1. VistA Imaging: An Update on IHS Activity and Directions Mark Carroll, MD; Janis Sollenbarger

2. Objectives Overview of VistA Imaging Current experience with VistA Imaging in Indian Health Next steps/planning

3. Today’s Presentation Overview of IHS Imaging Needs Overview of history of VI in VHA Brief history of VI in IHS Possible architectural models 7 Steps process to implement VI in Indian health Question and Answer

4. Why VistA Imaging? RPMS has no image storage capability Implications for the IHS EHR and for diverse Telehealth activities

5. EHR “Image” Needs Reports Consults from Outside Specialists Consents Advance Directives Patient Photos

6. Howard Hays, MD, MSPH IHS Technical Conference June 20, 2006

7. EHR Milestones and Status RPMS EHR was certified January 2005 7 test sites participated in 2004 Presently 53 facilities use EHR Goal for all Federal sites to be using EHR by end of 2008 Tribal sites encouraged to use EHR as well RPMS EHR was certified January 2005 7 test sites participated in 2004 Presently 53 facilities use EHR Goal for all Federal sites to be using EHR by end of 2008 Tribal sites encouraged to use EHR as well

8. EHR Sites as of 6/6/06 Federal Hospital15 Federal Health Ctr/Stn20 Tribal Hospital5 Tribal Health Ctr/Stn13

9. www.telehealth.ihs.gov

10. “Real-Time Telemedicine” Mental health Videoconference- based Other specialist consultation

11. “Store-and-Forward” Telemedicine

12. IHS-AFHCAN Collaboration National Telehealth Infrastructure Offer a secure enterprise solution for telemedicine across Indian health

13. Large Scale 248 Sites 586,412 square miles Multi-Agency 43 Autonomous Organizations Native/Tribal, Military, Veterans, State of AK 3 Federal Agencies Multi-Provider Community Health Aide / Practitioners (CHA/P) Nurse, ANP, PA MD Specialist Native Health Corporations (36) U.S. Army U.S. Air Force (3 bases) Veterans Administration U.S. Coast Guard Public Health Nursing

14. “Cart” Roadmap The “Classic” Cart Four Devices “Next Generation” Cart More Devices - Repackaged

16. ENT Tele-Consultation Center Specialists at Alaska Native Medical Center Patients at the Yakima Indian Health facility in eastern Washington “Expert triage” model

17. Integrated System of Care Integrated Health Enterprise architecture that includes: Images and telehealth information with the IHS Electronic Health Record

18. The Chronic Care Model Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4.

20. Why VistA Imaging? RPMS has no image storage capability Implications for the IHS EHR and for diverse Telehealth activities

21. Why VistA Imaging? Multi-faceted software program developed in federal sector for image capture, display, and storage of: Scanned documents Non-DICOM images DICOM images

22. Strong Foundation Build from existing successes

23. Please note! VI is not a mandate It is: Part of IHS IT strategic plan Part of ISAC priorities But it is an Unfunded opportunity Except for some support such as the IHS-VHA project agreement

24. Strategic Directions VI is the multimedia component of VHA CPRS VI is now offered as the multimedia component of IHS EHR

25. VistA Imaging in Indian Health Permission to use VI Proof-of-concept implementations Proprietary license review IT/IHS EHR integration issues Architectural planning and roll-out

26. IHS-VHA Project Agreement

27. IHS-VHA Distribution Agreement VHA is manufacturer of FDA regulated device IHS cannot modify VistA Imaging code Software is free (except for some embedded proprietary software) IHS must install VistA Imaging on hardware configuration certified by VHA Hardware configuration is “robust” I.E. Expensive

28. Vista Imaging Separate application Separate hardware Some proprietary software embedded within application

29. Why is the Hardware Expensive? Storage redundancy and security Image data is stored in 3 places – RAID Tape Magneto optical discs (Jukebox)

30. Phase 1: Proof-of-Concept Wind River as initial installation in Fall, 2004 Earlier software version of VI Portland Area regional installation in 2005 To support all Portland Area sites Warm Springs as initial site accessing VI via the IHS WAN “Live” in January, 2006

31. Regional Hardware Pros Cost-effective Opportunity for image sharing Facilitates technical support Capable of supporting teleradiology Cons Relies on Wide Area Network

32. Shared Hardware in the VHA? Some VISNs are consolidating their Jukeboxes The trend is to provide approx 7 years of on-line storage w/ the JB being accessed less and less Some VISNs have consolidated VistA databases

33. VI – EHR Integration VI Launches from EHR Maintains patient context Presently requires a separate enduser log-on Other customization work under review Annotation tool Patient photo

34. Proprietary Licenses Accusoft Image Gear run-time license 5 Regional server license purchased for first 5 installations Nationally funded for license Annual maintenance fee to be paid by Area or installation Other possible DICOM query and retrieve DICOM compression

35. Phase 2 Implementations Nashville Area August 2006 Installation Other Areas and facilities Navajo Area Phoenix Area Billings Area Bemidji Area Oklahoma Area Hastings Indian Medical Center

36. EHR Sites as of 6/6/06 Federal Hospital15 Federal Health Ctr/Stn20 Tribal Hospital5 Tribal Health Ctr/Stn13

37. Possible Deployment Model – circa 2005 FY05FY06FY07FY08FY09FY10 Proof of Concept Sites 4 FY05 EHR Sites 24 FY06 EHR Sites 40 FY07 EHR Sites 40 FY08 EHR Sites 40 FY09 EHR Sites 37

38. Possible Models – 2006 Different models are possible such as: Cluster at every site(!) Regional cluster Option 1: Regional Jukebox Option 2: National Jukebox or mirrored jukeboxes Note: PACS Hybrid blend with commercial PACS Use of VistA Rad as PACS systems

39. Regional VI Clusters Ordered Under Review Installed

40. Integrated Radiology Services Opportunity for standards DICOM and HL 7 conformance statements Transcription Requirements at contracting re: Reports integration into RPMS Workgroup forming re: white paper

41. Tele-Radiology

42. Thank You mark.carroll@ihs.gov