Webinar: http://www.medsphere.com/infinite/
Voice: (888) 346-3950
Participant code: 1302465

Challenges of Automating Radiology
with an Open Source Solution
November 2008 Community Call

Presenters
Ben Mehling
Kathy English
Janine Powell
Loyd Bittle
Adam Waterbury
Jon Tai
3

Agenda
OpenVista’s Capabilities today
– Radiology Worklist
– Autofax Introduction
– Autofax: Under the Hood
OpenVista’s Radiology challenges
Introduction to PACS
VistA Imaging
Market need
Today’s VA progress with VistA Imaging
Community Discussion
Medsphere.org Tip of the Month
4

Radiology Automation with
OpenVista in the Non VA Market
VistA Imaging/PACS for OpenVista®
Prepared by Kathy Doub-English, VP Product Management

OpenVista Imaging Today
VistA Radiology Information
System
Inbound image interface
(document or picture)
– from third party software to a CPRS
and CIS note & the demographic
patient banner (.jpg, .png, .bmp,
.tif, .pdf)
Upload of images
– from a file on the local computer or
network to a CPRS note or the
demographic patient banner (. jpg,
.png, .bmp, .tif, .pdf)
Integration with commercial
PACS/Radiology vendors (GE,
Kodak) has been delivered
– outbound orders and accessioning
– Inbound transcribed result
– Link (url) to the specific patient
study through the PACs image
viewing software to view the image
from CPRS’ orders and reports tab
6

OpenVista PACS Interface
ADT
OpenVista URL Link to
PACS
Database Image
RAD
Work-List
Orders/Exam
OV Radiology Status/Results
CIS/CPOE
Mirth
7

Outgoing Messages to PACs
Registration
– A message is sent to the PACs system whenever a patient
is registered in the OpenVista radiology system. This
registration creates the Case number which is sent to the
PACS in an OBR message
Examined/Images Collected
– The OpenVista software allows the site to determine the
exam status that will trigger an update message. This is
frequently done when the patient reaches the “examined”
status but can occur at other statuses
Cancellation/Deletion
– If an exam is cancelled or deleted in the OpenVista
software, the cancel message can be broadcast.
Verified/Released Report
– The report message is triggered when data is entered into
the findings that causes the report to move to a “verified”
(final) or Released/Unverified (preliminary) status. Sites
can determine if Released/Unverified status is allowed.
8

OpenVista Imaging Today
Automated faxing of result to
one or more physician offices
using an open source
technology named Hylafax
Radiology Worklist and
tracking board depicting
department workflow &
workload in real time
9

Radiology Work List
Overview by Adam Waterbury

Dashboard View of Radiology Workload
Configurable
– System Level
Status Display
Number of Days For Status To Display
– User Level
Columns Are Re-orderable and Re-sizeable
Columns Are Sortable
11

CIS Platform
Utilizes OpenVista Security
– Display Based on Access ID and Patient Image Type
12

Features
– Auto Refreshing
– At-A-Glance View Of Workload
– Customizable To Match Work Flow
13

Benefits
– Eliminates Need To Run and Print Status Reports
– Up To The Minute Information
– Can Be Run Remotely
14

Beta
– Completed
– 30 Day Beta At Century City Doctors Hospital
– Is Now GA
15

Phase II
– Visual Indication Of Stat Orders
– Inpatient/Outpatient Indicator
– Ability To Select Patient
Opens Terminal Emulator
16

17

Auto Fax Introduction
Overview by Adam Waterbury

Auto Fax
Automatically faxes verified laboratory
results to ordering physicians
Faxes all Inpatient and Outpatient
Results
Automatically faxes completed signed
radiology results to all physicians on the
patient record
Physicians who wish to receive faxes
must be set up in advance
Physicians must be active users in the
system and have ordering capabilities
19

Requirements
Scalable and Flexible
– One solution for all sites
– Can be used by other systems
Low Cost
– Open source solution preferred
HIPAA Compliant
– No ‘on the fly’ faxing
– Uses OpenVista security
– Customizable coversheet
– Secure displays
– Log of what information was sent where, when and
by who
20

Auto Fax Work Flow
Fax1
CIS
OpenVista
Fax2
Lab
Radiology
Module Module
HylaFAX
Fax3
Server
Fax4
21

Auto Fax Server
Offered by iFAX, provided by Dell
Tower, 1U and 2U configurations
Port sizes range from 2, 4 or 8 ports
Turnkey systems
– CentOS
– HylaFAX Open Source
22

Product Features
23

Auto Fax Features
No additional steps for technicians
HIPAA compliant
Web based interface
– Controls the Auto Fax server
– Faxes can be resent, failed faxes resolved, server
rebooted, and provides system state
– Uses OpenVista security module
24

Auto Fax Console
25

Auto Fax Queue Management
26

Beta Testing
Midland Memorial Hospital
– Completed
– Laboratory Package
– 28 docs
– 275 per week
Memorial Hospital Sweet Water County
– In Beta
– Radiology Package
27

Benefits
Reduced Turn Around Time
– Physicians receive results faster
Saves Paper
– No printing of results to fax
275 * 1 minute = 4.5 Hours a week
28

Phase II
Batch Faxing By Physician
Patient Type Parameter By Physician
– Location inclusion exclusion
Fax on demand
– The ability to override the phone number
Anatomic Pathology Reports
Rx Orders
Coversheet Option By Physician
Automated Transmission Report
29

Autofax: Under the Hood
Jon Tai

Design Goals
We tried to design a solution that would...
– Support both Windows and Linux OpenVista deployments
– Leverage as many existing Open Source components as
possible
– Only require “regular” off-the-shelf hardware
Our expertise is in OpenVista, not hardware
– Be easy to maintain
Beyond the initial setup, the impact to the IT department
should be minimal
– Allow lab/rad techs to manage fax queue themselves
The user interface should be user-friendly
– Scale
Solution should work for small and large facilities
– Be HIPAA compliant

Architecture
Hooks in OpenVista trigger faxes
Faxing handled by a separate machine, the “Fax Appliance”
– Appliance acts as a network (JetDirect) printer
– OpenVista prints reports to be faxed to the appliance
Report contains XML metadata
– Fax number, physician name, priority, etc.
If Appliance cannot be reached, the OS printing mechanism on the
OpenVista server queues the print job
– No data is kept on the fax appliance except for the outgoing fax
queue
– Allows flexibility and scalability
Does not matter what OS OpenVista is running on, as long as it can
print to a network printer
Can add additional fax appliances if fax volume increases
Appliance provides a web interface for end users to view fax
queues

Fax Appliance Software
CentOS 5
HylaFAX 4.4.4
xinetd
– Listens on port 9100 (JetDirect port)
– Calls custom Python script that parses XML metadata out of the incoming
report from OpenVista and submits the report to HylaFAX
Apache / mod_php
– Custom web interface written in PHP
Authenticates users using OpenVista RPC broker
– Secondary Menu Option controls access, much like CPRS
Directly inspects HylaFAX queues on disk
– Presents faxes by status - outgoing, sent, failed
Can be configured to allow end users to view fax contents
– PostScript to PNG conversion uses ImageMagick

Architecture Diagram
OpenVista Server Fax Appliance
RPC Broker Web Interface
Lab Modem
xinetd
OS
+ Phone
Print HylaFAX
python Network
Queue
script
Rad Modem

Fax Appliance Hardware
Modem: Mainpine IQ Express
– PCI Express
– Supported under Linux >= 2.4 and Windows >= 2000
– 1, 2, 4, and 8-port configurations
– Scalable and relatively inexpensive
Test hardware: HP desktop PC
– Used for internal development
– 2-port IQ Express
Production hardware: 1-2U Dell PowerEdge servers
– Hardware is purchased from iFax Solutions, Inc.
CentOS and HylaFAX pre-installed and supported by iFAX
– Exact hardware and number of modem ports depend on
anticipated fax volume

Fax Appliance Hardware
Example Configurations
– Dell PowerEdge R200 with a 2-port modem
Planned fax volume: 200 faxes per day
– Dell PowerEdge 2950 with a 4-port modem
Planned fax volume: 300 faxes per day
Testing under ideal conditions, we were able to send
about 66 faxes per hour on one phone line
– No busy signals
You should do your own estimates based on
– Number of hours during the day that you can send faxes
– Average number of pages per fax
– Receiving modem speeds
– Anticipated percentage of busy signals

XML Metadata Format
<fax>
<from>Medsphere Hospital</from>
<from-fax-number></from-fax-number>
<from-voice-number></from-voice-number>
<to>TAI,JONATHAN</to>
<to-fax-number>17605556789</to-fax-number>
<to-voice-number></to-voice-number>
<priority>63</priority>
<regarding>Laboratory Results</regarding>
<comments>MRN: 12345</comments>
</fax>
JetDirect protocol doesn't allow sending out-of-band metadata, so this XML is
included in the body of the report and is stripped out before submitting to
HylaFAX

XML Metadata Format
<fax>
<from>Medsphere Hospital</from>
<from-fax-number></from-fax-number>
<from-voice-number></from-voice-number>
<to>TAI,JONATHAN</to>
<to-fax-number>17605556789</to-fax-number>
<to-voice-number></to-voice-number>
<priority>63</priority>
<regarding>Laboratory Results</regarding>
<comments>MRN: 12345</comments>
</fax>
Passed to HylaFAX using sendfax -d flag
– Required; sendfax won't accept faxes without the -d argument

XML Metadata Format
<fax>
<from>Medsphere Hospital</from>
<from-fax-number></from-fax-number>
<from-voice-number></from-voice-number>
<to>TAI,JONATHAN</to>
<to-fax-number>17605556789</to-fax-number>
<to-voice-number></to-voice-number>
<priority>63</priority>
<regarding>Laboratory Results</regarding>
<comments>MRN: 12345</comments>
</fax>
Passed to HylaFAX using sendfax -P argument
– 63 means “high” priority; 127 means “normal” priority
– HylaFAX adjusts priority after failed fax attempts

XML Metadata Format
<fax>
<from>Medsphere Hospital</from>
<from-fax-number></from-fax-number>
<from-voice-number></from-voice-number>
<to>TAI,JONATHAN</to>
<to-fax-number>17605556789</to-fax-number>
<to-voice-number></to-voice-number>
<priority>63</priority>
<regarding>Laboratory Results</regarding>
<comments>MRN: 12345</comments>
</fax>
Used to generate cover sheet
– From/to fax/voice numbers are configured in OpenVista

XML Metadata Format
<fax>
<from>Medsphere Hospital</from>
<from-fax-number></from-fax-number>
<from-voice-number></from-voice-number>
<to>TAI,JONATHAN</to>
<to-fax-number>17605556789</to-fax-number>
<to-voice-number></to-voice-number>
<priority>63</priority>
<regarding>Laboratory Results</regarding>
<comments>MRN: 12345</comments>
</fax>
Shown in web interface to help lab/rad techs identify faxes

HylaFAX Configuration Considerations
Options to accommodate the web frontend
– JobFmt: \"%-9j %3I %3i %1a %5P %5D %-96.96s %-14.14e\"
Fixed-width fields are more easily parsed
Include more information about the job
– Append “:14” to lines in hosts.hfaxd
Forces spool files to be written with group id = 14 (uucp) so
that web interface can read them
Requires that you add apache to the uucp group
If your appliance needs to dial a prefix to reach the
outside
– ModemDialCmd: ATDT9,%s
Dials “9”, then pauses before dialing the number given by
OpenVista

Additional Considerations
If your OpenVista server runs Linux, it should be
technically possible to run everything on one server
– May be good for small deployments
– Lose some performance/scalability/flexibility
OpenVista OS must be Linux
– HylaFAX only runs on Linux
Cannot scale as easily
Hardware platform must support your modem
The web frontend is optional
– If your end users don't need it, you don't have to run it
– You can use the regular HylaFAX commands to manage your
queues

OpenVista Gap Today
Acquisition of static & multimedia images through
DICOM
Ability to review, manipulate and drill into images
with direct access within OpenVista product line
Modality integration and Worklists
Storage solution for images (Jukebox, SAN, etc.)
Load balancing of work across Radiologists
Results inbound from medical devices to clinical
procedures (Will be delivered with clinical
flowsheet initiative using HL7 for cardiac
monitors, ventilators)
44

What is PACS?
In medical imaging, Most PACS handle
picture archiving and images from various
communication systems medical imaging
(PACS) are computers or instruments, including
networks dedicated to ultrasound, magnetic
the storage, retrieval, resonance, PET,
distribution and computed tomography,
presentation of images. endoscopy,
The medical images are mammograms, etc.
stored in an independent
format. The most
common format for
image storage is DICOM
(Digital Imaging and
Communications in
Medicine).
http://en.wikipedia.org/wiki/Picture_archiving_and_communication_system
45

VistA Imaging
Goal: To facilitate medical decision-making by delivering
complete multimedia patient information to the clinician's
desktop in an integrated manner (Cardiology, Radiology,
Ophthalmology, Pathology, GI, Pulmonary, Hematology, etc…)
Modules:
– Clinical Display Station – Standalone GUI application for the clinical user
outside of Radiology to view & manipulate static & multimedia images
– VistA Rad – Standalone GUI application integrated to VistA Radiology for
use by the technicians and Radiologists for image review & manipulation,
worklist management & capturing of diagnostic interpretation
– Core Infrastructure – Set of background clustered Windows Servers
(Caché) with a proprietary HSM communicating to an optical jukebox
– DICOM Gateways
Acquisition Gateway - waveforms/images from machines to GUI
applications
Text Gateway – data to and from machines to applications support
ADT, demographic data acquisition and modality worklists
Routing Processor – Routes data within and external to a facility with
associated rules to determine who would interpret a study (load
balancing). Picks up where DICOM leaves off
– Telereader – Originated in ophthalmology supporting a teleradiology
concept for non-radiology departments (remote access to images and
multimedia)
46

Medical Imaging and PACS Market
Medsphere community hospital customers are
asking for an open source solution to view,
manipulate and interpret Radiology Images and
support modality worklists
Medsphere prospects are asking for Medical
Imaging and Picture Archiving and
Communication System (PACS) automation
The United States has more than 60% of the
acute care hospitals using PACS systems today
Access to the complete medical record from the
point of care provides real time informed decision
making which leads to care transformation
Other points?
47

Initial Findings
In 2006, VistA Imaging was not ready for the
commercial market for the following reasons:
– There was a dependency on two proprietary software
components that were no longer available for purchase or
distribution
DSM: acquired by Intersystems
Accusoft: older version of commercial toolkit no longer
available for purchase. VistA Imaging is dependent
upon this for compiling and distribution
– Strategy for posting to FOIA related to FDA requirements
was not fully vetted
– VistA Imaging was in the early deployment phases of its
evolution and was not well proven
48

Today’s Progress
Proprietary Software Dependency
– DSM has been moved to Caché on a Windows Server platform eliminating
the dependency on a no longer available Mumps server.
– The VA has rewritten the software to eliminate the dependency on Accusoft
Patch 72 which was due to be ready 9/15/2008 for VA deployment
FOIA postings have followed as much as one year later than the
availability
Strategy for posting to FOIA related to FDA requirements has
been determined
– Anyone that requests VistA Imaging through the FOIA channels (formal
written request & $15.00) will be reported to the FDA
– The FOIA software is distributed as source code and must be compiled by
those intending to install and distribute
– Use intent will determine FDA regulatory requirements for the providing
vendor
Document images only: no FDA requirement
2 Dimensional image review without Mammography: Class I device
with less rigid certification process and follow on reporting and, in
some cases requires 510K premarket notification
3 Dimensional image view with Mammography: Requires certification
as a Class II device with 510K premarket notification and 2 year
reviews for design review and validation of safe use under GMP
49

Community Discussion
Is there a need to incorporate VistA Imaging into
an open source solution?
Has anyone had any experience with FDA
registration in an open source manner?
Should Medsphere sponsor the FDA certification
for the community? If so why?
50

Medsphere.org Tip of the Month
Jon Tai

Default Home Page
Default home page was designed to
– Help new users find what they are looking for
– Help returning users see what has changed since their
last visit
– Encourage participation
Attempts to appeal to a wide audience
Is generalized, not individualized
– Knows nothing about your interests, groups, and friends

Personalized Home Page
The “Your View” tab allows you to select and lay
out your own widgets
– Widgets are the individual boxes of content you see
throughout Medsphere.org
– Widgets can be customized to only show content from the
communities you are interested in
– There are widgets for following specific users or tags
– Easily see popular discussions, documents and tags
– And more...
You can change the layout of the page
You can make “Your View” the default tab when
you login
You must be logged in to view or change your personalized home page

Personalized Home Page
Example: A community member who is a
Clinical Application Specialist
– Would like to see recent discussions about CIS
– Would like to see popular (often viewed) documents
related to CIS
– Would like to see new blog postings anywhere on
Medsphere.org
– Would like to see new and updated information
related to Pyxis (ADM) devices
– Likes to read news from YYY site daily
– Would like to see all the changes and additions being
made anywhere on Medsphere.org