1. 752 VistA Imaging: Image Routing, Telerad, & Remote Image Display John Di Lorenzo

2. –VistA Imaging Routing Terminology Routing is the combination of methods and software used to identify and transmit exams produced at one site to a storage location at another site. Routing takes two major forms –VistARad –DICOM Routed images are triggered in one of two ways: –Autorouting –Route on demand –VistA Imaging Routing Terminology Routing is the combination of methods and software used to identify and transmit exams produced at one site to a storage location at another site. Routing takes two major forms –VistARad –DICOM Routed images are triggered in one of two ways: –Autorouting –Route on demand

3. Routing Uses Workload sharing between institutions or service providers Rapid access of exams at remote clinics or other facilities Remote specialist interpretation or consultation Off-hours, holiday, or emergency “WET” reads Off-site contract radiology services for primary interpretation Film printing Specialized viewing stations, CD burners Peer Review

4. Autorouting In autorouting, automatically selected images are transmitted to one or more destinations. Images are selected based on a predefined set of routing rules. Autorouting functions are managed using the Routing Gateway. In autorouting, automatically selected images are transmitted to one or more destinations. Images are selected based on a predefined set of routing rules. Autorouting functions are managed using the Routing Gateway.

5. Autorouting –How Autorouting Works –How Autorouting Works

6. Autorouting Set up the rules for autorouting in the “route.dic” DICOM("ARC") when MODALITY="DX" SOURCE="AUGUSTA UPTOWN“ NOW={FRI 07:59AM to 17:00PM } PriorStudy YES SEND("ARC") when MODALITY="DX" SOURCE="AUGUSTA UPTOWN" NOW={FRI 07:59AM to 17:00PM } PriorStudy NO Set up the rules for autorouting in the “route.dic” DICOM("ARC") when MODALITY="DX" SOURCE="AUGUSTA UPTOWN“ NOW={FRI 07:59AM to 17:00PM } PriorStudy YES SEND("ARC") when MODALITY="DX" SOURCE="AUGUSTA UPTOWN" NOW={FRI 07:59AM to 17:00PM } PriorStudy NO

7. On Demand Routing –On-Demand Routing manually selected exams are transmitted to one or more destinations. Exams are selected using the VistARad client and are transmitted by the Routing Gateway.

8. On Demand Routing –How On-Demand Routing Works

9. On Demand Routing In on-demand routing, manually selected exams are transmitted to one or more destinations. Exams are selected using the VistARad client and are transmitted by the Routing Gateway. In on-demand routing, manually selected exams are transmitted to one or more destinations. Exams are selected using the VistARad client and are transmitted by the Routing Gateway.

10. On Demand Routing Displaying Routed Exams and Demand Routing In VistA Imaging, the VistARad manager is used to route exams as well as display which exams have been routed. A routed exam is available for display when the RC (Remote Cache) column in a VistARad exam list contains the destination name established for your site. Displaying Routed Exams and Demand Routing In VistA Imaging, the VistARad manager is used to route exams as well as display which exams have been routed. A routed exam is available for display when the RC (Remote Cache) column in a VistARad exam list contains the destination name established for your site.

11. On Demand Routing

12. Remote Cache Indicator

13. DICOM VS VistARad Routing –VistARad Routing Network Location File Images Remain in the same format as in Archive Uses routing transmission Processor –DICOM Routing SCU_List.DIC File Images converted to DICOM Sends DICOM files to remote SCP –VistARad Routing Network Location File Images Remain in the same format as in Archive Uses routing transmission Processor –DICOM Routing SCU_List.DIC File Images converted to DICOM Sends DICOM files to remote SCP

14. How it all Works Routing Gateway locates routable images, determines where the images are to be routed to, and sends copies of those images to other locations. Depending on workload, routing gateway can be set up: –On a standalone gateway –Co-hosted on a text or image gateway Routing Gateway locates routable images, determines where the images are to be routed to, and sends copies of those images to other locations. Depending on workload, routing gateway can be set up: –On a standalone gateway –Co-hosted on a text or image gateway

15. How it all Works

17. Routing Prerequisites Administrative Technical Administrative Technical

18. Routing Prerequisites An executed Site Agreement must be filed with the VistA Imaging development group. A contingency plan must be implemented at all sites in the routing system and filed with the VistA Imaging development group. The contingency plan must include information from the clinical and IT side of the house. An executed Site Agreement must be filed with the VistA Imaging development group. A contingency plan must be implemented at all sites in the routing system and filed with the VistA Imaging development group. The contingency plan must include information from the clinical and IT side of the house.

19. Routing Prerequisites Reporting / transcription requirements for routed exams Bandwidth utilization guidelines and priorities Management of patient confidentiality and privacy issues related to routed exams Methods for addressing performance issues and/or misuse of the routing system Documentation used for Auto Routing: VistARad User Guide Routing User Guide V.3.0 Patch 54 Reporting / transcription requirements for routed exams Bandwidth utilization guidelines and priorities Management of patient confidentiality and privacy issues related to routed exams Methods for addressing performance issues and/or misuse of the routing system Documentation used for Auto Routing: VistARad User Guide Routing User Guide V.3.0 Patch 54

20. Routing Prerequisites –Security Background Investigations on Contractors Privacy & Security Course Requirement –www.ees-learning.netwww.ees-learning.net Encryption is required once it leaves the VAMC LAN Data should be encrypted on devices that it lives on once it leaves the VAMC –Access VPN Accounts –Radiologist –Transcriptionist –Administrative Support –Security Background Investigations on Contractors Privacy & Security Course Requirement –www.ees-learning.netwww.ees-learning.net Encryption is required once it leaves the VAMC LAN Data should be encrypted on devices that it lives on once it leaves the VAMC –Access VPN Accounts –Radiologist –Transcriptionist –Administrative Support

21. Routing Prerequisites If remote interpretation is being performed, one or more VistARad diagnostic workstations for the display of routed exams. An operational VistA Hospital Information System, an operational Image Gateway, and an operational Routing Gateway, configured as described in the routing documentation. An operational Local Area Network (LAN). An operational Wide Area Network (WAN) with sufficient bandwidth to manage the anticipated volume of routed exams. Windows-based servers to provide exam storage at each routing destination, configured as described in the routing documentation. If remote interpretation is being performed, one or more VistARad diagnostic workstations for the display of routed exams. An operational VistA Hospital Information System, an operational Image Gateway, and an operational Routing Gateway, configured as described in the routing documentation. An operational Local Area Network (LAN). An operational Wide Area Network (WAN) with sufficient bandwidth to manage the anticipated volume of routed exams. Windows-based servers to provide exam storage at each routing destination, configured as described in the routing documentation.

22. Routing Prerequisites Connection Options & Requirements for routing outside the VA Network –Business Partner Gateways –Site to Site VPN Tunnels –LAN Extension http://vpnportal.vansoc.va.gov/ Connection Options & Requirements for routing outside the VA Network –Business Partner Gateways –Site to Site VPN Tunnels –LAN Extension http://vpnportal.vansoc.va.gov/

23. Challenges –Access Control List – Firewalls –Bandwidth – “Your best friend or Worst enemy” –Equipment – “ Who pays for it and where does it go.” Challenges –Access Control List – Firewalls –Bandwidth – “Your best friend or Worst enemy” –Equipment – “ Who pays for it and where does it go.”

24. Routing Optimization –Technical Optimization Use compression Evaluate bandwidth Autoroute prior exams –Logistical Optimization Defined schedules Contracts/MOUs Standard Operating Procedures

25. Routing Optimization –Routing Compression Works with “VistARad” routing Reduces file size before sending images Will not compromise image quality Aware JPEG 2000 proprietary software

26. Routing Optimization

30. –Evaluate bandwidth Is all bandwidth being used?

31. Routing Optimization XRAY DR images

32. Routing Optimization –Evaluate bandwidth Is all bandwidth being used? Yes –Get more –Change routing rules –Lower expectations Yes –Get more –Change routing rules –Lower expectations 1.5 Mb (T-1 speed) per radiologist

33. Routing Optimization Ultrasound images

34. Routing Optimization –Evaluate bandwidth Is all bandwidth being used? Yes –Get more –Change routing rules –Lower expectations Yes –Get more –Change routing rules –Lower expectations No –Autoroute more –Send less files –Send images simultaneously No –Autoroute more –Send less files –Send images simultaneously 1.5 Mb (T-1 speed) per radiologist

35. Routing Optimization Ultrasound images

36. Routing Optimization

38. Simultaneous sends to single site

39. Routing Optimization

41. Simultaneous sends to multiple sites

42. Routing Optimization –Autorouting prior exams Saves time & frustration for user Uses more bandwidth

43. Routing Optimization

45. –Editing prior exam logic VistA MAG RAD PRIOR EXAMS LOGIC file (2006.65) Used for identifying priors for both routing and JB prefetch Critical fields for routing: –AUTO-DISPLAY (should this be routed?) –DAYS LIMIT/AUTO-DISPLAY (max. date range to route) –VERSION LIMIT/AUTO-DISPLAY (how many?)

46. Routing Optimization Logistical Optimization & Telerad Business Practices

47. Routing Optimization –Defined schedules Radiologists PACS Admins Support staff

48. Routing Optimization –Memorandum of Understanding or contract How many employees? Recurring expenses Changing scope of work Equipment failure and replacement Contingency plan

49. Routing Optimization –Standard Operating Procedures Monitoring transmission of images Contact lists in place –Image quality issues –Routing/technical problems –Significant clinical findings Modifying routing rules Productivity and QA measurement

50. Routing Troubleshooting –Common Routing Problems and Solutions

51. Routing Troubleshooting

52. –Transmission processor not sending images Network or remote site unavailable VistA down or temporary disconnect –Set up critical devices for manual send

53. Routing Troubleshooting –Transmission queue backlogged

54. Routing Troubleshooting VistARad loading images slowly

55. Routing Troubleshooting

57. –VistARad loading images slowly Decompression not working

58. Routing Troubleshooting –VistARad loading images slowly Decompression not working Check Magj.ini file Remote storage full –Log a remedy ticket –Never delete folders manually!

59. Recent Advances –VistARad remote reading enhancements Multiple site worklist display Switching between multiple sites with single signon Use of VIX for remote DOD/VA images and data Imaging Patch 90 –VIX Server (VistA Imaging eXchange) Integrated DOD/VA imaging Automates compression and routing of images Handles local caching and purging Imaging Patch 83

60. Cumulative Images Captured

61. VistA Imaging eXchange (VIX) VA to VA image sharing (VIX enhanced Remote Image View)

62. VistA Imaging eXchange (VIX) DOD to VA image sharing

63. VistA Imaging eXchange (VIX)

65. BHIE PATIENT Area of Clinical Interest DoD Image WBAMC 03/2007 VA Image El Paso 10/2001

66. VistA Imaging eXchange (VIX) VistARad Manager

67. VistA Imaging eXchange (VIX)

68. Questions?