VA/DoD and VA to VA Image Sharing Class 755 Julian Werfel and Roger Coney

Cumulative Images Captured 2003-2010 This is why image sharing is important VistA Imaging stores 1.4 billion images

Image Sharing Provides more patient information to use in diagnosis and treatment Reduces number of procedures for patient by making remote data available Saves money by reducing procedures Saves patient and staff time “A picture is worth a thousand words”

VA Remote Image Views Clinical Display communicates across the VA WAN to retrieve images from the VistA Imaging systems at remote VA facilities Image sharing in the VA started with Remote Image Views in 2005 (Patch 45) All work done by Clinical Display Requires VistA/Image Share Access for all clients Allows all clinicians access to the entire VA patient record

Full access to patient record VA/DoD Image Sharing NDAA (National Defense Authorization Act) El Paso pilot to share radiology images and reports with DoD Full access to patient record DoD provides images to VA, viewed in Clinical Display In 2006, VistA Imaging began work to share images with the DoD Many VA sites share facilities and hardware with DoD sites, want to be able to share data as well Many patients (particularly polytrauma patients) move between VA and DoD facilities for care

VA/DoD Image Sharing Provide VA images to DoD users Particularly important for Polytrauma patients Transfer images in DICOM with JPEG 2000 compression Thumbnail, Lossy, and Lossless quality Realized as the VIX service – Imaging Patch 83

VIX for VA/DoD Image Sharing VistA Imaging Exchange (VIX) Service VIX implemented as part of VISA (VistA Imaging Service Architecture) Encapsulates VistA Imaging behind well defined interfaces - SOA Standards based: JPEG2000, DICOM, XCA Clinical Display requests DoD images from site VIX DoD images available to clinicians since Patch 72 Display client VISA is a Service Oriented Architecture implementation for image sharing VIX servers deployed at the local site to provide functionality for Clinical Display users

VA/DoD Sharing Field Testing DoD only has access to VA images at the original 7 sites shown above Additional test sites for Patch 83 include: Tucson Baltimore Fayetteville, NC Fayetteville, AK Louisville Prescott Phoenix Little Rock Oklahoma City Charleston Muskogee All sites with Imaging Patch 83 can see DoD images

View DoD Radiology Images View DICOM Radiology images for shared patients from the 7 original DoD NDAA sites BHIE Image Adapter (BIA) requests DoD images from site PACSi (analogous to VIX) Compression and caching to boost performance VA/DoD Image sharing as part of NDAA El Paso project Get compression information – what is the percentage?

View VA Radiology Images in DoD Provide DICOM radiology images for shared patients Access images from all VA sites with a VIX Server Available to DoD facilities with a PACSi server Images viewable from the web based Advanced Medical Image Viewer (AMIV) VA/DoD Image sharing as part of NDAA El Paso project

Imaging Patch 72 DoD images integrated with VA images Goal to make DoD images easy to access for VA users Did not require new training Easy to use, it just works!

Enhanced Remote Image Views We realized we can harness the functionality and abilities of the VIX to enhance remote image views No longer requires the client to implement all functionality, work is done by servers Client doesn’t have to be aware of all remote site information and how to access it. Built on the functionality implemented to allow improved performance With DoD image access through the VIX, now able to provide VA image access through VIX Access remote VA images through VIX Remote VA and DoD images now available to VistARad in Imaging Patch 90

Enhanced RIV Benefits Take advantage of VIX Caching and Compression Image is compressed at source before transfer over WAN Image cached at local and remote VIX VIX handles remote connection rather than client Fewer connections over WAN Enhanced RIV seamless to user

Enhanced RIV Image Quality

Imaging Patch 93 Updated user interface UI updated in Patch 93 RIV Toolbar moved to list view window Can view information in list, tree, abstracts in window, full resolution in window DoD appears in the RIV toolbar like any other VA site Updated user interface

Viewing Remote Images DoD accessible same as VA data You can see we have connected to several remote VA sites and the DoD. The images from the remote sites are integrated with the local images and the DoD images are available just like VA images. By selecting the study from the DoD you can preview the abstract and report just like VA images. Site column shows specific facility images from the DoD come from Patch 93 uses enhanced remote image views for VA sites by using the local VIX. The VIX does the work of connecting to the remote site. Seamless integration for user, does not notice anything has changed but images will be available faster because of the VIX User doesn’t have to do anything to make enhancement RIV work, client and VIX do all the work. When Patch 93 was installed at sites with a VIX, the VIX began to handle the remote image views without the site noticing DoD accessible same as VA data

Viewing DoD Images Accessing images from DoD same as VA Viewing DoD images is the same as viewing VA images No special viewer or tools to use Accessing images from DoD same as VA

Viewing DoD Images Users can apply measurements to DoD images If a user wants to view all of the images in a study, the user can cache the selected study – this brings all of the images to the workstation in the background allowing the user to view other images while the images are being cached.

Viewing DoD Images No special tools for DoD, same as VA Viewing DoD images is just as easy as VA images No special tools Same manipulation tools as for VA images No special tools for DoD, same as VA

Comparing VA and DoD images BHIE PATIENT DoD Image WBAMC 03/2007 VA Image El Paso 10/2001 On the left is an image from 2007 from William Beaumont AMC, on the right is an image from 2001 in El Paso Area of Clinical Interest

VistARad and the VIX View images and reports from DoD View images, reports and requisition reports from remote VA sites Monitor exam lists from remote sites without requiring user to login Exams from remote sites integrated with exams from local site

VistARad Manager VistARad Manager shows exams from multiple sites including the DoD

VistARad Displaying DoD Images Displaying DoD images using same controls as viewing VA images

Monitor Remote Sites Monitor remote sites without logging in

Support New DoD Architecture HAIMS, the Healthcare Artifact and Image Management Solution, will replace the NDAA El Paso solution in the DoD enterprise NDAA El Paso pilot will be sustained through the transition No changes will be required to the VA architecture

Providing VA Images to DoD with HAIMS No changes required by VA to continue to provide VA images to DoD No changes will be required to the VA architecture

VA/DoD Artifact Sharing Share Artifacts Non radiology images NCAT (Neurocognitive Assessment Test) reports from DoD Bidirectional Implemented with IHE profile Cross Community Access (XCA) Development in progress

Expanding the VIX – the CVIX Centralized VistA Imaging Exchange (CVIX) Service Enterprise gateway for image sharing Currently deployed in AITC (Austin Information Technology Center) Highly Available, Load Balanced, Clustered Deployment Based on the VIX design Doing more than just site VIX servers, more sharing with enterprise services Will be used for several image sharing initiatives DoD Radiology access through CVIX will provide a single interface for the DoD and other communities to access VA images

CVIX Provides Artifacts available to VA Users Artifacts from VA to DoD Artifacts from HAIMS NCAT (Neurocognitive Assessment Test) reports Artifacts from VA to DoD Radiology sharing through CVIX Support Future Interfaces NHIN (National Health Information Network) VLER (Virtual Lifetime Electronic Record)

View DoD Artifacts and Radiology Images CVIX retrieves HAIMS artifact and radiology lists from the BHIE Framework for viewing by VistA Imaging client applications CVIX retrieves HAIMS artifact lists from the BHIE Framework for viewing by VA applications CVIX retrieves HAIMS and NCAT artifacts for viewing by VistA Imaging client applications – Imaging Patch 104 (June 2010 – Pending Approval) With the CVIX in place, we will be able to move all DoD access behind it to make a cleaner interface for our site VIX servers. This will provide access to DoD artifacts and DoD radiology images from within Clinical Display Working to provide DoD artifacts to VA users and provide VA artifacts to DoD Includes viewing NCAT assessments from DoD DoD artifacts will be listed in VistAWeb and Clinical Display Artifact transfers go directly from CVIX to repository (NCAT or HAIMS) Artifacts are transferred using XCA (Cross Community Access) IHE profile

Providing VA Artifacts and Radiology Images to DoD with CVIX * CVIX communicates with site VIX servers or directly with the VistA system at the site CVIX provides VA study and artifacts lists to the BHIE Framework for consumption by HAIMS CVIX provides radiology images to the BHIE framework for consumption by HAIMS CVIX provides artifacts directly to the HAIMS gateway

Image Enabling VistaWeb VistA Imaging providing Advanced Web Image Viewer (AWIV) to VistaWeb for image viewing View images associated with Progress Notes and Radiology Reports VistaWeb users can view VA images within VistaWeb Similar to CPRS/Clinical Display interface VistaWeb version 12 One use of the CVIX is image enabling VistAWeb Working with VistAWeb team to provide VA images to VistAWeb users VistAWeb version 12, VistA Imaging Patch 105

AWIV Uses components from Clinical Display Easy access from VistaWeb Does not show all images stored in VistA Imaging Will view DoD Radiology and artifacts in future AWIV uses Centralized VistA Imaging Exchange (CVIX) server Currently in field testing (June 2010) – Imaging Patch 105

VistaWeb Viewing VA Images VistAWeb passes information to the AWIV All AWIV communication through CVIX CVIX communicates with site VIX servers or directly to VistA systems at sites without VIX AWIV retrieves all images from CVIX CVIX communicates with VA sites with and without a VIX

VistaWeb Progress Notes New icon indicates images are associated with note

AWIV Viewing VA Note Based on Clinical Display Hosted inside VistAWeb Shows Photo ID Abstracts of images in study Full Resolution and Radiology viewer for images

AWIV Viewing VA Note

VistaWeb Radiology Reports New icon indicates images are associated with report

AWIV Viewing VA Radiology Image

VistaWeb Viewing DoD Artifacts Prototype of Artifact Sharing Future Development

AWIV Viewing NCAT Report

AWIV Viewing DoD Artifacts Artifacts viewed in AWIV

VA/DoD Radiology Sharing Today DoD radiology images available in Clinical Display and VistARad

AWIV Viewing VA Images AWIV can view VA images through VistaWeb – Field Testing June 2010

VA Viewing DoD Artifacts DoD Artifacts available in Clinical Display HAIMS providing artifacts and radiology Field Testing December 2010

Server Deployment Changes - 2011 CVIX clustered and moved to Philadelphia NDAA fully replaced by HAIMS

AWIV Viewing DoD Artifacts - 2011 Artifacts available in VistaWeb and AWIV

Image Sharing Big Picture Sharing of images improves patient care VA users can now view Radiology Images from VA and DoD in Clinical Display and VistARad DoD can view VA images VistaWeb users can view VA images with AWIV Artifact sharing with DoD coming soon

VIX Makes Image Sharing Work VIX provides access to images for VA and DoD Improves performance within VA VIX is reliable Optimized for delivery of images as quickly and safely as possible VIX encapsulates functionality with standards using VISA

Questions? Julian Werfel Julian.werfel@va.gov (240) 638-2634 Roger Coney Roger.coney@va.gov (240) 638-2604

VIX Development Team Julian Werfel (julian.werfel@va.gov) Keith Buck (donald.buck@va.gov) Chris Beckey (christopher.beckey@va.gov) Csaba Titton (csaba.titton@va.gov) Roger Coney (roger.coney@va.gov)

Shared Modalities CT – Computed Tomography CR – Computed Radiography MR – Magnetic Resonance US - Ultrasound DX – Digital Radiography RF – Radio Fluoroscopy NM – Nuclear Medicine XA – X-Ray Angiography PT – Positron Emission Tomography DS – Digital Subtraction Angiography