Ruth E. Dayhoff’s research while affiliated with University of Maryland, Baltimore and other places

The interfacing of digital image acquisition modalities to the picture archiving and communication system (PACS) plays a major part in the conversion from a traditional film-based radiology practice to one that relies almost entirely on soft-copy reading. The Baltimore Veterans Affairs Medical Center (VAMC) is one of the first filmless hospitals in the world. Since 1993, it has used computed tomography (CT) scanners connected to a commercial PACS to provide digitized patient images for filmless reading. Over the years, the evolution of Digital Imaging and Communications in Medicine (DICOM) standards, advances in networking technologies, and enhancements in PACS and hospital information system (HIS) software have greatly improved this system’s robustness and patient/study identification accuracy. The result has been a major increase in productivity.

A patient has an imaging study performed at one facility and has the study exported to portable media. Later, the patient takes the media to a different institution. The study on that media may need to be imported into that new institution's imaging system. This would be done to avoid a repeat examination, or so that the study can be on file for reference purposes. Importing prior studies is best performed by creating a new order on the institution's imaging system and then associating the DICOM objects from the prior study with it. In this way the prior study is actually inserted into the imaging system's electronic health record (EHR) and is properly indexed so that it can be identified and later retrieved as needed. In the past at the Department of Veterans Affairs (VA), importing prior DICOM studies into the VA systems had been a very slow labor-intensive process that took anywhere from 10 to 30 min to import a single study. We have developed a new DICOM Importer application that reduces the manual effort to import a prior study to less than a minute. We have redesigned and automated the process to make it much more efficient for the user. The Importer also handles contract examinations that are ordered by the VA and performed at outside imaging facilities, with similar time savings. This work is important because is addresses one of the major unsolved problems with import reconciliation workflow: how to efficiently handle the importing of prior studies.

This chapter discusses the multimedia patient record as implemented by the U.S. Department of Veterans Affairs (VA), the largest health care network in the United States. The VA's experience indicates that seamless integration of all types of patient data is a critical feature for clinical workstation software. It must be easy and reliable for users to capture patient data in their procedure rooms and view their patients' online multimedia records on workstations anywhere in a medical center. Accurate, synchronized patient identification is essential in all systems that will capture data for inclusion in the online multimedia patient record. This is a key factor in system efficiency, usability, and user acceptance. Because the VistA system is integrated, data that are entered into any part of the system serve all users. No duplicate data entry is needed. An online multimedia patient record can present data in ways not possible with a paper chart or other physical media. Data or images can be manipulated on the workstation to present different views. Clinical activities are more efficient, and errors are reduced. Obtaining a critical mass of information online is essential to user satisfaction and efficiency, as well as to achievement of maximum benefits from an integrated patient record system. The involvement of frontline providers in system requirements and design, the use of performance measures in monitoring health care services, and the universal use of the multimedia patient record have enabled the VA to provide the best care anywhere.

As part of its patient care mission, the U.S. Veterans Health Administration performs diagnostic imaging procedures at 141 medical centers and 850 outpatient clinics. VHA's VistA Imaging Package provides a full archival, display, and communications infrastructure and interfaces to radiology and other HIS modules as well as modalities and a worklist provider In addition, various medical center entities within VHA have elected to install commercial picture archiving and communications systems to enable image organization and interpretation. To evaluate interfaces between commercial PACS, the VistA hospital information system, and imaging modalities, VHA has built a fully constrained specification that is based on the Radiology Technical Framework (Rad-TF) Integrating the Healthcare Enterprise. The Health Level Seven normative conformance mechanism was applied to the IHE Rad-TF and agency requirements to arrive at a baseline set of message specifications. VHA provides a thorough implementation and testing process to promote the adoption of standards-based interoperability by all PACS vendors that want to interface with VistA Imaging.

The VA’s complete online multimedia patient record, which operates at all VA medical centers, includes interactive patient chart components, clinical images from a variety of specialties, and scanned documents containing signatures or handwritten information. Multimedia records currently exist that span 15 years, and there are presently more than 250 million images online at 158 VA medical centers. Recently, standardized index terms for images and documents have been added to allow viewing of information stored locally or at other facilities on the network.

A number of clinical specialties routinely use images in treating patients, for example ophthalmology, dentistry, cardiology, endoscopy, and surgery. These images are captured by a variety of commercial digital image acquisition systems. The US Department of Veterans Affairs has been working for several years on advancing the use of the Digital Imaging and Communications in Medicine (DICOM) Standard in these clinical specialties. This is an effort that has involved several facets: (1) working with the vendors to ensure that they satisfy existing DICOM requirements, (2) developing interface software to the VistA hospital information system (HIS), (3) field testing DICOM systems, (4) deploying these DICOM interfaces nation-wide to all VA medical centers, (5) working with the healthcare providers using the system, and (6) participating in the DICOM working groups to improve the standard. The VA is now beginning to develop clinical applications that make use of the DICOM interfaces in the clinical specialties. The first of these will be in ophthalmology to remotely screen patients for diabetic retinopathy.© (2004) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.

A number of clinical specialties routinely use images in treating patients, for example ophthalmology, dentistry, cardiology, endoscopy, and surgery. These images are captured by a variety of commercial digital image acquisition systems. The US Department of Veterans Affairs has been working for several years on advancing the use of the Digital Imaging and Communications in Medicine (DICOM) Standard in these clinical specialties. This is an effort that has involved several facets: (1) working with the vendors to ensure that they satisfy existing DICOM requirements, (2) developing interface software to the VistA hospital information system (HIS), (3) field testing DICOM systems, (4) deploying these DICOM interfaces nation-wide to all VA medical centers, (5) working with the healthcare providers using the system, and (6) participating in the DICOM working groups to improve the standard. The VA is now beginning to develop clinical applications that make use of the DICOM interfaces in the clinical specialties. The first of these will be in ophthalmology to remotely screen patients for diabetic retinopathy.