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

752 VistA Imaging:Image Routing, Telerad, & Remote

Image Display

752 VistA Imaging:Image Routing, Telerad, & Remote

Image Display

John Di LorenzoJohn Di Lorenzo

– 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

Routing UsesRouting 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

• 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

AutoroutingAutorouting

• 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.


– How Autorouting Works

– How Autorouting Works


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

On Demand RoutingOn 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.

– 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.


– How On-Demand Routing Works– How On-Demand Routing Works


• 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.


Displaying Routed Exams and Demand RoutingIn 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 RoutingIn 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.



•Remote Cache Indicator

DICOM VS VistARad RoutingDICOM 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

How it all WorksHow 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



Routing PrerequisitesRouting Prerequisites

Administrative

Technical

Administrative

Technical


• 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.


• 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


– Security• Background Investigations on Contractors• Privacy & Security Course Requirement

– www.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.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

http://www.ees-learning.net/

http://www.ees-learning.net/


• 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.


•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




ChallengesChallenges

•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.”

Routing OptimizationRouting Optimization

– Technical Optimization• Use compression• Evaluate bandwidth• Autoroute prior exams

– Logistical Optimization• Defined schedules• Contracts/MOUs• Standard Operating Procedures

– Technical Optimization• Use compression• Evaluate bandwidth• Autoroute prior exams

– Logistical Optimization• Defined schedules• Contracts/MOUs• Standard Operating Procedures


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

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






– Evaluate bandwidth• Is all bandwidth being used?



XRAY DR imagesXRAY DR images




Yes– Get more– Change routing

rules– Lower

expectations


rules– Lower

expectations1.5 Mb (T-1 speed) per radiologist


Ultrasound imagesUltrasound images





rules– Lower

expectations


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


Ultrasound imagesUltrasound images




Simultaneous sends to single siteSimultaneous sends to single site




Simultaneous sends to multiple sitesSimultaneous sends to multiple sites


– Autorouting prior exams• Saves time & frustration for user• Uses more bandwidth

– Autorouting prior exams• Saves time & frustration for user• Uses more bandwidth




– 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?)

– 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?)


Logistical Optimization &

Telerad Business Practices

Logistical Optimization &

Telerad Business Practices


– Defined schedules• Radiologists• PACS Admins• Support staff

– Defined schedules• Radiologists• PACS Admins• Support staff


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

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


– 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

– 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

Routing TroubleshootingRouting Troubleshooting

– Common Routing Problems and Solutions

– Common Routing Problems and Solutions



– Transmission processor not sending images• Network or remote site unavailable• VistA down or temporary disconnect

– Set up critical devices for manual send

– Transmission processor not sending images• Network or remote site unavailable• VistA down or temporary disconnect

– Set up critical devices for manual send


– Transmission queue backlogged– Transmission queue backlogged


VistARad loading images slowlyVistARad loading images slowly




– VistARad loading images slowly• Decompression not working

– VistARad loading images slowly• Decompression not working


– VistARad loading images slowly• Decompression not working• Check Magj.ini file• Remote storage full

– Log a remedy ticket– Never delete folders manually!

– VistARad loading images slowly• Decompression not working• Check Magj.ini file• Remote storage full

– Log a remedy ticket– Never delete folders manually!

Recent AdvancesRecent 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

– 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

Cumulative Images CapturedCumulative Images Captured

VistA Imaging eXchange (VIX)VistA Imaging eXchange (VIX)

VA to VA image sharing(VIX enhanced Remote Image View)


DOD to VA image sharing


AITC

DoD Enterprise

BHIE Framework

El Paso VAMC

Denver VAMC

North Chicago VAMC

Washington VAMC

Tampa Polytrauma

Richmond Polytrauma

Biloxi VAMC

Evans ACH

Great Lakes NHC

Walter Reed AMC

Bethesda NNMC

Landstuhl RMC

VA EnterpriseWilliam Beaumont AMC

Keesler AFB



BHIE PATIENT

Area of Clinical Interest

DoD Image

WBAMC 03/2007

VA Image

El Paso 10/2001


VistARad Manager


Questions?Questions?

Documents

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