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  • My HealtheVet is a web-based personal health record portal which includes access to patient education, VA benefits and resources, a comprehensive personal health journal, and online prescription refills. Collaborating agencies include the Department of Defense; National Institutes of Health; Centers for Disease Control; and the American Health Information Community.
    The My HealtheVet Program provides America’s veterans with secure universal access to their personal health information in order to improve their health care. My HealtheVet is based on the core belief that knowledgeable patients are better able to make informed health care choices, stay healthy, and seek services when they need them. The program enables and supports veterans by making them more empowered health care consumers. Quality, access, value, and patient satisfaction are improved through the development of a collaborative health care tool.
    My HealtheVet uses innovative technology to complement the delivery of traditional health care services. The program meets the President’s charge to agencies to use technology to its fullest potential to provide services and information that are centered on citizen groups.
    My HealtheVet furthers the aim of electronic government (E-Gov) by exemplifying citizen-centric, interactive tools that the government can provide to veterans and their relatives.
    The My HealtheVet Program meets the needs of veterans, families, and caregivers by providing secure and universal access to comprehensive health and medical information that is crucial to patient care. This access is an important patient safety factor for high quality care, and it becomes critically important during emergencies ranging from an individual situation to a natural disaster or some other catastrophe.
    My HealtheVet allows Veterans and their families to collaborate in the management of their personal healthcare through innovative capabilities: online viewing of Personal Health Records (PHR); filling prescriptions; and management of medical history. This collaboration serves to map the care accessible online to existing clinical practices within VA hospitals. The result is improved quality and greater satisfaction of care. Additionally, My HealtheVet assists both long-term veterans and new veterans transitioning from active duty by integrating with the Department of Defense.
    An Executive Order issued on August 22, 2006 directed agencies to “ensure that health care programs administered or sponsored by the Federal Government promote quality and efficient delivery of health care through the use of health information technology.” As a complement to VA’s award-winning fully Electronic Medical Record, the My HealtheVet Personal Health Record enables veterans to more fully participate as partners with physicians in their health care. My HealtheVet is part of VA Strategic Initiative 1.2 that uses the PHR to enhance the veteran/provider partnership and optimize veteran health.
    My HealtheVet goals are:
    Using MHV to support the dissemination of standard patient education and clinical business practices.
    Using Information Technology to increase convenience and response time for veterans requesting VHA services.
    Increasing communication / collaboration between veterans and clinicians.
    Enabling veterans to consolidate and monitor their own health records and share this information with non-VA clinicians and others involved in their care.
    Empowering the patient to control what information is accessible by others.
    Collaboration with DoD eHealth portal TriCareONLINE to maximize VA and DoD resources and achieve a seamless transition from military to civilian life.
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    HL7 Data can be real time messages or batch files.
    HL7 customization is required. Ex. Up stream from radiology - Registering,
    Format can be standards based or proprietary. Proprietary can be defined by the hospital, organization, or by the vendor. i.e. patient sensitivity.
    DICOM- storage is static BLOBs (binary large objects) that never get updated
    What make objects different from messages? Persistence, Stewardship, Authentication, Context, Wholeness, Human Readability.
  • Hopefully this will make it easier to start reading and using the DICOM standard
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    CDRH regulatory powers include the authority to require certain technical reports from the manufacturers or importers of regulated products, to require that radiation-emitting products meet mandatory safety performance standards, to declare regulated products defective, and to order the recall of defective or noncompliant products. The CDRH also conducts limited amounts of direct product testing.
  • Electronic Medical Record: An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization.
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    Will a standard last over two thousand years?
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    Will a standard last over two thousand years?
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    The VA healthcare enterprise consists of 157 medical centers and over 850 outpatient clinics.
    The VA is installing approximately 140 retinal camera systems for its diabetic retinopathy surveillance project. In order to be convenient for the patient, the examinations are performed at sites chosen to minimize travel. The VA is also establishing approximately 20 reading centers around the country for diagnosis. A reading center can serve any acquisition site, not just the ones in its region.
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    Remember the song by Chicago, “Old Days” good times I’ll Remember. I don’t think they were singing about radiology.
    Do you remember how difficult film work flow was? Here is a typical flow, 59 steps involving 11 hospital staff.
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  • 321_VI.ppt

    1. 1. 321 VI Using Standards Andrew Casertano VistA Imaging
    2. 2. 2 Disclaimer • 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.
    3. 3. 3 What does PACS stand for? • Picture your Assets Completely Spent • Promise Anything to Close Sale • Pain And Constant Suffering • Press Anykey to Crash System • Property the Administrator Can’t Sell • Picture Archiving and Communications System • (all of the above?) Ref: SCAR 2005, Horii
    4. 4. 4 HL7 and DICOM • HL7 – Message protocol to update product databases – Standard used by Hospital, Radiology, & Lab Information Systems • DICOM – Used to exchange objects and to integrate with Information Systems – Standard used by acquisition modalities, PACS
    5. 5. 5 Typical Standards Overview Training Summary: “DICOM is the standard for medical imaging.” The details: Read these 4,000 pages. Today: Let’s learn about standards differently …
    6. 6. 6 Lack of HIT Standards • Inhibits Interoperability • Costs More • 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
    7. 7. 7 Nightmares • Disaster response and recovery • Human and Software Errors leading to patients safety in jeopardy • Improper disclosure of patient health information • Cost Overruns • …
    8. 8. 8 HIT Standards • Patient Safety • Interoperability • Rapid Deployment of integrated systems • Reduced cost of integrating devices • Data Recovery • Security/Privacy • Streamlining Patient Care
    9. 9. 9 Roles of VistA Imaging • Technical Strategy • Support/Assistance • Honest Broker/ Facilitator • Develop/Integrate 1: Pt registration  12: Pt Update  1: Pt registration  12: Pt Update Pt registration: 1  Pt Update: 12   2: Placer Order Management  3: Filler Order Management ADT Master Patient Index  4: Procedure Scheduled  12: Patient Update  13: Procedure Update Image Manager Image Archive Order PlacerOrder Filler
    10. 10. 10 Executive Order on Interoperability • Interoperability – exchange data accurately, securely and consistently between HIT systems • HIT systems shall use interoperability standards in contracting
    11. 11. 11 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:
    12. 12. 12 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 – Conformance testing
    13. 13. 13 What Interoperability provides • HIT systems are unified through a shared VistA EMR • All providers have access to complete, up-to-date patient information PhysiciansPhysicians & Staff& Staff HospitalsHospitals PharmaciesPharmacies DiagnosticDiagnostic LabsLabs PatientsPatients RadiologyRadiology
    14. 14. 14 VistA Integrated Multimedia EMR
    15. 15. 15 The Challenge of Interoperability • Unwillingness of healthcare providers – Psychological and cultural issues – Resistance to change Lack of enterprise vision, Loss of control, Perceived risk • Unwillingness of vendors – Proprietary systems and formats – Loss of competitive advantage – Technical obstacles
    16. 16. 16 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
    17. 17. 17 Evolution of Imaging Single modality applications Radiology-wide applications Interfaced radiology information systems and medical imaging management – RIS/PACS Fully integrated enterprise imaging and workflow solutions
    18. 18. 18 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 Petabytes of images to be stored and managed for decades Content management & Multi-site image sharing Content management & Multi-site image sharing Compute intensive reconstruction & analysis Compute intensive reconstruction & analysis Integrated IT architecture Integrated IT architecture Standards-based interoperability Standards-based interoperability
    19. 19. 19 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 Proto 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
    20. 20. 20 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, Otolaryngology • Microscope Imaging, Pathology
    21. 21. 21 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
    22. 22. 22 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 Petabytes More Data Over the Last 3 Years Than Previous 42,000 years Combined
    23. 23. 23 Cumulative Images Captured 2003 – 2008 Over 20K new images captured each hour • 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.
    24. 24. 24 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
    25. 25. 25 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
    26. 26. 26 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
    27. 27. 27 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
    28. 28. 28 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.
    29. 29. 29 Consistent Integration • 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
    30. 30. 30 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
    31. 31. 31 • 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."
    32. 32. 32 “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
    33. 33. 33 US Population Dose 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 Radon Medical Internal Cosmic Terrestrial Other Source mSv/year 1987 - 3.6 2003 - 6.3 CT 1.45 Nuclear 0.70 Rad. & Fluoro 0.60 Interventional 0.40 Other 0.02 07 NCRP PRELIMINARY Ref: Dr. S. Balter, Columbia University, Radiation Dose Data Management, February 2008
    34. 34. 34 Radiation Overexposure • 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
    35. 35. 35 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
    36. 36. 36 Ready for a Disaster?
    37. 37. 37 Katrina comes through the window
    38. 38. 38 Data Recovery • 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
    39. 39. 39 Gulfport Before and After
    40. 40. 40 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/
    41. 41. 41 Reference, The Los Angeles Times, California Department of Health Services, May 13, 2008, accessed online http://www.latimes.com/news/
    42. 42. 42 Old School Reference: Journal of Digital Imaging, Siegel and Reiner, 2003
    43. 43. 43 Law & Order Analogy
    44. 44. 44 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