Department of Veterans Affairs

VIReC Clinical Informatics CyberSeminar

June 17, 2014

Jonathan Medverd, MD

Staff Radiologist, PSHCS

Seattle, WA

Jonathan.Medverd@va.gov

Modernizing VA Legacy Healthcare IT:

RAPTOR Project

(Radiology Protocol Tool Recorder)

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Disclosure & Acknowledgements

Disclosure

• No financial interests

Gratitude:

• VA Center for Innovation

• SAN Business Consultants, Rockville, MD

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R A P T O R

Radiology Protocol Tool Recorder (RAPTOR)

• Developed through VA Center for Innovations

• Decision Support & Workflow tool

 Safety

 Quality

 Efficiency

 Compliance

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Objectives

Why RAPTOR?

What is RAPTOR?

Expected results?

Implications for VA legacy healthcare IT 

Modernization

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Radiology Protocol Tool Recorder (RAPTOR) 
Department of Veterans Affairs

Dx Imaging – Workflow Needs

Advanced Medical Imaging

• CT | MR | Nuclear Med

Compliance requirement

• Protocol assignment mandate (Joint Commission)

• Workflow documentation (best practices)

Reality requirements

• Efficient (“invisible” work value, therefore undervalued) 

• Accuracy important (optimize information) 

• Responsibility (accountability & documentation) 

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VA Form 519a

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Poll Question

How long does it take to progress from advanced 

medical imaging order placement to completed 

protocol using existing paper system?

• A) 4 Minutes

• B) 4 Hours

• C) 4 Days 

• D) 4 Weeks

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R A P T O R - Objective 

Convert paper-based work flow for advanced 

medical imaging (CT, MR, Nuclear Med) to an 

optimized web-based tool

Leverage existing VHA Information Systems

Simultaneous improvements:

• Productivity

• Quality

• Safety

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R A P T O R

Tailored electronic environment

• Display and coordinate functionality of information and 

resources needed to make rapid, informed protocol 

decisions & actions; facilitate communication

• Capture these medical events reliably and retrievably

PROTOCOL & RECORDING

ACTION SPACE

Communication Portal

Information Portals

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R A P T O R

Current Paper 519a Form RAPTOR

Current CPRS order & exam workflow

supported in RAPTOR web form

Radiologist & Technologist

comments captured

Additional patient safety checks

& contraindications

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R A P T O R – Worklist 

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R A P T O R – Worklist 

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R A P T O R – Worklist SORTING 

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R A P T O R - Workflow

Protocol

• Active order is assigned then selected.

• Hydration, contrast, informed consent & sedation based on case.

• Radiologist or Resident reviews and approves the protocol.

Examination

• Technologist acknowledges protocol. 

• Actual hydration, contrast & sedation and radiation are noted.

• Exam is completed. 

Interpretive

• Radiologist reviews actual vs. planned.

• Post-examination observations are noted.

• Quality Control is noted for completed exams.

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R A P T O R – Protocol Page

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R A P T O R – 

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Information

Dashboard 
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R A P T O R – 

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Pre-populated

Template
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R A P T O R – 

Custom Text

Pre-population Options
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Contraindication details

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RAPTOR will compare the 

patient’s Allergy list against a set 

of user configurable key words to 

identify patients with a past history 

of adverse reaction to imaging 

contrast agents. If RAPTOR 

identifies a match, then RAPTOR 

will flag with user configurable 

message that consent is required.
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Protocol suspended

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Vitals tab 

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Labs tab

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R A P T O R – Features

Tracks entire Protocol Workflow

• Who did what, when

Detect “at-risk” drug interactions

Detect need for informed consent

Contraindications are acknowledged

Monitor radiation dose history

Protocol Library maintained

RAPTOR can be used throughout the workflow

• Protocol, Examination and Interpretation phases

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R A P T O R – Before & After

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Attribute Before RAPTOR With RAPTOR

Environment Paper Web-based, paperless

Level of 

Interoperability

Lowest – paper or 

scanned paper

Highest – Computational electronic 

data

Patient Identifiable 

Information

Poor (if any) 

security control

Role based authentication

Collaboration, 

communication

Handwritten, Fax or 

phone

Automated into workflow

Work distribution Stacks of paper 

manually distributed

Entire worklist process is automated 

with business priorities set by 

configurable rules 

Records 

Management

Shred or scanned Entire process is recorded for 

management review and reporting
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RAPTOR – Expected Benefits

Improve clinical decisions & patient care

Replace inefficient paper-based processes 

• No lost paperwork

• No duplication of paperwork (and effort)

• No vague documentation of responsibility

Improve radiologist & department productivity/efficiency

Benefit medical appropriateness

Benefit patient safety

Audit patient consent

...the future of VA legacy healthcare IT modernization?

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Department of Veterans Affairs

VA Legacy Healthcare IT

New development takes too long to deliver

• Multi-year release cycle is normal

New technology/ideas integration takes too long

Dated technology, needlessly complex

Maintenance, installation and operations difficult

Unanimous panel recommendation for migration 

to an openly architected, modular, and standardsbased platform

Reference: American Council for Technology – Industry Advisory 

Council VistA Modernization report (May 2010)

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VistA Evolution Program Plan

(March 2014)

Focus on delivering an evolved VistA that is open 

architected and non-proprietary in design

Based firmly upon the work that has come before

• Harness powerful core of software and business 

processes embedded within VistA

• Apply modern computing architecture

 Modular, Extensible

• Fully leverage VA’s investment in VistA

Achieve an interoperable EHR (e.g. DoD, VA)

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VistA Evolution Program Plan

(March 2014)

4.1.5 Ancillary Services 

Improvements to ancillary systems such as laboratory, 

pharmacy, and radiology solutions will provide enhanced 

support of laboratory, pharmacy, and imaging functions 

that allow pathologists, pharmacists, radiologists, and 

associated technicians to more efficiently follow best 

practices. These enhanced ancillary services will also 

enable more robust CDS for clinicians, allowing them to 

provide improved quality, safety, efficiency, and 

satisfaction in healthcare for Veterans, Service members, 

and their dependents. 

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Modernization – 

RAPTOR Approach

Open architecture; modular, standards-based 

platform

• e.g. Linux, Apache, MySQL, PHP (“LAMP stack”) 

Open source tools

• e.g. Drupal CMS

Reuse existing components/services

• e.g. Web Services

 VA Medical Domain Web Services (MDWS)

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RAPTOR Open Architecture

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Drupal

PHP

Apache 

Data 

Adapters

Web 

Services

VistA Data 

record

Open 

DBMS 

RAPTOR Users
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Open Source – Benefits

Innovation Opportunities 

• using building blocks

• using abstraction layers

Modification & Extension Opportunities

• build on existing resources

• replacement of volatile things simplified

Value Opportunities

• lower cost (e.g. zero or minimized licensing fees)

• more options

• reduced proprietary lock-in risks

• easier integrations

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Modernization – 

RAPTOR evolution >>> VIPER 

RAPTOR demonstration – an opportunity for VA 

and other US government agencies

VA Integrated Platform for Enterprise Radiology 

(VIPER); currently a concept

• Achievable

 Read-Write interactivity with VistA

 Integration of additional modules (e.g. scheduling, radiology 

information system (RIS) functions, imaging modality 

interfaces, etc.)

 Targeted interactivity to de-silo the info and resources

 Build from what works and is familiar

• Hugely facilitated by open source

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Thank You