Modality

25. 24 Workflow Messages CPRS Consult Request Tracking Images diagnosed on VistA Imaging Modality DICOM Gateway

26. 25 Workflow Messages CPRS Consult Request Tracking Images diagnosed on VistA Imaging Modality DICOM Gateway

27. 26 Workflow Messages CPRS Consult Request Tracking Images diagnosed on VistA Imaging Modality DICOM Gateway

28. 27 Workflow Messages CPRS Consult Request Tracking Report is entered Imaging Modality DICOM Gateway

29. 28 Workflow Messages CPRS Consult Request Tracking Image icon appears on CPRS note Imaging Modality DICOM Gateway Image icon on CPRS note

30. 29 Workflow Messages CPRS Consult Request Tracking Image icon appears on CPRS note, and message sent to gateway Imaging Modality DICOM Gateway Image icon on CPRS note

31. 30 Workflow Messages CPRS Consult Request Tracking DICOM Gateway Request Complete Imaging Modality

32. 31 Workflow Messages CPRS Consult Request Tracking DICOM Gateway Request Complete

33. 32 Workflow Messages CPRS Consult Request Tracking Request Complete

34. 33 VAs Role in Advancement of DICOM in Dentistry Prior to 2001, dental IODs & CDs existed, but no networking VA wanted dental IODs with MWL & Storage networking March, 2001 – VA Moratorium August, 2001 – 1 st demonstration of MWL & Storage for Dentistry ADA is now picking up this effort 1024x1536 8-bits

35. 34 Results - Dentistry 2 kinds of sensors –CCD (DX) –Phosphorescent Plate 3 kinds of radiographs –Intraoral (18-20 image/study) –Panoramic –Cephalometric Color (VL) Various sized CCD sensors

36. 35 Results - Dentistry 2 kinds of sensors –CCD (DX) –Phosphorescent Plate 3 kinds of radiographs –Intraoral (18-20 image/study) –Panoramic –Cephalometric Color (VL)

37. 36 VAs Role in Advancement of DICOM in Ophthalmology Initially no Ophthalmology specification in DICOM Could not even tell left from right 2002 - VA encouraged AAO develop new specification 2004 - Ophthalmic Photography Image DICOM Supplement 91 2005 - VA Diabetic Retinopathy Screening program Fundus Image 3072 x 2048 24-bit

38. 37 Results - Ophthalmology External color photographs Retinal (fundus) –Color photographs –Stereoscopic photographs –R/G/B filtered photographs –Fluorescein angiography (up to 30 images/eye) –Near infrared fluorescein angiography Ultrasound Visual Fields (not DICOM) Diagrams (not DICOM)

39. 38 Results - Ophthalmology External color photographs Retinal (fundus) –Color photographs –Stereoscopic photographs –R/G/B filtered photographs –Fluorescein angiography (up to 30 images/eye) –Near infrared fluorescein angiography Ultrasound Visual Fields (not DICOM) Diagrams (not DICOM) Magnified Fundus Image

40. 39 Results - Ophthalmology External color photographs Retinal (fundus) –Color photographs –Stereoscopic photographs –R/G/B filtered photographs –Fluorescein angiography (up to 30 images/eye) –Near infrared fluorescein angiography Ultrasound Visual Fields (not DICOM) Diagrams (not DICOM) Fluorescein angiography 1108x1016 8-bit

41. 40 Diabetic Retinopathy Screening Diabetes mellitus causes degeneration of retina Leading cause of blindness in U. S. Treatable if detected in early stage Diagnosis can be made from digital retinal images VA has 763,000 patients with diabetes mellitus Goal: have all diabetic patient screened annually so that effective treatment can be scheduled

42. 41 VAs Teleophthalmology Diabetic Retinopathy Screening Program Uses CPRS & DICOM for Clinical Specialties Retinal cameras in OPCs Images acquired remotely and sent to reading sites Orders & results directly entered into VistA CPRS Proliferative Diabetic Retinopathy

43. 42 VAs Teleophthalmology Diabetic Retinopathy Screening Program Uses CPRS & DICOM for Clinical Specialties Retinal cameras in OPCs Images acquired remotely and sent to reading sites Orders & results directly entered into VistA CPRS Successful Treatment with Laser

44. 43 VAs Role in Advancement of DICOM in Endoscopy 1024x768 24-bit Acquisition Context (2005)

45. 44 VAs Role in Advancement of DICOM in Pathology Microscopic Slide 1520 x 1144 24-bit 2004 – first vendor interfaced

46. 45 Validated DICOM Clinical Specialty Imaging Systems SpecialtyManufacturers DentalGendex, Dexis, GE Dental, Planmeca, Schick, Sirona, Kodak, Medicor OphthalmologyCanon, Carl Zeiss, Kowa, Medivision OIS, Nidek, Topcon EndoscopyOlympus, Stryker Endoscopy, Utech Products PathologyApollo Telemedicine CardiologyHeart Lab, ScImage (DICOM imaging only)

47. 46 Thank You!