# Presentation: 395987

## Coming Attractions – Future Capabilities for VistA Imaging

- Ruth Dayhoff and the VistA Imaging Team

## DICOM

## Patch 69 (Caché)

- Migration of DICOM Gateway from MSM to InterSystems Caché
- Supported version of MUMPS
- Same implementation as VistA HIS
- Minimal application code change
- Much better installation procedure

## Patch 66 (DICOM Query/Retrieve)

- Query/Retrieve is the DICOM Standard mechanism used by a medical device to find and retrieve studies from another medical device containing the desired information
- Query gives a medical device the ability to determine a study’s existence on the VistA Imaging database
- Retrieve gives a medical device the ability pull the study from VistA Imaging back to the requesting medical device.
- Causes VistA Imaging to send the studies as DICOM objects

##  Update Commercial PACS Interface

- Current 1997 commercial PACS interface is outdated
- Uses VA-defined non-standard messages
- Migrate to IHE-based PACS interface
- Promotes interoperability
- Improves Patient Safety
- Needed to support the requirement for VistA Imaging to be the permanent archive for all digital medical images

## Migrate to IHE-based PACS Interface

- Benefits of IHE-based deployment
- Well-understood, industry-standard definitions of data elements and communications
- Enables validation of commercial systems against industry profile
- Uses HL7 messaging for orders and demographics
- Uses DICOM messaging for worklist queries and images

## Current state of VistA interfacing to commercial PACS (1997 vintage)

**Notes:**
VistA Imaging subscribes to HL7 order messages from VistA Radiology
HL7 messages are passed from VistA HIS to the DICOM Text Gateway
Order and demo information are sent to PACS using a VA-defined DICOM message
VA-defined message from PACS to DICOM Image Gateway contains information about images
Images are retrieved from the PACS

## Current state of VistA interfacing to commercial PACS (1997 vintage)

## IHE-Based VistA interfacing to commercial PACS

**Notes:**
VistA Imaging subscribes to HL7 order messages from VistA Radiology
HL7 messages are passed from VistA HIS to the DICOM Text Gateway
Order and demo information are sent to PACS using a VA-defined DICOM message
VA-defined message from PACS to DICOM Image Gateway contains information about images
Images are retrieved from the PACS

## IHE-Based VistA interfacing to commercial PACS

**Notes:**
VistA Imaging subscribes to HL7 order messages from VistA Radiology
HL7 messages are passed from VistA HIS to the DICOM Text Gateway
Order and demo information are sent to PACS using a VA-defined DICOM message
VA-defined message from PACS to DICOM Image Gateway contains information about images
Images are retrieved from the PACS

## IHE-Based VistA interfacing to commercial PACS

**Notes:**
VistA Imaging subscribes to HL7 order messages from VistA Radiology
HL7 messages are passed from VistA HIS to the DICOM Text Gateway
Order and demo information are sent to PACS using a VA-defined DICOM message
VA-defined message from PACS to DICOM Image Gateway contains information about images
Images are retrieved from the PACS

## Patch 49: IHE-based HL7 PACS Interface Messages

- Works with RAD*5.0*47
- Study Instance UID generated by VistA Imaging and passed to Commercial PACS
- Improves Patient Safety
- Site-specific Accession Number
- Needed for VA enterprise-wide imaging
- Specifications are published on the Web
- www.va.gov\imaging

## Patch 55: IHE-based DICOM PACS Interface Messages

- Provides industry-standard method for copying of images from PACS to VistA
- Image Availability Notification message sent from PACS to VistA
- Indicates DICOM objects that can be retrieved from the PACS
- VistA will pull these objects to its archive
- VistA will contain an additional capability to track the progress of missing PACS studies and pull them, when necessary

## Patch 34: Storing all DICOM Objects in VistA Imaging in DICOM format

- VistA Imaging is the long-term archive for the VA (System of Record)
- Any DICOM object will be able to be stored on VistA and accessed via Q/R
- Some DICOM objects stored on VistA may not be displayable (e.g., “used for processing”)

## Patch 34: Enhanced Duplicate DICOM UID Checking

- Unique Identifiers (UIDs) designate Study, Series, and Image entities in DICOM
- Problems have occurred in the VA when UIDs are not unique
- VistA Imaging will check for duplicate DICOM UIDs
- Email will automatically be generated used to notify people of duplicates
- First part of a comprehensive duplicate UID handling scheme

## Outside Radiology Reports

- Radiology Project that includes VistA Imaging enhancements
- Indicator for Outside Reports
- Administratively complete outside radiology reports in VistA
- Provide proper workload credit

## DICOM IMPORTER

- Importing DICOM images from outside institutions is labor intensive
- Must place Radiology order on VistA & use DICOM Modality Worklist
- IMPORTER application will use new radiology automated order entry capability
- User time to import a study drops from 7-15 minutes to 30 seconds
- Will work for both CDs and miss-associated DICOM images

## Select Study from CD

## Verify Study Selected

## Select Image to Review

## Verify Image

## Select Radiology Procedure for Study

## Select Patient for Importation of Study

## Select Additional Studies for Patient

## Importing Study 

## Studies Available for Viewing in CPRS and VistA Imaging

## Clinical Display (P72)

- Clinical Display Demo
- VA/DOD Image Sharing
- Radiology Viewer Changes

## Patch 72

- DICOM Encapsulated PDF
- Provides a means to obtain computer generated reports into VistA Imaging
- Some newer instruments can output these directly
- 3rd party vendors can convert printer output from legacy devices
- Complements DICOM Structured Reporting

- Original PDF

## DICOM ECGs (far future)

- ECGs are handled as DICOM objects
- Allows ECG equipment components to be interchangeable (carts, interpretation software, databases)
- Discrete data permits a variety of processing capabilities
- Different kinds of presentation (different leads, for example)
- Comparisons between examinations, difference analysis

## Recent Patch Releases

- Patch 59 – TIU <-> Imaging Enhancements
- Targeted for release August 2007
- Link Image to New Note, Addendum, Existing Note
- Administrative Closure
- Select date of document
- Date/Time of Image <-> Note Association

**Notes:**
Before 59 – Images could be attached to any TIU Note. Signed or Unsigned.
But after the fact, after an Image is attached to a Signed Note, there was no way of telling if the Image was available at the time Note was signed.  This went against HIMs policy
Note Association Date is saved, so HIMs personnel can tell at a later date, which came first.  The Image or the Signature.

New Functions : From Capture Workstation.  
User can Create a New Note, attach the Image to it, and Sign it.   Mark it as Electronically Filed (admin closed) or leave it Unsigned.
User can Create a Note and assign someone else as the Author.
If a consult Note is created, the user is prompted to select from a list of existing consults, 

Uses can Create an Addendum to an existing Note, and attach the Image to that.  And again, Sign it, mark it Electronically Filed, or leave it Unsigned.
During the capture process the user can select from the list of Image Index Terms.  Index Type, Specialty, Procedure, Origin.

Then to save time, and decrease the change of incorrectly indexing an Image, the
User can set up a a configuration button to save all the above information.  So with the Click of a Button, A New Note is created, Index Terms are applied, and both are saved in VistA.

Date/Time of Image <-> Note Association date (was it before or after signature)

## Upcoming Patch Releases

- 62 – Imaging Release of Information (ROI)
- Print All/Selected documents and images
- Copy (Burn) Images to CD
- Create PDF from Images for export
- 93 – Imaging Display
- Usability enhancements - Image groups
- Filter enhancements
- 94 – Imaging Capture
- Multiple page color documents

**Notes:**
ROI – easy way for ROI manager to Print all Images for a ROI Request.
      - Keep track of all Imaging ROI activity and be able to print report for date range,  user, or patient.
As an option to printing, we will enable exporting the images to a CD.
 - possibly have a function to  - Create one PDF File that contains all the patients images.  

At present, we don’t enable the creation of a MultiPage Color Image, we suggest that images be scanned separate and saved an Image Group.  60 (94) will fix that.

93 is the next maintanance patch for Clinical Display.  We’ll have improvements for Displaying Image Groups, Multiple Page images and  Improvements for Creating and managing Image Filters, 

## Future Patches

- Watermarking of Rescinded Advance directives
- Placeholder for Deleted Image
- No more scanning placeholder.
- Image Edit functions
- Images scanned/attached to wrong report
- Images scanned/attached to wrong patient.
- Image Index Edit
- Modify index fields

## VistARad

## VistARad

- Patch 76 in field test
- Integration with Voxar 3D
- Section 508 compliance

## VistARad – 508 Compliance and Voxar 3D Integration

## VistARad – 508 Compliance and Voxar 3D Integration

## VistARad

- End of life: Patch 32
- Acquisition Date/Time

## VistARad User Site Survey

- Establish VistARad priorities
- Collect input from users on needs
- Prioritization of enhancements
- Planning for future patch releases

## VistARad User Input

- Routing tracking and management
- Auto-route related priors with On-Demand Routing
- Teleradiology improvements
- Ability to read exams from multiple sites
- Multi-site combined worklist features
- Remote image view capability

## VistARad User Input

- Hanging Protocol Enhancements
- Simplify Master Image Set definitions
- Definitions to display exams in the VistARad “Browser Window” on load
- Export/Import of HP definitions
- Annotation improvements
- Ultrasound measurements support

## VistARad User Input

- Open images from the series (vs. study) level
- Immediate image display when loading
- Workflow management improvements
- ReadList interactions
- Display images from a Reserved exam
- Flag problem exams; interrupted session
- Enhance Integration with Dictation and 3D systems

## VistARad User Input

- Teaching file support
- Support Mammography screening on mammography approved video sub-systems
- Technology upgrades
- 64-bit platform for expanded memory requirements
- Technologist QA/Status tracking function
- Display of scanned documents

## VistARad User Input

- Mensurated Scale
- DICOM Conformance Updates
- Enhanced CT and MR (Multiframe)
- Process Group 6000 Overlay data
- Grayscale Softcopy Presentation State
- Contrast/Brightness adjustment for color images

## Thank You!