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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

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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

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VistA & Computerized Patient Record System

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Multimedia Patient RecordCombines 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.

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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

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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.

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VA’s 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

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Using DICOM to Acquire Images in the Clinical Specialties

• Dentistry

• Ophthalmology

• Endoscopy

• Cardiology

• Pathology

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Goal of Project

Interface the VistA HIS Consult package to new DICOM-based image acquisition devices used in the clinical specialties

Panoramic Image3064x1536 16-bits

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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

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Workflow Messages

CPRS Order Entry VistA Appointment Management

Order entered for a Consult or Procedure or Clinical Procedure

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Workflow Messages

CPRS Order Entry VistA Appointment Management

DICOM Gateway

Order signed

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Workflow Messages

CPRS Order Entry VistA Appointment Management

DICOM Gateway

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Workflow Messages

CPRS Consult Request Tracking VistA Appointment Management

DICOM Gateway

Patient scheduled for appointment

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Workflow Messages

CPRS Consult Request Tracking VistA Appointment Management

DICOM Gateway

Patient arrives at image acquisition modality

Imaging Modality

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Workflow Messages

CPRS Consult Request Tracking VistA Appointment Management

DICOM Gateway

Modality obtains patient demographics and study information

Imaging Modality

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Workflow Messages

CPRS Consult Request Tracking VistA Appointment Management

DICOM Gateway

Images acquired and sent to VistA

Imaging Modality

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Workflow Messages

CPRS Consult Request Tracking VistA Appointment Management

DICOM Gateway

Images acquired and sent to VistA

Imaging Modality

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Workflow Messages

CPRS Consult Request Tracking VistA Appointment Management

DICOM Gateway

Images verified on VistA

Imaging Modality

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Workflow Messages

CPRS Consult Request Tracking VistA Appointment Management

DICOM Gateway

Patient leaves image acquisition modality

Imaging Modality

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Workflow Messages

CPRS Consult Request Tracking VistA Appointment Management

DICOM Gateway

Patient checked out

Imaging Modality

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Workflow Messages

CPRS Consult Request Tracking

DICOM Gateway

Patient checked out

Imaging Modality

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Workflow Messages

CPRS Consult Request Tracking

Images diagnosed on VistA

Imaging Modality

DICOM Gateway

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Workflow Messages

CPRS Consult Request Tracking

Images diagnosed on VistA

Imaging Modality

DICOM Gateway

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Workflow Messages

CPRS Consult Request Tracking

Images diagnosed on VistA

Imaging Modality

DICOM Gateway

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Workflow Messages

CPRS Consult Request Tracking

Report is entered

Imaging Modality

DICOM Gateway

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Workflow Messages

CPRS Consult Request Tracking

Image icon appears on CPRS note

Imaging Modality

DICOM Gateway

Image icon on CPRS note

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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

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Workflow Messages

CPRS Consult Request Tracking

DICOM Gateway

Request Complete

Imaging Modality

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Workflow Messages

CPRS Consult Request Tracking

DICOM Gateway

Request Complete

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Workflow Messages

CPRS Consult Request Tracking

Request Complete

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VA’s 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 – 1st demonstration

of MWL & Storage for Dentistry• ADA is now picking up this effort

1024x1536 8-bits

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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

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Results - Dentistry

• 2 kinds of sensors– CCD (DX)– Phosphorescent Plate

• 3 kinds of radiographs– Intraoral (18-20

image/study)– Panoramic– Cephalometric

• Color (VL)

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VA’s 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

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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)

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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

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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 angiography1108x1016 8-bit

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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

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VA’s Teleophthalmology Diabetic Retinopathy Screening Program

• Uses CPRS & DICOM for Clinical Specialties

• Retinal cameras in OPC’s

• Images acquired remotely and sent to reading sites

• Orders & results directly entered into VistA CPRS Proliferative Diabetic Retinopathy

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VA’s Teleophthalmology Diabetic Retinopathy Screening Program

• Uses CPRS & DICOM for Clinical Specialties

• Retinal cameras in OPC’s

• Images acquired remotely and sent to reading sites

• Orders & results directly entered into VistA CPRS Successful Treatment with Laser

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VA’s Role in Advancement of DICOM in Endoscopy

1024x768 24-bit

• Acquisition Context (2005)

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VA’s Role in Advancement of DICOM in Pathology

Microscopic Slide 1520 x 1144 24-bit

• 2004 – first vendor interfaced

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Validated DICOM Clinical Specialty Imaging Systems

Specialty Manufacturers

Dental Gendex, Dexis, GE Dental, Planmeca, Schick, Sirona, Kodak, Medicor

Ophthalmology Canon, Carl Zeiss, Kowa, Medivision OIS, Nidek, Topcon

Endoscopy Olympus, Stryker Endoscopy, Utech Products

Pathology Apollo Telemedicine

Cardiology Heart Lab, ScImage (DICOM imaging only)

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Thank You!