10 Years of DICOM at the
Department of Veterans Affairs
• Peter Kuzmak, VistA Imaging Project DICOM Team Leader
• Dr. Ruth Dayhoff, National Director, VistA Imaging Project
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VA Healthcare Enterprise
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173 Medical Centers & 650+ Outpatient Clinics
Serves a patient population of 24 million veterans
>130 sites acquire DICOM images
>100 million DICOM images online
DICOM used for Clinical Specialties besides Radiology
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How did this happen?
Synergy between six forces:
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Rapid evolution in computer technologies
Development of DICOM Standard and IHE
Advances in VA HIS technologies (RPC, GUI)
VistA Imaging Project
Commercial PACS
Economic: Need to do more, better, with less
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Original VistA Imaging System
1990-1993
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Washington – Baltimore
Pre-VistA HIS (DHCP)
386/20 Workstations
2nd monitor for RGB
Truevision AT-VISTA
board (frame-grab/display)
• 4 Gb Raid, 35 Gb Jukebox
• Beginning of Multimedia
Patient Record
• Focus: Clinical Specialties,
not Radiology
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VistA Multimedia Object Table
File Server
Patient Database
Multimedia Object Table
Image
File A
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Multimedia Group N
Image
File B
File A Type Q Patient X Group N
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Medicine Procedure Table
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File B Type Q Patient X Group N
File C Type Q Patient X Group N
Image
File C
Radiology Report Table
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Progress Notes Table
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First successful PACS – May 1993
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Baltimore VA Medical Center
Dr. Eliot Siegel
Siemens Gammasonics Inc.
6 modalities (2 CR, 2 CT, MR,
NM)
• 36 workstations (7 for dx)
• 95% softcopy reading
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Baltimore VAMC PACS
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MacIntosh workstations – hardware compression
40 Gbyte proprietary RAID (Loral Western Digital)
100 Mb/s proprietary fiber optic for images
1.2 Tbyte 14-inch platter Kodak optical jukebox 7
ACR-NEMA VistA/PACS Interface
Ethernet 10 mb/s
Siemens Ethernet
Bridge
Siemens VAX
Bridge
Shared Novell
File Server
NFS & DOS
Novell Image
File Server
PC MUMPS
ACR/NEMA
Gateway
Novell Image
File Server
Siemens
MacIntosh
Gateway
Novell Image
File Server
Jukebox
Main Hospital
Information
System
DHCP Imaging Network
Fiber Optic
100 mb/s
DHCP
Imaging
Workstation
PACS
DHCP
Imaging
Workstation
…
DHCP
Imaging
Workstation
HIS
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HIS – PACS Interface Messages
• HIS to PACS
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Patient Demographics
ADT
Order Entry
Examination Change
Report Transfer
Get PACS Image
Request
• PACS to HIS
– Examination Complete
– Get PACS Image Data
and Reply
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VistA & Computerized Patient
Record System - 1997
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Multimedia Patient Record –1995-97
Combines Computerized Patient Record and VistA Imaging
• Chart Data
– Textual chart data
– Computable data
– Handwritten and
non-electronic chart
data
• Multimedia Data
– Images, graphics,
waveforms, audio,
etc.
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Wide Variety of Images Integrated with the
Online Patient Record
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Cardiology
Bronchoscopy
Gastrointestinal
Endoscopy
Hematology
Pathology
Surgery
Nuclear Medicine
Dental
Radiology
Dermatology
Ophthalmology
Podiatry
Vascular
Urology
Nursing
Electrocardiography
Scanned Documents
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VistA Imaging DICOM - 1997
• DICOM Storage and
Modality Worklist Provider
• First VistA Radiology PACS
(Wilmington, DE)
• DICOM PACS Interface
(EMED – Boston)
• Publication of VA DICOM
Requirements Documents
VistA Radiology
PACS – 1997
• Advances allowed PACS
to be constructed from
commercially available
components
• Major cost-savings
incentive to internally
develop a PACS
• Named VistARAD
• Tremendously boosted
use of DICOM in VA
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VistA Imaging Network Topology – 1997
Main VistA HIS
CWS
CWS
CWS
CWS
CWS
CWS
CWS
CWS
Switch
Switch
CWS
Fast Ethernet
Commercial
EKG System
Main hospital backbone
Image File Servers
DxWS
DxWS
DxWS
DxWS
DxWS
DxWS
DICOM
Gateway(s)
Background
Processor
NT File
Servers
NT File
Server
Jukebox
Gigabit
Ethernet
Switch
DICOM
Device
DICOM
Device
DICOM
Device
DICOM
Device
DICOM
Device
DICOM
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Device
Original VistARad Workstation for
Filmless Reading
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DICOM Conformance Requirements for
Image Acquisition Modalities in
Radiology, Cardiology, Dental, Ophthalmology,
and Other Specialties
Draft Version 2.3
Authors: Herman Oosterwijk, Peter Kuzmak,
Dr. Ruth E. Dayhoff, and Dezso Csipo
Department of Veterans Affairs
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VistA to Commercial PACS
DICOM Text Messages
• HL7 transactions are generated by HIS/RIS
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ADT & Patient Demographic Changes
Orders and Cancellations
Examination Verification
Report Transfer (Preliminary & Final)
• HL7 data plus additional fields (e.g., UIDs)
are converted to a DICOM Message
• DICOM Messages are sent to the PACS
VistA to Commercial PACS
DICOM Images
• All images on the PACS are sent to VistA
• Image Verification is performed on PACS
– Sends Examination Complete message to VistA
• VistA uses DICOM Query/Retrieve service
to obtain the images from the PACS
VistA to Commercial PACS
DICOM Image Gateway Messages
VistA
Order Entry
PACS Text
Gateway
Examination Verification
Examination Complete
Commercial
PACS
Image
Gateway
Storage
Provider
Get Image Request (C-MOVE Request )
Image Transfer
Get Image Response (C-MOVE Response)
Modality
Worklist
Provider
Modality Worklist
Imaging
Modality
VistA DICOM Commercial
PACS Interface (text and images)
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GE – seven sites
EMED (Boston)
Brit/IBM (Dallas)
AGFA - six sites
Cemax/Icon - three sites
Marconi (Atlanta)
Using DICOM to Acquire Images
in the Clinical Specialties
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Dentistry
Ophthalmology
Endoscopy
Cardiology
Pathology
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Goal of Project
Interface the VistA HIS to
new DICOM-based image
acquisition devices used in
the clinical specialties
Cephalometric Image
2500 x 2024 16-bits
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Goal of Project
Interface the VistA HIS to
new DICOM-based image
acquisition devices used in
the clinical specialties
Panoramic Image
3064x1536 16-bits
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Extending DICOM to the Clinical
Specialties - a Broad Project!
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Learn about workflow in the clinical specialties
Find out how healthcare providers use VistA
Develop interfaces for clinical specialties to VistA
Insist that vendors support DICOM Modality
Worklist (MWL) & Storage
• Validate each vendor’s system over Internet
• Field tests at many sites with multiple vendors
• Work to improve DICOM specifications
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Workflow in the Clinical Specialties
• Workflow is far more diverse than radiology,
and is sometimes more complicated
• Varies among the different specialties
• Ordering patterns differ between specialties
– GI Endoscopy – every patient is scheduled
– Eye Clinic – some scheduled, walk-ins, ER
• Long lead time between order placement &
appointment
– 6 months for routine dental examinations
– 2 years for eye checkups
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Assign every Image Acquisition
Instrument to a Medical Specialty
• Map CT to radiology,
endoscope to medicine,
laparoscope to surgery
• Used by MWL to show
requests by specialty
• Used by Storage to
associate images to the
corresponding part of
the patient record
369x359 24-bit
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Assign every Image Acquisition
Instrument to a Medical Specialty
• Map CT to radiology,
endoscope to medicine,
laparoscope to surgery
• Used by MWL to show
requests by specialty
• Used by Storage to
associate images to the
corresponding part of
the patient record
1024x768 24-bit
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Field Test
• 11 Vendors
– 6 Dental
– 5 Ophthalmology
• 20 VA Sites
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Validated DICOM Clinical
Specialty Imaging Systems
Specialty
Manufacturers
Dental
Dentsply Genex, Instrumentatium Imaging,
Planmeca, Schick, Sirona, Trophy
Ophthalmology
Endoscopy
Canon Medical Systems, Humphrey Zeiss,
Medivision OIS, Topcon, Kowa, Joslin Vision
Network
Olympus, Stryker Endoscopy, Utech Products
Cardiology
Heart Lab, ScImage
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VA’s Role in Advancement of
DICOM in Dentistry
• Prior to 2001, dental IODs & CDs,
but no networking
• VA wanted dental IODs with
MWL & Storage to talk to VistA
• March, 2001 – Moratorium
• April, 2001 - Meet with vendors
• August, 2001 – 1st demonstration
of MWL & Storage for Dentistry
• ADA is now picking up this effort
1024x1536 8-bits 31
Results - Dentistry
• 2 kinds of sensors
– CCD (DX)
– Phosphorescent Plate
• 3 kinds of radiographs
– Intraoral (18-20
image/study)
– Panoramic
– Cephalometric
• Color (VL)
Various sized CCD sensors
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Results - Dentistry
• 2 kinds of sensors
– CCD (DX)
– Phosphorescent Plate
• 3 kinds of radiographs
– Intraoral (18-20
image/study)
– Panoramic
– Cephalometric
• Color (VL)
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Panoramic Image
3064x1536 16-bits
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Results - Ophthalmology
• External color photographs
• Retinal (fundus)
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Color photographs
Stereoscopic photographs
R/G/B filtered photographs
Fluorescein angiography
(up to 30 images/eye)
– Near infrared fluorescein
angiography
• Ultrasound
• Visual Fields (not DICOM)
• Diagrams (not DICOM)
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Results - Ophthalmology
• External color photographs
• Retinal (fundus)
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Color photographs
Stereoscopic photographs
R/G/B filtered photographs
Fluorescein angiography
(up to 30 images/eye)
– Near infrared fluorescein
angiography
• Ultrasound
• Visual Fields (not DICOM)
• Diagrams (not DICOM)
Fundus Image
3072x2048 24-bit
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Results - Ophthalmology
• External color photographs
• Retinal (fundus)
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Color photographs
Stereoscopic photographs
R/G/B filtered photographs
Fluorescein angiography
(up to 30 images/eye)
– Near infrared fluorescein
angiography
• Ultrasound
• Visual Fields (not DICOM)
• Diagrams (not DICOM)
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Results - Ophthalmology
• External color photographs
• Retinal (fundus)
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Color photographs
Stereoscopic photographs
R/G/B filtered photographs
Fluorescein angiography
(up to 30 images/eye)
– Near infrared fluorescein
angiography
• Ultrasound
• Visual Fields (not DICOM)
• Diagrams (not DICOM)
Fluorescein angiography
1108x1016 8-bit
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Need Additional DICOM Specifications
• There are no IODs for Ophthalmology or color
Dental images
• Need to indicate the kind of procedure performed
– Modality XA: coronary angio or retinal angio?
• No hanging protocols – how do you get the
images to line up the way providers want them?
• Need to identify the sensor apart from the system
that handles the images
– Acquisition Context Sequence generally empty
because there are no template definitions in the IODs
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Conclusion
Our goal is to incorporate all of the patient’s data
into the electronic medical record. DICOM is
making this easier for everyone.
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VistA Hospital Information System
• Making it possible to see the complete multimedia
patient record anywhere at anytime!
Acknowledgements
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Dr. Eliot Siegel, Chief of Imaging, Baltimore VAMC
Gerrald Perry, Radiology Administrator, Wilmington, DE VAMC
Dr. Greg Zeller, Assistant Director for Dental Informatics, VACO
Dr. Glenn Haggan, Assistant Chief, Dental Service, Wash VAMC
Chiao Wu, VistA Imaging Computer Specialist, Wash VAMC
Dr. Rex Ballinger, Staff Optometrist, Baltimore VAMC
Dr. Martha Farber, Lead Physician Ophthalmology, Albany VAMC
Lucille Barrios, Computer Specialist, VistA Imaging Project
Stuart Frank, Consultant, VistA Imaging Project
Elsie Casugay, Consultant, VistA Imaging Project
Rosemary Carr, Consultant, VistA Imaging Project
Herman Oosterwijk, DICOM Consultant, President, Otech
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Thank
You!
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