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Session I'm a VistA Imaging Coordinator with a New System

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1 Session 702 - I'm a VistA Imaging Coordinator with a New System
Session I'm a VistA Imaging Coordinator with a New System. Now What ? Presented by Jeannie Jernigan, VistA Imaging PACS Administrator, OI&T VAMC Fayetteville, NC

2 Session Outline Terms - Contingency Plans
Configurations - Implementation Workgroup DICOM Basics - Getting Support DICOM Gateways - Troubleshooting Image Quality - Patches and Testing Adding New Devices Preventive Maintenance

3 TERMS VistA Veterans Information System and Technology Architecture.
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 and run in the Cache’ Database environment. VistA - text-based, command-driven The initial Imaging system configurations have been/are being upgraded with additional terabytes of storage. This is in response to the increased demands and storage capabilities of new devices (PET CT’s and the like) in addition to the TeleHealth projects underway (TeleDerm, for example). The increased local storage capability allows for faster retrieval to the providers’ desktop.

4 TERMS (continued) PACS - Picture Archiving and Communication Systems (PACS) are computer systems dedicated to the storage, retrieval, distribution and presentation of images. HL7 – Health Level 7 (HL7) is standard based electronic message format supporting administrative, logistical, financial as well as clinical processes. DICOM - Digital Imaging and Communications in Medicine (DICOM) is a standard for handling, storing, printing, and transmitting information in medical imaging. CPRS – Computerized Patient Record System. Clinical Workstation – Software installed on workstations without any additional enhanced viewing software or monitors. Diagnostic Workstation – Specialized workstation that allows Radiologists to interpret radiology images without film (calibratible monitors). PACS - The medical images are stored in an independent format. The most common format for image storage is DICOM. You may also see JPEG2000 format from outside CD’s, other CPACS. HL7- (message streams) Within the Radiology framework, messaging occurs at the radiology package interface and consists of both outbound orders and inbound results messages. Medical text communication protocol. DICOM - It includes a file format definition and a network communications protocol. DICOM enables the integration of scanners, servers, workstations, printers, and network hardware from multiple manufacturers into a PACS. Digital Imaging and Communications in Medicine (DICOM) is a standard for handling, storing, printing, and transmitting information in medical imaging. It includes a file format definition and a network communications protocol. The communication protocol is an application protocol that uses TCP/IP to communicate between systems. DICOM files can be exchanged between two entities that are capable of receiving image and patient data in DICOM format. The National Electrical Manufacturers Association (NEMA) holds the copyright to this standard.[1] It was developed by the DICOM Standards Committee, whose members[2] are also partly members of NEMA.[3] Enhanced review workstations—workstations with Diagnostic review software on them but used in clinical setting (key workstations) (used in ER, or specialties such as Neurology, Pulmonary, or the like). The exams can be reviewed on a workstation with VistARad, but no interpretations done.

5 WHAT’S IN IMAGING? 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 Dermatology images And more…

6 If you attend a clinical display session, you will see the newest features being shown (as above). The tree view was introduced with Patch 93 to allow easier retrieval of groups of images (by package/specialty/type, etc.) Session 227HR

7 This slide is very useful in demonstrating the different kinds of images that are available via clinical display.

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 (includes Tele Retinal and Tele Derm images) 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

9 BASIC CONFIGURATION Per VA requirement each facility must have VistA Imaging storage in place to handle scanned documents, Clinical Procedure reports, and PACS Archive. This is the minimum configuration. 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. This is from the original 2001 VHA Directive and sets the basic guidelines for Imaging.

10 DICOM CONFIGURATION 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 Dermatology Image Capture Transferring DICOM images to other modalities, such as DICOM Printers (via DICOM Store) Encapsulated PDF’s

11 MORE DEFINITIONS 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… The DICOM storage commitment service is used to confirm that an image has been permanently stored by a device (either on redundant disks or on backup media, e.g. burnt to a CD). The Service Class User (SCU - similar to a client), a modality or workstation, etc., uses the confirmation from the Service Class Provider (SCP - similar to a server), an archive station for instance, to make sure that it is safe to delete the images locally. DICOM restricts the filenames on DICOM media to 8 characters (some systems wrongly use 8.3, but this is not legal). No information must be extracted from these names (PS3.10 Section ). This is a common source of problems with media created by developers who did not read the specifications carefully. This is a historical requirement to maintain compatibility with older existing systems. It also mandates the presence of a media directory, the DICOMDIR file, which provides index and summary information for all the DICOM files on the media. The DICOMDIR information provides substantially greater information about each file than any filename could, so there is less need for meaningful file names. DICOM files typically have a .dcm file extension.

12 ? Optical Archive DICOM Text Gateway VistA Image Storage
Patient One DICOM Text Gateway Patient Two VistA Image Storage (RAID - Magnetic) DICOM Image Gateway X:2056 Y:1998 Patient, Two Worklist Image Capture QA/Storage Background Processor ? HL7 DICOM 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. VI Session 757 VI-DICOM Gateways Behind the Scenes Worth noting here that this interaction makes the device somewhat dependent on VistA. MUST HAVE CONTINGENCY!

13 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 Currently Patch 101 Free software The prior example involved ANY DICOM modality, but the remaining configurations will be focusing on Radiology. Improved loading capabilities with Patch 101, annotation tools fixes (houndsfield units measurements), integrated Voxar (3D viewing capabilities) Integration with Talk and PowerScribe (IP passing interface)

14 VistARad Diagnostic WS
Optical Archive VistA Image Storage (RAID - Magnetic) Background Processor VistARad Diagnostic WS 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. Recent pregnancy status Radiology PATCH!!! Radiology Status Waiting for Exam Examined Interpreted Transcribed Complete

15 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 “Autorouted”. VI Session 752 VI-VistA Imaging: Image Routing, Teleradiology, & Remote Image Display VI Session 762HR1&2 – VI Importing DICOM Images from Outside Facilities into VistA

16 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

17 COMMERCIAL PACS RIS Image Storage PACS Diagnostic WS IMAGPAT, 1
Worklist Image Capture QA/Storage Image Storage PACS Diagnostic WS RIS 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.

18 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, and QA’d on both systems. Expensive to Buy and Maintain Data Stored in Proprietary Format HIPAA compliance (restricted records) Able to handle JPEG images with Imaging patch 99

19 DICOM Text Gateway Used to run Micronetics Mumps (MSM) on Windows 2000/XP, now 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. Text GW Builds local database from HL7 messages from VistA global MAGDHL7. HL7 message stored in global where TXT Gateway can query it.

20 DICOM Image Gateway Up Close
Like the Text Gateway, also runs MSM on Windows 2000/XP, now 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 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 One of the items introduced with our more recent clinical patches is the interaction with the ICN (Identification Control Number) of the patient. This was introduced to alleviate the problems in viewing images that had an IDmismatch. With the advent of Patch 72 (now 93/94), we can now open images that were captured using a different SSN, for example. If EITHER the SSN OR the ICN matches, the images will remain viewable. HOWEVER, if you ROUTE the images, you can run into some problems.

21 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. 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. Patch 99 allows the optional storage of currently supported DICOM images in DICOM format without changing or transforming the presentation. This includes files from modalities, such as CR and DX, which previously could only be stored in TGA format. It also allows users to revert back to storing DICOM images in TGA format for a specific modality, if necessary (depending on the modality). In addition to the enhancements to storing images in DICOM format, in Patch 99 the DICOM Gateway can process and store selected JPEG lossless and lossy compressed images.

22 VistA RAD Terms of Use Use of the VistARad diagnostic workstation is subject to the following provisions: Caution: Federal law restricts this device to use by or on the order of either a licensed practitioner or persons lawfully engaged in the manufacture or distribution of the product. No modifications may be made to this software without the express written consent of the VistA Imaging National Project Manager. The Food and Drug Administration classifies the VistARad software as a medical device. Modifications to the VistARad diagnostic workstation, such as the installation of unapproved software, will adulterate the medical device. The use of an adulterated medical device violates US federal law (21CFR820). Image presentation quality depends on monitor resolution, and on regular monitor testing and calibration to correct for display degradation over time. It is the responsibility of the clinical practitioner to determine if images presented on a VistARad workstation are of sufficient quality for clinical interpretation. Any concerns regarding monitor resolution or calibration should be reported immediately to the Imaging Coordinator before interpretation is performed. Any diagnostic review is governed by FDA regulations. The next slides review some of the basics required when viewing images diagnostically. ALSO of note for your gateways AND for many of your medical devices: FDA classified VistA Imaging, and the VIX (as a component of VistA Imaging) as a medical device. Modifications to VistA Imaging, including the VIX, such as the installation of unapproved software will adulterate the medical device. The use of an adulterated medical device violates US federal law (21CFR820). Because software distribution/inventory management tools can install inappropriate or unapproved software without a local administrator’s knowledge, sites must exclude Imaging servers (such as the VIX server) from automated update systems such as Microsoft’s Systems Management Server (SMS) software.

23 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 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 (calibrate to the settings of the work area—how is it lit? Does the provider keep the door closed? Has the room configuration changed?) Correcting Grayscale: SMTPE, hardware, software

24 Image Quality and Grayscale Calibration Producing a Good Curve
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. This can be automated.

25 Adding New DICOM Modalities
Tools to Help Ensure Successful Interface DICOM Conformance Statement – Should be required BEFORE procurement. Vendor Survey – Required component of Directive 6550 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 (VHA VI DICOM Validation mail group) 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 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. Reference patch 53 and import of images. Open a Remedy ticket to request interface validation. Send a DCS (DICOM conformance statement) to Silver Spring (VHA VI DICOM Validation mail group) Vendor device May have just never been validated May not work If not validated it may possibly be validated. Start the process at the soonest point possible (before it arrives on station). 4. A number of vendors have squirmed on this, but STAND FIRM!!! Biomed may also have vendors come in for equipment maintenance/upgrades. Stay in that loop also! Test images will come across your gateways and must ALSO be validated by Radiology/Silver Springs if there is a version change to their software/equipment.

26 Documentation 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/Clinical Procedures Web Site Remember to involve your Radiologist/clinician involved in reviewing the images. Sometimes this means that the Biomed folks will need to bring in the vendor technicians for assistance. You must keep in good contact with them at all times. Upload the forms so that there is a record of the image certifications for your site (site designated FTP). Due to the import process performed on the BGP, I also recommend utilizing the Clinical Procedures website. This is a very good resource when you are being asked about new devices. It literally takes a village—end users, CAC’s, HAS ADPAC’s, Biomed, Imaging, ISO, LAN/WAN Managers, etc. to get a modality properly interfaced.

27 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 DIGS are arrayed on separate monitors for quick review and check frequently during the day. Quick review by scanning the displays Check event logs on each machine Review VistA error trap Check backups for success/failure Do you have a contracted media storage such as Iron Mountain for your off site storage, or, do you have an agreement with another site to securely store and retrieve your tapes? DICOM corrects? Check your tapes

28 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 SCA

29 Implementation Workgroup
Group comprised of key individuals representing key disciplines (Required by Directive 6550) 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 VA network. 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. CAC (Clinical Application Coordinator) 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. Develop ancillary workgroups if you can - HIMS Document Scanning Workgroup for VISN 6 is one example. Don’t forget your local CAC’s (especially with TIU business rules, etc). They are generally the CPRS guru’s and can help you tremendously in getting consults interfaced, update progress note titles, and troubleshoot issues (CP, iMedConsent, and the like). Some of the problems reported to Imaging are actually a result of a business rule in place that protects the patient record.

30 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 Expertise Center – Will help with server hardware issues

31 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 – , code Monthly HP Imaging Conference Call Held 3rd Tuesday of the month from 2:00 – 3:00 PM Eastern Time ( , Passcode: ) Forum for hardware issues Get on the ListServe to receive critical updates and requests. Learn, learn, learn. Learn from the experts, learn from your peers. Learn from your experiences and share them with others. Do NOT be afraid to ask questions. Use the forums (VistA Imaging/HP/test patch calls). Network with other Imaging Coordinators/PACS Administrators. Remedy tickets can be reviewed for content and may help you resolve a local issue more quickly. Listen to your users.

32 TROUBLESHOOTING I’m still getting an “ID Mismatch” Why? Answer: If BOTH the ICN and the SSN have been changed, the images will be non-viewable. No images on a patient, but the case says it’s complete. a. Did the images really get sent from the modality/device? b. Are they a DICOM correct? Image is there but non-viewable. Answer: Patch 93 introduced the TIU Business rule association. If an image is associated to a progress note that is non-viewable, you will no longer be able to view that image. Get to know your local site HAS and HIMS contacts. They can be useful in researching issues with ID mismatch. LAN/WAN managers and know your ports, rights for your workstations (medical device isolation architecture and how it affects YOU). DICOM corrects show up on your gateways, but are resolved to the patient exams—it is site-specific as to who will do the DICOM corrects. If you are a Teleretinal site (reader or acquisition), you may get contacted by a clinician not being able to view images at all (patient does not show up in their listing). This is an MPI issue (master patient index) and must be resolved by HAS/HIMS.

33 Keys/Menu Options IMAG Imaging System Manager Menu ... [MAG SYS MENU] **> Locked with MAG SYSTEM MAG WINDOWS MAG DELETE MAGDISP Clin/MAGDISP Admin MAG CAPTURE, MAGCAP TIU, MAGCAPMAGJ VISTARAD MAGJ VISTARAD WINDOWS WINDOWSVRAD Keys: MAGJ There are several powerful keys within the VistA Imaging Coordinator menus. With the introduction of new capabilities, new menu options and keys are introduced. Remember to review ALL patches for any new keys or options that might need to be allocated. Security keys allow controlled access and also further “lock down” menu options to specific users (VIC Card photo key – MAGCAP PhotoID, for example) On the VRAD side, MAGJ SYSTEM USER was introduced with Patch It allows a user to create and delete site-level hanging protocols, templates, and image presets. Patch 101 added MAGJOVERRIDE Annotations, but didn’t modify the MAGJ System User key. Patch 90 introduces the MAGJ Remote Access Control Key. This Key allows a VistARAD user to access the Monitored Sites configuration subset of the VIX Configuration settings tab and to view exam list data in the Monitored Sites tab of the VistARAD Manager window. It is required to make any edits to the “Local Site VIX” settings in the VIX Configuration table. Without this key, the Monitored Sites tab will not be accessible, nor will your user be able to edit the Monitored Sites configuration in the VIX Configuration tab (new tab introduced by the patch).

34 Patches Patch 94 Clinical Capture/Display Client Patch 90 VistARAD
Patch 83 VistA Imaging Exchange (VIX support Patch 39 BGP Enhancements 66 DICOM Query/Retrieve Others VistA Imaging is constantly working on improvements to the current configurations. Does anyone recall when Patch 45 was released? It allowed for remote Image view in Clinical Display. MAG_VistARAD Patch 90 now allows for remote Image view AND remote reading capabilities. Patch 94 is a Clinical Capture Maintenance patch that includes the Broker Security Enhancement (BSE) support for TeleReader and Clinical Display. In patch 94, Version Checking is turned ON for all sites and the option for turning Version Checking off is disabled. Broker Security Enhancement (BSE) uses a token based authentication method to connect to remote sites that improves security over the existing CAPRI remote site authentication method. The CAPRI authentication method will be used as a back up to the BSE authentication method. Clinical Display and TeleReader are affected by BSE changes. The BSE changes do not affect the usability of the applications and are transparent to the user. If the BSE remote site authentication fails the CAPRI remote site authentication method will be automatically enabled. When CAPRI is used the system will generate a log entry to track the usage of the CAPRI authentication method.

35 Patch 90 is a VistARad enhancement patch that also has BSE and includes remote image views in the patient exams list, the capability to remotely read/interpret studies; and provides a single sign-on to a group of selected remote sites and the local site. Patch 83 allows remote image viewing of VA/DoD and VA-to VA Image Sharing (using the VIX environment). It allows access to DoD radiology images using existing Clinical Display remote image views functions. And, in conjunction with 90, allows new VA-to-VA remote image access and remote exam list monitoring for VistARad (enhanced remote reading capabilities). Patch 39 is the Background Processor Enhancement patch that allows for automatic restart of the BGP upon disconnection, PGP system monitor status failure user notifications (set frequency intervals and recipients); and an improved GUI interface for managing the BGP settings (BGP queues, etc) in addition to improved purge options (manual purge by selected shares, purge by Date Modified, purge by Date Created). (VEHU Imaging Session 760) Patch 66 DICOM Query/Retrieve provides the ability for DICOM to serve as a Service Class Provider (SCP) to enable current specialty workstations, PACS, and teleradiology systems to query and retrieve images stored in VistA Imaging. Some other improvements in field testing include (not a complete listing): 98 Storage Utilities (MagDexter, MagUtility, MagKat) – to backfill specific fields in Image file #2005 to address discrepancies that may appear in displaying older images; new storage mgmt utilities with GUI’s. 99 DICOM Object Storage – Allow the option to store all currently supported DICOM modalities images in native DICOM format that would otherwise be stored in Targa formate (e.g. CR & DX modalities) WITHOUT changing or transforming the presentation. 105 Advanced Web Image Viewer (AWIV) Development – will let VistAWeb users locate and display VA images associated with progress notes (supports display of images associated with Radiology reports as well) Some others to mention that are in Development: 34 Storing DICOM objects Phase 3 – takes patch 99 further in that it allows storage of all composite DICOM objects that are transmitted to VistA Imaging for currently supported and unsupported SOP class images regardless of modality. The images are retained in DICOM format without alteration. The storage of DICOM objects in DICOM format will be mandatory in Patch 34. 106 Teledermatology – includes DICOM image capture via the VistA Imaging Clinical Capture/Display client; controlled use of Telereader with Thin Clients; and limited annotation when reviewing images in Telereader/display. (currently specialized software is utilized to capture TeleDerm images). 115 – VistA Rad Enhancements – Includes a process for automatically updating the VistARad client software; CCOW integration, provides management functions including remove or disable a user from the settings file (e.g. residents who leave). Also provides a default profile to copy settings/hanging protocols to new users. 117 Maintenance for Display and capture – (improve QA reporting features, ability to print multiple images, deleted image placeholder, to name a few) There are several other maintenance and enhancement patches for VistARad, Display and Capture and the gateways that are underway. Each will improve the current products being used and address Remedy ticket issues that have been reported.

36 Becoming a Test Site Why should I? Test Phases Test Documentation
Helps the project Helps your site (help shape new software) Test Phases E3R/NSR 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 PMAS and its effect on patch testing has made it a little more difficult for both the sites and developers to completely resolve issues within a single patch release. If you can test, please do so. Your input is invaluable. There are several other sessions regarding new Imaging applications and technologies 758 – VI-New Frontiers for VistA Imaging Telemedicine Software 750 – VI-New Imaging Applications and Technologies

37 Questions…

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