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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



...
Agenda

     OpenVista’s Capabilities today
      – Radiology Worklist
      – Autofax Introduction
      – Autofax: Under...
Radiology Automation with
OpenVista in the Non VA Market
VistA Imaging/PACS for OpenVista®
Prepared by Kathy Doub-English,...
OpenVista Imaging Today

    VistA Radiology Information
    System
    Inbound image interface
    (document or picture)
...
OpenVista PACS Interface


                       ADT




                    OpenVista                 URL Link to
      ...
Outgoing Messages to PACs

     Registration
      – A message is sent to the PACs system whenever a patient
        is re...
OpenVista Imaging Today

    Automated faxing of result to
    one or more physician offices
    using an open source
    ...
Radiology Work List
Overview by Adam Waterbury
Dashboard View of Radiology Workload
     Configurable
     – System Level
          Status Display
          Number of Da...
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 Remo...
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
  ...
17
Auto Fax Introduction
 Overview by Adam Waterbury
Auto Fax



      Automatically faxes verified laboratory
      results to ordering physicians
      Faxes all Inpatient a...
Requirements

      Scalable and Flexible
       – One solution for all sites
       – Can be used by other systems
      ...
Auto Fax Work Flow




                                            Fax1
                     CIS

              OpenVista
...
Auto Fax Server

      Offered by iFAX, provided by Dell
      Tower, 1U and 2U configurations
      Port sizes range from...
Product Features




23
Auto Fax Features




      No additional steps for technicians
      HIPAA compliant
      Web based interface
       – C...
Auto Fax Console




25
Auto Fax Queue Management




26
Beta Testing

      Midland Memorial Hospital
       –   Completed
       –   Laboratory Package
       –   28 docs
      ...
Benefits



      Reduced Turn Around Time
       – Physicians receive results faster


      Saves Paper
       – No prin...
Phase II

      Batch Faxing By Physician
      Patient Type Parameter By Physician
       – Location inclusion exclusion
...
Autofax: Under the Hood
         Jon Tai
Design Goals

 We tried to design a solution that would...
 – Support both Windows and Linux OpenVista deployments
 – Leve...
Architecture
 Hooks in OpenVista trigger faxes
 Faxing handled by a separate machine, the “Fax Appliance”
  – Appliance ac...
Fax Appliance Software
 CentOS 5
 HylaFAX 4.4.4
 xinetd
 – Listens on port 9100 (JetDirect port)
 – Calls custom Python sc...
Architecture Diagram


OpenVista Server       Fax Appliance

      RPC Broker               Web Interface


    Lab       ...
Fax Appliance Hardware
 Modem: Mainpine IQ Express
  –   PCI Express
  –   Supported under Linux >= 2.4 and Windows >= 200...
Fax Appliance Hardware
 Example Configurations
 – Dell PowerEdge R200 with a 2-port modem
       Planned fax volume: 200 f...
XML Metadata Format
<fax>
   <from>Medsphere Hospital</from>
   <from-fax-number></from-fax-number>
   <from-voice-number>...
XML Metadata Format
<fax>
   <from>Medsphere Hospital</from>
   <from-fax-number></from-fax-number>
   <from-voice-number>...
XML Metadata Format
<fax>
   <from>Medsphere Hospital</from>
   <from-fax-number></from-fax-number>
   <from-voice-number>...
XML Metadata Format
<fax>
   <from>Medsphere Hospital</from>
   <from-fax-number></from-fax-number>
   <from-voice-number>...
XML Metadata Format
<fax>
   <from>Medsphere Hospital</from>
   <from-fax-number></from-fax-number>
   <from-voice-number>...
HylaFAX Configuration Considerations
 Options to accommodate the web frontend
  – JobFmt: quot;%-9j %3I %3i %1a %5P %5D %-...
Additional Considerations
 If your OpenVista server runs Linux, it should be
 technically possible to run everything on on...
OpenVista Gap Today

      Acquisition of static & multimedia images through
      DICOM
      Ability to review, manipula...
What is PACS?

      In medical imaging,                     Most PACS handle
      picture archiving and                 ...
VistA Imaging

      Goal: To facilitate medical decision-making by delivering
      complete multimedia patient informati...
Medical Imaging and PACS Market

      Medsphere community hospital customers are
      asking for an open source solution...
Initial Findings

      In 2006, VistA Imaging was not ready for the
      commercial market for the following reasons:
  ...
Today’s Progress

      Proprietary Software Dependency
       – DSM has been moved to Caché on a Windows Server platform ...
Community Discussion

      Is there a need to incorporate VistA Imaging into
      an open source solution?
      Has any...
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...
Personalized Home Page

 The “Your View” tab allows you to select and lay
 out your own widgets
  – Widgets are the indivi...
Personalized Home Page

 Example: A community member who is a
 Clinical Application Specialist
  – Would like to see recen...
Challenges of Automating Radiology with an Open Source Solution
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Challenges of Automating Radiology with an Open Source Solution

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The presentation included some discussion of the VistA Imaging product, need within the community for a PACS solution, Radiology automation/worklist queuing, Autofaxing system (including technical details on integrating with Hylafax), and closed with a tip on customizing the Medsphere.org interface to be more useful to individual needs.

When: November 20, 12:30 - 2pm Pacific
Where: Dial-in: (888) 346-3950 // Participant Code: 1302465
Web conference: http://www.medsphere.com/infinite/
What: Challenges of Automating Radiology with an Open Source Solution

- Introduction

Solutions:
- Integrating PACS to RIS
- Radiology Worklist and Flow Monitoring
- Autofax
- Autofax Under the Hood

- Open Discussion
- Medsphere.org Tip of the Month

Details and Recording available from here: http://medsphere.org/blogs/events/2008/11/20/community-call-november-2008

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Transcript of "Challenges of Automating Radiology with an Open Source Solution"

  1. 1. Webinar: http://www.medsphere.com/infinite/ Voice: (888) 346-3950 Participant code: 1302465
  2. 2. Challenges of Automating Radiology with an Open Source Solution November 2008 Community Call
  3. 3. Presenters Ben Mehling Kathy English Janine Powell Loyd Bittle Adam Waterbury Jon Tai 3
  4. 4. 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
  5. 5. Radiology Automation with OpenVista in the Non VA Market VistA Imaging/PACS for OpenVista® Prepared by Kathy Doub-English, VP Product Management
  6. 6. 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
  7. 7. OpenVista PACS Interface ADT OpenVista URL Link to PACS Database Image RAD Work-List Orders/Exam OV Radiology Status/Results CIS/CPOE Mirth 7
  8. 8. 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
  9. 9. 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
  10. 10. Radiology Work List Overview by Adam Waterbury
  11. 11. 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
  12. 12. CIS Platform Utilizes OpenVista Security – Display Based on Access ID and Patient Image Type 12
  13. 13. Features – Auto Refreshing – At-A-Glance View Of Workload – Customizable To Match Work Flow 13
  14. 14. Benefits – Eliminates Need To Run and Print Status Reports – Up To The Minute Information – Can Be Run Remotely 14
  15. 15. Beta – Completed – 30 Day Beta At Century City Doctors Hospital – Is Now GA 15
  16. 16. Phase II – Visual Indication Of Stat Orders – Inpatient/Outpatient Indicator – Ability To Select Patient Opens Terminal Emulator 16
  17. 17. 17
  18. 18. Auto Fax Introduction Overview by Adam Waterbury
  19. 19. 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
  20. 20. 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
  21. 21. Auto Fax Work Flow Fax1 CIS OpenVista Fax2 Lab Radiology Module Module HylaFAX Fax3 Server Fax4 21
  22. 22. 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
  23. 23. Product Features 23
  24. 24. 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
  25. 25. Auto Fax Console 25
  26. 26. Auto Fax Queue Management 26
  27. 27. Beta Testing Midland Memorial Hospital – Completed – Laboratory Package – 28 docs – 275 per week Memorial Hospital Sweet Water County – In Beta – Radiology Package 27
  28. 28. 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
  29. 29. 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
  30. 30. Autofax: Under the Hood Jon Tai
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. Architecture Diagram OpenVista Server Fax Appliance RPC Broker Web Interface Lab Modem xinetd OS + Phone Print HylaFAX python Network Queue script Rad Modem
  35. 35. 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
  36. 36. 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
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. HylaFAX Configuration Considerations Options to accommodate the web frontend – JobFmt: quot;%-9j %3I %3i %1a %5P %5D %-96.96s %-14.14equot; 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
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. 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
  51. 51. Medsphere.org Tip of the Month Jon Tai
  52. 52. 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
  53. 53. 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
  54. 54. 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
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