# Presentation: 884717

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

- Brent Fugett - Huntington, WV
- Michele Krajewski – Philadelphia, PA

**Session 130 – Imaging Coordinators:  Getting Started!**

**Notes:**
Welcome to VEHU class 120, titled “Ready Set Go!”
The title of this class is very appropriate, I felt a certain weight on my shoulders as I first sat in the middle of a computer room space that would soon be populated with Imaging storage and processing equipment.   If you’re new to Imaging my hope is that this course will help part the clouds a bit.  
It should be noted that I am and employee of the Department of Veteran affairs and any mention of third party products in this presentation is purely for reference purposes and in no way should be considered an endorsement of that product.

## 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

**Notes:**
My background is in Information Technology (IT), Programming, Hardware repair, technical support.
I Bring up my background here because being an Imaging coordinator is a jewel with many facets, and can be approached from a number of directions.
IT, Biomedical Engineering (Biomed), Clinical (Radiology Tech, Clinical Coordinator), Administrative
POLL Class for Background
Introductory, not much detail.
In producing this course I tried to bring the concepts I had to grapple with the most as a new coordinator.
Review outline
I would ask that you please hold questions until the end of the session.

## What is VistA Imaging?

- VistA
**V**eterans **I**nformation **S**ystem and **T**echnology **A**rchitecture.
- 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.

**Notes:**
VistA Imaging can best be described by describing the components of it’s name.
VistA is the VA’s custom-written Hospital Information System (HIS).
Text based, meaning it is designed to work with text data.  It is not designed for handling large data sets, which digital medical imaging brings.
Imaging brings a parallel system that IS designed to handle large volumes of data, supporting 
Storage and Archive of the images (TB > 1,500 CD’s, > 100,000 Chest films), 
Management of the images (which includes correcting errors and deleting flawed images), 
and probably most importantly, retrieval of the Images.

## 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
- CT’s				Diagram Annotations
- MRI’s				And more...

## Slide 5

**Notes:**
Sagittal MRI view of the skull

124H Not just for Radiology Any More – Dental and Ophthalmology 
164 VistA Imaging: An Image to Remember (Digital Camera capture)
170Hr1 VistA Imaging: Driver’s Ed for Providers 

## Slide 6

## 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.

**Notes:**
Because of the criticality of the FDA classification of VistA Imaging I felt it import to show the disclaimer that is on virtually every routine in Imaging.

## Some Terms to Know

_**PACS**_ – Picture Archival and Communication System.  System designed to store and retrieve a patient’s medical Images.  Historically Radiology-centered.
_**DICOM**_ – **D**igital **I**maging and **Communication** in **M**edicine.
_**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

**Notes:**
PACS – Vista Imaging considered a PACS that is NOT centric to a particular specialty.  Commercial PACS.  Purists don’t like “PACS System”.
DICOM –Stands for Digital Imaging and Communications in Medicine – DICOM is a protocol (which is a standard of communication) that allows different types of Medical devices and display equipment to move image data. In the dim times commercial PACS were black boxes.  DICOM compatibility helps assure interface.  We will discuss more later.
HL7 – Like DICOM HL7 is a protocol which allows communication of medical data, but UNLIKE DICOM, HL7 is designed to communicate ONLY text data, no image data (Although a new version is in the works to handle image data also).  Again, we’ll see where this fits into the picture later.
Modality – See Slide
Clinical Workstation – As we saw in the previous overview, this is the software that runs on hospital workstations that allows users to retrieve images.
Diagnostic Workstation – Similar to the Clinical workstations (in that they display images) Diagnostic Workstation are designed to reproduce images in a a way that assures Radiologists that they are seeing an Image that is reproduced as faithfully and accurately as possible.   (VistaRad, Commercial PACS).  More on this later.
Hard and Soft Copy Interpretation – 

## 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

## Configuration 1: Basic

- 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

**Configuration 1: Basic**

**VistA**

**Background Processor**

**Image Storage**
**(RAID - Magnetic)**

**Notes:**
140   Vista Imaging: VistA Imaging - Document Imaging from Theory to Practice to Quality Improvement 
174H Vista Imaging: A Fine Import – Capturing from Digital Camera
175H VistA Imaging: The ABCs of Scanning - Basics

163 Vista Imaging:  Core Concerns – Configuring and troubleshooting Core storage.

167 Vista Imaging: Don’t Rock the Jukebox

## 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)

## 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...

**Notes:**
SCU – a Modality querying for patient information (worklist)
SCP – Text GW or another Modality Worklist Provider

## ?

**DICOM Text Gateway**

**Patient Two**

**VistA**

**Image Storage**
**(RAID - Magnetic)**

**DICOM Image Gateway**

**Patient Two**

**Patient Two**

**Patient Two**
**000-28-1665**
**X:2056**
**Y:1998**

**Patient, Two**
**000-28-1665**
**X:2056**
**Y:1998**

- Worklist

- Image Capture

- QA/Storage

**Background Processor**

**Patient Two**
**000-28-1665**
**X:2056**
**Y:1998**

**?**

**Patient Two**
**000-28-1665**
**X:2056**
**Y:1998**

**Notes:**
For this example, we’re focusing on a Radiology exam, but this could be Dental or Ophthalmology just as well.

First DICOM Gateways probably installed via Implementation team.
Recommend installing at least one on your own even if just for a test.
Session 168H – Gateway to the Images, Hands on setup session

Worth noting here that this interaction makes the device somewhat dependent on VistA.  MUST HAVE CONTINGENCY!

## 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

**Notes:**
The prior example involved ANY DICOM modality, but the remaining configurations will be focusing on Radiology.

## Waiting for Exam

**VistA**

**Image Storage**
**(RAID - Magnetic)**

**Background Processor**

**VistARad Diagnostic WS**

**Waiting for Exam**

**Examined**

**Interpreted**

**Transcribed**

**Complete**

- _Radiology Status_

**Notes:**
Waiting for Exam – Exam ordered, Patient checked in, triggers worklist for modality.
Examined – Image captured and QA’d, and has been stored on Vista, ready to interpret.
Interpreted – Tracked by VistaRad once read by Radiologist and report is dictated.
Transcribed – Tracked by transcriptionist once report has been entered
Completed – Tracked by radiology once the report in confirmed.

176H VistA Imaging (VistA RAD): No Longer Hanging by a Film

## 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”.

## 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

## Commercial PACS

**Worklist**

**Image Capture**

**QA/Storage**

**Commercial PACS**

**Image Storage**

**PACS Diagnostic WS**

**RIS**

**Notes:**
From the VistA Imaging perspective we can illustrate the PACS as taking the modality as seen in the DICOM configuration and adding components.
HIS
Image and Data Storage
Diagnostic Workstations
Clinical (non diagnostic) workstations

Making the system self contained.  From Imaging, worklist is provided via Text Gateway and Images are transmitted to Vista Imaging via the Image Gateway.

## 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

## 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 it’s internal database.
- Converts data to DICOM and sends to the requesting modality.

**Notes:**
Text GW Builds local database from HL7 messages from VistA global MAGDHL7.  
HL7 message stored in global where TXT Gateway can query it.

## 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

**Notes:**
Is a Storage Service Class Provider

Does a Fileman call to receive the next available IEN
Stores/copies
Notifies by setting pointers in Vista
Queues an entry for copy to the Jukebox

## DICOM Image Gateway Up CloseSaving 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 1:8 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 it’s associated TXT and ABS file.**

**Notes:**
Targa conversion was originally used because (at the time) DICOM was not universally accepted, and then only for Radiology.  Since VistA Imaging was intended to be used in a wide range of applications, a universal, lossless image format was needed.  And that was Targa.

307H Vista Imaging: The Blue Print (Mumps, Fileman, Globals)

## Image Quality Basics

**Image Quality is Everything**
**Good, Working, **_**Appropriate**_** Equipment**
**Appropriate Resolution (aka Image Matrix)**
- 1:1 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**

**Notes:**
Proper image quality is the final product of Vista Imaging.
Substandard equipment, non-functional equipment, inappropriate equipment.
What is inconvenience elsewhere may be a problem in medical display.
Resolution: Define resolution
Elements to consider when determining appropriate resolution
Define 1:1 pixel ratio, 
Below 1:1 is sub-sampling, above is super-sampling aka interpolation
Image type dictates resolution requirement

Grayscale
Grayscale is a range of gray from white to black.   What is important that our eyes can see and our brains are able to smoothly DISCERN as much of the spectrum from white to black as possible,
Define 0% - 100% Grayscale
What can effect perceived Grayscale?
Hardware limitations, settings, environment
Correcting Grayscale: SMTPE, hardware, software

## Image Quality and Grayscale CalibrationProducing 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/medical.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.

**Notes:**
SMPTE - Society of Motion Picture and Television Engineers 
SMPTE Pattern
Should be able to discern 5% and 95% grayscale simultaneously.  Should not mistakenly assume that seeing both indicates an ideal setup.  If both are NOT visible that is a strong indication that you have real visibility issues and need to take steps.
Hardware/Software
If the video card supports lookup tables (LUT) then the card can be calibrated for the attached monitor.  
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.
Image Smiths used on most recent workstation deployment.

## 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/imaginterface.pdf

**Notes:**
Just because it is DICOM does NOT necessarily mean it can communicate with all DICOM devices.  DICOM is a Language (English, French), but you can still have DICOM devices that are not compatible (IT people at the barber shop).  Imaging has several requirements of DICOM devices, important that those requirements are met or exceeded by the equipment.
Vendor survey probably not binding, but it does keep the vendor from claiming they didn’t know...
Open a Remedy ticket to request interface validation. Send a DCS to Silver Spring
Vendor device
May have just never been validated
May not work
	If not validated it may possibly be validated.
5.	A number of vendors have squirmed on this, but STAND FIRM!!!

## 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

- 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](http://vaww.va.gov/imaging/IMGNewHardwr_OpSys.htm)_

**Documentation**

## Preventive MaintenanceNot official OR comprehensive!

**Each Morning**
- Review basic operation, DICOM Gateways, BGP, Jukebox, etc.
- Review System logs for events
- Review VistA error trap
- Review prior night’s 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

**Notes:**
Session 169 VistA Imaging: Countdown to Performance
DIGS are arrayed on separate monitors for quick review
 Quick review by scanning the displays
 Check event logs on each machine
 Review VistA error trap
 Check backups for success/failure

## 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

## 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.

**Notes:**
The Implementation Workgroup – Not an option
One primary element of the successful implementation of a project like this, as well as the long term level of customer satisfaction, is the existence and vitality of the Implementation Workgroup comprised of:
IRM
Biomedical Engineering
Acquisition
ADPAC or knowledgeable representative of the service being interfaced.
It’s been said the devil is in the details.  Leaving key positions out of the loop is the best way to see that an overlooked detail causes sometimes major problems at implementation.  
Prior to VistA Imaging implementation convene your group as often as necessary with the Implementation manager on conference phone (not needed since all sites implemented?).

## 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

## Weekly Imaging Conference Call
Held each Thursday from 12:00 – 1:00 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 2:00 – 3:00 PM Eastern Time
Forum for hardware issues
Get on the ListServe to receive critical updates and requests.

- Held each Thursday from 12:00 – 1:00 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 2:00 – 3:00 PM Eastern Time
- Forum for hardware issues
**Get on the ListServe to receive critical updates and requests.**

**Getting Support**

## 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

## 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!

## VistA Imaging

- Questions...

**Notes:**
In conclusion I would like to thank the VEHU staff for allowing me to participate
And I would especially like to thank my wife Cathy and daughters Emily and Erin for their love and support.

Questions