321 VI Using Standards Andrew Casertano VistA Imaging
This summarizes work of the Veterans Health Administration, Office of Information (VHA OI).
It may amplify elements of private sector activities or products.
None of the information is meant to endorse private sector activities, obligate the Federal Government to follow any particular course of action, nor to espouse an official position of the Federal Government, for the present or in the future.
What does PACS stand for?
P icture your A ssets C ompletely S pent
P romise A nything to C lose S ale
P ain A nd C onstant S uffering
P ress A nykey to C rash S ystem
P roperty the A dministrator C an’t S ell
Picture Archiving and Communications System
(all of the above?)
Ref: SCAR 2005, Horii
HL7 and DICOM
Message protocol to update product databases
Standard used by Hospital, Radiology, & Lab Information Systems
Used to exchange objects and to integrate with Information Systems
Standard used by acquisition modalities, PACS
Typical Standards Overview
Training Summary: “DICOM is the standard for medical imaging.”
The details: Read these 4,000 pages.
Let’s learn about standards differently …
Lack of HIT Standards
Slows Adoption of new technologies
Introduces Medical errors and Patient Risk
Proprietary interfaces mean vendor lock-in and an inflexible environment for any changes
Less effective and efficient
Disaster response and recovery
Human and Software Errors leading to patients safety in jeopardy
Improper disclosure of patient health information
Rapid Deployment of integrated systems
Reduced cost of integrating devices
Streamlining Patient Care
Roles of VistA Imaging
Honest Broker/ Facilitator
Executive Order on Interoperability
Interoperability –exchange data accurately, securely and consistently between HIT systems
HIT systems shall use interoperability standards in contracting
Clinical Endorsements of Interoperability
The Anesthesia Patient Safety Foundation and The Board of Directors of the American Society of Anesthesiologists endorsed the following statement of support for interoperability: “…that intercommunication and interoperability of electronic medical devices leads to important advances in patient safety and patient care, and that the standards and protocols to allow such seamless intercommunication should be developed fully with these advances in mind.”
“… interoperability poses safety and medico legal challenges as well. The development of standards and production should achieve maximum patient safety, efficiency, and outcome benefit.”
Reference: MDPnP Getting Connected for Safety,
http:// mdpnp.org/Endorsements_of_Interop.html February 2008:
Devices rely on standards
FDA CDRH – oversees the manufacturing performance and safety of devices
Class II devices require a ‘510K’ Pre-market Notification
The risk analysis
Reliance on standards - a declaration of conformity
What Interoperability provides
HIT systems are unified through a shared VistA EMR
All providers have access to complete, up-to-date patient information
Resistance to change Lack of enterprise vision, Loss of control, Perceived risk
Unwillingness of vendors
Proprietary systems and formats
Loss of competitive advantage
Imaging Beyond Radiology
The medical enterprise has significant imaging volume beyond radiology
PACS has a proven ROI
Moving the vision of radiology PACS to other clinical departments will:
Improve the effectiveness of your clinical team with a single point of image display
Improve patient care with a more integrated record
Improve the speed of clinical care
Evolution of Imaging
Single modality applications
Interfaced radiology information systems and medical imaging management – RIS/PACS
Fully integrated enterprise imaging and workflow solutions
Evolution of Medical Imaging Over the next 10 years, storage, computing, and data integration needs will grow exponentially driven by Medical Imaging. Petabytes of images to be stored and managed for decades Content management & Multi-site image sharing Compute intensive reconstruction & analysis Integrated IT architecture Standards-based interoperability
VistA Imaging Timeline 1988 - 2009 2008 - 2009 VA/DoD Importer VA/DoD Image Sharing TeleDermatology 1997 VistARad 1995 DICOM Development 1993 1st VistA Imaging PACS Interface 1990 VistA Imaging Operational at Washington DC 1980’s Personal Computers 1990’s MS Windows – TCP/IP 2007 TeleReader & IHS Using VI 1998 Gigabit Ethernet 1988-90 VistA Imaging Prototype for VA 1997 VistA Imaging 2.0 2001 VistA Imaging 2.5 FDA Clearance 2002 Document Scanning 2002 VistA Imaging 3.0 Mandate 2003 Index Terms 2005 Remote Image Views 1996 VistA Imaging GUI 2006 VistARad Redesign 1980’s Decentralized Hospital Computer Program 1998 CPRS GUI
Where Are We Going?
Respiratory Imaging, Bronchscopy
Gastrointestinal Imaging, Endoscopy
Intra-Operative Imaging, Laproscopy
Orthopedic Imaging, Arthoscopy
Imaging of the eye, Opthalmology
Ear / Nose / Throat, O tolaryngology
Microscope Imaging, Pathology
Imaging Enhances an Interdisciplinary Approach
PTSD is strongly associated with mild traumatic brain injury (i.e., concussion), NEJM, January 2008, Vol. 358, No. 5 and The war within : Neurobiological alterations in posttraumatic stress disorder utilized neuroimaging (including PET, MR) accessed May 2008
Active prevention in diabetic eye disease (visual impairment in diabetics can be prevented with active regular screening) National Library of Medicine www.ncbi.nlm.nih.gov accessed May 2008
Dental images can detect potentially dangerous calcium deposits in the carotid arteries (associated with strokes and heart attacks) www.sciencedaily.com accessed May 2008
Source: UC Berkeley, School of Information Management and Systems. 0 C.E. 2005 40,000 BCE cave paintings bone tools 3500 writing paper 105 1450 printing 1870 electricity, telephone transistor 1947 computing 1950 1990 The Web 2000 Late 1960s Internet P e t a b y t e s More Data Over the Last 3 Years Than Previous 42,000 years Combined
Cumulative Images Captured 2003 – 2008
As of May 2008, 808 million images have been captured, stored and available online using VistA Imaging Software.
FY 2004 – 72 million new images.
FY 2005 – 104 million new images.
FY 2006 – 155 million new images.
FY 2007 – 183 million new images.
Over 20K new images captured each hour
VistA Saves Money
The cost per patient has remained low and stayed steady for the VA
Compare with Medicare and the medical consumer price index have remained high and are increasing.
GRAPHIC SOURCE: The Washington Post, April 10, 2007
Standards last a long time
The major design feature of what is arguably the world's most advanced transportation system was determined over two thousand years ago by the width of a horse!
The Space Shuttle engineers who designed the Solid Rocket Boosters was shipped by train from the factory to the launch site
Standards last a long time
The US standard railroad width derives via Europe standard
This is traced back to original specification of the Imperial Roman war chariot
Technology Lifetime Standards (DICOM, HL7, IHE, SNIA…) 25- 50 years Infrastructure (IP, SAN,…) 10- 20 years Programming Languages (PL/1, Pascal, C, C++, Java, …) 5-10 years Software (data formats, compatibility, …) 2-5 years Hardware (Network cards, video cards, processors, …) 1-2 years Shapiro, IBM
Volume, Value and Velocity
Volume of Data
Reference data is growing exponentially and is being stored for long periods of time.
Value of Information
Image data is actively referenced, and must be stored and protected for life to meet clinical and regulatory requirements.
Velocity of Change
Address the demands for increased storage and higher performance.
VistA was awarded with both an Innovations in Government Award and a IHE User Success Story
One interface for over 400 different models of instruments!
Consistency & Interoperability throughout the US
Patient Safety: Current Statistics
One in five Americans (22%) report that they or a family member have experienced a medical error of some kind.
Nationally, this translates into an estimated 22.8 million people with at least one family member who experienced a mistake in a doctor's office or hospital.
Reference - http:// www.patientsafetyfocus.com / accessed May 2008
Deaths and costs continue to rise. In their fifth annual Patient Safety in American Hospitals Study , Health Grades Inc. , cites that errors in treatment resulted in 238,337 potentially preventable deaths of Medicare patients in the US, costing $8.8 billion.
HealthGrades Inc. analyzed over 41 million patient records for the study and found that approximately 3 percent of all Medicare patients suffered from some medical error- - which equates to about 1.1 million Patient Safety Incidents (PSIs) from 2004-2006. In the report, Health Grades describes medical errors as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim…[including] problems in practice, products, procedures, and systems."
There were 270,491 actual in hospital deaths that occurred among patients who developed one or more of 16 PSIs and the report states, "Using previous research, we calculated that 238,337 were attributable to patient safety incidents and potentially preventable."
“ Issues arising from badly designed and poorly integrated HIT systems harm or kill more patients every year than do medications and medical devices yet there is absolutely no control or regulation over them”
Quote Reference: Duke University Health System CIO Asif Ahmad Computerworld, April 28, 2008
US Population Dose Ref: Dr. S. Balter, Columbia University, Radiation Dose Data Management, February 2008
FDA CDRH case study of radiation therapy overexposure resulting in death
Contributing factors include lack of clinic verification, no method for entering data into software, interpretation of data by the software
Vendors now have proprietary solutions
Reference: FDA Safety Assurance Case Workshop, February 21, 2008
Getting Connected for Patient Safety
“Many improvements in patient safety and healthcare efficiency require systems solutions that cannot be implemented due to the lack of interoperability”
Safe device #1 + Safe device #2 = Unsafe system
Reference: FDA Safety Assurance Case Workshop, February 21, 2008
Ready for a Disaster?
Katrina comes through the window
5.4 M images were recovered after Hurricane Katrina, New Orleans in 2006
13.08 M images were recovered in Tennessee, after a computer room flood in 2008
Gulfport Before and After
The Selling of Sensitive Patient Data Reference, The Los Angeles Times, California Board of Health Report, May 13, 2008, accessed online http://www.latimes.com/news/
Reference, The Los Angeles Times, California Department of Health Services, May 13, 2008, accessed online http://www.latimes.com/news/
Old School Reference: Journal of Digital Imaging, Siegel and Reiner, 2003
Law & Order Analogy
Why Healthcare IT Standards?
HIT Standards last much longer than hardware and software systems
Standards based solutions provide a higher level of effectiveness and efficiencies
Medical Errors contribute to more than 100K US deaths/yr
Interoperability and proprietary are often mutually exclusive
HIT Standards based solutions provide lower costs, more flexibility and enable better patient care