Ruth E. Dayhoff

Integrating Digital Imaging and Communications in Medicine (DICOM)-structured reporting into the hospital environment.

The Digital Imaging and Communications in Medicine (DICOM) Standards Committee has balloted and accepted a new class of objects dealing with the generation, distribution, and management of reports. The structured reporting (SR) objects bridge the traditional separation between imaging and information systems. The DICOM SR objects offer a higher level of integration of the medical enterprise, providing practitioners with an effective tool to cover all aspects of the medical process from admission to discharge. This report presents the technical challenges posed by integrating the concepts introduced by SR with a complete hospital information system (HIS).

Experience with an architecture for integrating images into a hospital information system

An integrated image system to provide high-quality image data from cardiology, pulmonary and gastrointestinal endoscopy, pathology, radiology, hematology, and nuclear medicine for hospital information systems has been developed. Images and associated text data are presented to clinicians throughout the hospital on high-resolution workstations which are interfaced to the main hospital system in a client-server architecture. The systems architecture is described, and experience in the first six months of operation is discussed. Initial use has validated the approach and has indicated a number of unanticipated benefits for patient care and teaching.<<ETX>>

Bidirectional ACR-NEMA interface between the VA's DHCP integrated imaging system and the Siemens-Loral PACS

At the Baltimore VA Medical Center, the DHCP Integrated Imaging System and a commercial Picture Archiving and Communication System (PACS) work in concert to provide a wide- range of departmental and hospital-wide imaging capabilities. An interface between the DHCP and the Siemens-Loral PACS systems enables patient text and image data to be passed between the two systems. The interface uses ACR-NEMA 2.0 Standard messages extended with shadow groups based on draft ACR-NEMA 3.0 prototypes. A Novell file server, accessible to both systems via Ethernet, is used to communicate all the messages. Patient identification information, orders, ADT, procedure status, changes, patient reports, and images are sent between the two systems across the interface. The systems together provide an extensive set of imaging capabilities for both the specialist and the general practitioner.

Experience with DICOM for the clinical specialties in the healthcare enterprise

DICOM is a success for radiology and cardiology and it is now beginning to be used for other clinical specialties. The US Department of Veterans Affairs has been instrumental in promoting this technological advancement. We have worked with a number of non-radiology imaging vendors over the past several years, encouraging them to support DICOM, providing requirement specifications, validating their implementations, installing their products, and integrating their systems with the VA healthcare enterprise. We require each new non-radiology vendor to support the DICOM Modality Worklist and Storage services, as specified in the IHE Technical Framework, and insist that they perform validation testing with us over the Internet before installing at a VA site. Three years ago we began working with commercial DICOM image acquisition applications in ophthalmology and endoscopy. Today we are interfacing with six vendors in ophthalmology, six in dental, and two in endoscopy. Getting imaging modality vendors to support DICOM is only part of the story, however. We have also developed the capabilities of the VistA hospital information system to properly handle DICOM interfaces to the different clinical specialties. The workflow in the clinical specialties is different than that of radiology, and is much more diverse. We designed the VistA DICOM image acquisition and display interface to use the generic order entry, result entry, result reporting, and appointment scheduling applications of our hospital information system, which are common to other hospital information systems, in order to maintain existing clinical workflow, minimize operational disruptions, simplify training, and win user acceptance. This software is now being field tested with dental and ophthalmology systems at a large number of VA medical centers. We have learned several things from this field test. The DICOM Modality Worklist and Storage services can be successfully used for image acquisition in the clinical specialties, although the specifications for some of the clinical specialty image types need to be enhanced. Special consideration needs to be given to the healthcare provider workflow in order to support DICOM requirements and to minimize change. The clinical specialties handle a large number of different kinds of requests, and imaging procedures may comprise only a small subset, which may need to be isolated out for efficient operation of DICOM Modality Worklist. The clinical specialties will acquire a large volume of images. Our goal is to incorporate all of the patient’s data into the electronic medical record and DICOM is making this easier for everyone. The work involved in extending DICOM to the clinical specialties and integrating them with the hospital information systems continues to be an ongoing and worthwhile challenge.

Success of HIS DICOM interfaces in the integration of the healthcare enterprise at the Department of Veterans Affairs

The US Department of Veterans Affairs (VA) is integrating imaging into the healthcare enterprise using the Digital Imaging and Communication in Medicine (DICOM) standard protocols. Image management is directly integrated into the VistA Hospital Information System (HIS) software and the clinical database. Radiology images are acquired via DICOM, and are stored directly in the HIS database. Images can be displayed on low-cost clinicians workstations throughout the medical center. High-resolution diagnostic quality multi-monitor VistA workstations with specialized viewing software can be used for reading radiology images. Two approaches are used to acquire and handle imags within the radiology department. Some sties have a commercial Picture Archiving and Communications System (PACS) interfaced to the VistA HIS, while other sites use the direct image acquisition and integrated diagnostic reading capabilities of VistA itself. A small set of DICOM services have been implemented by VistA to allow patient and study text data to be transmitted to image producing modalities and the commercial PACS, and to enable images and study data to be transferred back. The VistA DICOM capabilities are now used to interface seven different commercial PACS products and over twenty different radiology modalities. The communications capabilities of DICOM and the VA wide area network are begin used to support reading of radiology images form remote sites. DICOM has been the cornerstone in the ability to integrate imaging functionality into the Healthcare Enterprise. Because of its openness, it allows the integration of system component from commercial and non- commercial sources to work together to provide functional cost-effective solutions. As DICOM expands to non-radiology devices, integration must occur with the specialty information subsystems that handle orders and reports, their associated DICOM image capture systems, and the computer- based patient record. The mode and concepts of the DICOM standard can be extended to these other areas, but some adjustments may be required.

Extending DICOM imaging to new clinical specialties in the healthcare enterprise

DICOM is a success for radiology and cardiology and it is now starting to be used for the other clinical specialties. The US Department of Veterans Affairs has been instrumental in promoting this advancement. We have worked with a number of non-radiology clinical speciality imaging vendors over the past two years, encouraging them to support DICOM, providing requirement specifications. Validating their implementations, using their products, and integrating their systems with the VA healthcare enterprise. We require each new clinical speciality vendor to support the DICOM Modality Worklist and Storage services and insist that they perform validation testing with us over the Internet. Two years ago we began working with two commercial DICOM image acquisition applications in ophthalmology and endoscopy. We are now dealing with over a dozen: five in ophthalmology, two in endoscopy, and six in dental. This has been a very productive endeavor. Because mature software development toolkits now exist, the vendors can quickly integrate DICOM with their existing imaging products. Each of the dental vendors, for example, was able to accomplish this task in less than three months. Getting the imaging modality vendors to support DICOM is only part of the story, however. We are also working on getting the VistA hospital information system to properly handle DICOM interfaces to various clinical specialties. This has been more difficult than expected because the workflow in clinical specialties is much more varied than that in radiology. This required us to develop software that is much more flexible than that used for radiology. Fortunately, the standard DICOM Modality Worklist and Storage services can be used without change. In addition to a more variable workflow, the use of structured reporting is much more advanced in clinical specialties than in radiology, and significant work is needed to define templates and communicate this data using DICOM. Since some speciality modules of our hospital information system currently store only report text, we also have to figure out how to store and display the discrete structured report data. The work involved in extending DICOM to the clinical specialties, and in integrating them with the hospital information system is an ongoing and worthwhile challenge. Our goal is to incorporate al of the patients data into the electronic record, and DICOM is making this easier for everyone. Considerable investment, however, has to be made in the hospital information system software to accrue the full benefit.

Experience with MUMPS-based DICOM interfaces between the department of veterans affairs HIS/RIS and commercial vendors

The VA has developed a set of DICOM capabilities in MUMPS as an integral part of its hospital/radiology information system (HIS/RIS). DICOM is being used at the VA to transfer text and image data between the HIS/RIS to download patient study information to the commercial medical imaging equipment and to obtain digitized images from them. Our general experience with the commercial DICOM offerings that we have tested has been very favorable. These products were developed using toolkits that are quite mature, and interfacing to them has been fairly easy. The use of DICOM has the potential to reduce costs by allowing open systems solutions consisting of in-house and commercial multi-vendor offerings.

Experiences with a comprehensive hospital information system that incorporates image management capabilities

The Department of Veterans Affairs has undertaken a project to integrate image management functionality within its hospital information system. One of the goals of this integrated image system is to provide high-quality image data from cardiology, pulmonary and gastrointestinal endoscopy, pathology, radiology, hematology, and nuclear medicine to clinicians throughout the hospital. Images are presented to clinicians on high-resolution workstations simultaneously with associated text data. This DHCP Integrated Imaging System is currently being installed and tested at the Washington DC VA Medical Center. Initial use has revealed a number of expected as well as unanticipated benefits for patient care and medical teaching.

Integrated Multimedia Patient Record Systems

Publisher Summary 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.

Operational experience with DICOM for the clinical specialties in the healthcare enterprise

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.