VEHU Session 253H CONSULTING VISTA IMAGING Improving the Image of CPRS

1. VEHU Session 253HCONSULTING VISTA IMAGING – (Improving the “Image” of CPRS) Jeannie Jernigan, OI&T Michele Krajewski, OI&T Renee George, NTEO

2. Interface CPRS Consult Request Tracking to DICOM image acquisition devices used in the non-radiology clinical specialties Eye Care Dentistry Endoscopy Dermatology Pathology DICOM (Digital Imaging and Communications in Medicine) was developed for radiology and was first supported for that service. The VistA DICOM Interface for Healthcare Providers supports image acquisition devices in the clinical specialties outside of Radiology (teleretinal imaging, Dentistry, teledermatology, etc). This interface allows the image acquisition device to download patient and study information from CPRS Consults Request Tracking and to upload images to VistA, where they are automatically associated with the corresponding patient consult OR procedure request and stored in the multimedia database The DICOM interface supports CPRS Consults, Procedures and Clinical Procedures, but not Progress Notes. (reference: VistA Imaging DICOM Gateway V.3.0 User Manual-Revision 1, Chapter 14 – VistA DICOM Interface for Healthcare Providers Operation) Ok, that’s a mouthful. BUT, in simpler terms—the Radiology DICOM interface was so good, it’s process was modified to be utilized as an effective way to get images into the patient record from other modalities in a more efficient, streamlined manner. (While Clinical Procedures is also used by many modalities to get information across into the patient record, it has its own “special” conditions and can be quite cumbersome for the end-user). In this session, we will concentrate on teleretinal imaging. Maintaining and exceeding current rates of screening for diabetic retinopathy is the VHA's rational for exploring the use of teleretinal imaging. Since January 2006, VHA has implemented comprehensive teleretinal imaging programs in 158 sites nationwide. We've trained over 160 teleretinal imagers and 75 teleretinal readers since March 2006. DICOM (Digital Imaging and Communications in Medicine) was developed for radiology and was first supported for that service. The VistA DICOM Interface for Healthcare Providers supports image acquisition devices in the clinical specialties outside of Radiology (teleretinal imaging, Dentistry, teledermatology, etc). This interface allows the image acquisition device to download patient and study information from CPRS Consults Request Tracking and to upload images to VistA, where they are automatically associated with the corresponding patient consult OR procedure request and stored in the multimedia database The DICOM interface supports CPRS Consults, Procedures and Clinical Procedures, but not Progress Notes. (reference: VistA Imaging DICOM Gateway V.3.0 User Manual-Revision 1, Chapter 14 – VistA DICOM Interface for Healthcare Providers Operation) Ok, that’s a mouthful. BUT, in simpler terms—the Radiology DICOM interface was so good, it’s process was modified to be utilized as an effective way to get images into the patient record from other modalities in a more efficient, streamlined manner. (While Clinical Procedures is also used by many modalities to get information across into the patient record, it has its own “special” conditions and can be quite cumbersome for the end-user). In this session, we will concentrate on teleretinal imaging. Maintaining and exceeding current rates of screening for diabetic retinopathy is the VHA's rational for exploring the use of teleretinal imaging. Since January 2006, VHA has implemented comprehensive teleretinal imaging programs in 158 sites nationwide. We've trained over 160 teleretinal imagers and 75 teleretinal readers since March 2006.

3. Workflow Messages Order entered for a Consult or Procedure The Workflow for getting this information across is accomplished in the following steps. There is a lot of flexibility for different workflow scenarios, however. Some of the CPRS steps can be omitted, and all of the PIMS (Patient Information Management System) Scheduling/Appointment module messages are optional. But, it is essential to complete each CPRS consult/procedure request by entering a signed TIU result note. Otherwise, the images will not be properly associated and the request will remain on the worklist. First, the clinician enters an order for a consultation, a procedure, or a clinical procedure. The Workflow for getting this information across is accomplished in the following steps. There is a lot of flexibility for different workflow scenarios, however. Some of the CPRS steps can be omitted, and all of the PIMS (Patient Information Management System) Scheduling/Appointment module messages are optional. But, it is essential to complete each CPRS consult/procedure request by entering a signed TIU result note. Otherwise, the images will not be properly associated and the request will remain on the worklist. First, the clinician enters an order for a consultation, a procedure, or a clinical procedure.

4. Workflow Messages Once the order is signed, the consult service gets notified about the request. The consult service actions on the request by accepting it (with notification sent back to the patient’s clinician); or the consult service may forward the request to a different service; or, the consult service can discontinue or cancel the request. Once the consult service accepts the request, an appointment is scheduled for the patient (PIMS)Once the order is signed, the consult service gets notified about the request. The consult service actions on the request by accepting it (with notification sent back to the patient’s clinician); or the consult service may forward the request to a different service; or, the consult service can discontinue or cancel the request. Once the consult service accepts the request, an appointment is scheduled for the patient (PIMS)

5. Workflow Messages NOTE: VistA Imaging Abstract Window has been added. This is the beginning of the communication with VI. No images have been sent.NOTE: VistA Imaging Abstract Window has been added. This is the beginning of the communication with VI. No images have been sent.

6. Workflow Messages

7. Workflow Messages Once the appointment is scheduled, VI receives that message. The DICOM interface receives information (patient demographics, ordering details, what service will perform the request, etc.) from the CPRS Consult/Procedure Request tracking application and the VistA Appointment Management package during various steps of the workflow. The VistA DICOM Text Gateway supports a DICOM service called Modality Worklist, which is used to pass patient demographics and ordering information to the image acquisition device (AKA modality -- such as TopCon Teleretinal machine). Scheduling information from the Appointment Management package is also sent to the VistA DICOM Text Gateway as well. Once the appointment is scheduled, VI receives that message. The DICOM interface receives information (patient demographics, ordering details, what service will perform the request, etc.) from the CPRS Consult/Procedure Request tracking application and the VistA Appointment Management package during various steps of the workflow. The VistA DICOM Text Gateway supports a DICOM service called Modality Worklist, which is used to pass patient demographics and ordering information to the image acquisition device (AKA modality -- such as TopCon Teleretinal machine). Scheduling information from the Appointment Management package is also sent to the VistA DICOM Text Gateway as well.

8. Workflow Messages Now the patient has arrived for his/her appointment, has been checked in, and sent to the teleretinal imager (person taking the patient eye photos with the TopCon camera). Now the patient has arrived for his/her appointment, has been checked in, and sent to the teleretinal imager (person taking the patient eye photos with the TopCon camera).

9. Workflow Messages The imager pulls the modality worklist, which produces a list for all the pending and scheduled consults and procedures for that clinical specialty. The internal entry number (IEN) of the consult or procedure request is used as the accession number. The accession number identifies the consult/procedure and is displayed on the CPRS screen with the request. This value can be used in either the Accession Number or Requested Procedure ID matching key to retrieve the specific request. The accession number is actually more useful in Radiology. Using the “quick PID” query is more useful—it allows a patient query by use of the abbreviated identifier consisting of the first letter of the patient’s last name follwed by the last four digits of the social security number (much easier for all involved and more reliable).The imager pulls the modality worklist, which produces a list for all the pending and scheduled consults and procedures for that clinical specialty. The internal entry number (IEN) of the consult or procedure request is used as the accession number. The accession number identifies the consult/procedure and is displayed on the CPRS screen with the request. This value can be used in either the Accession Number or Requested Procedure ID matching key to retrieve the specific request. The accession number is actually more useful in Radiology. Using the “quick PID” query is more useful—it allows a patient query by use of the abbreviated identifier consisting of the first letter of the patient’s last name follwed by the last four digits of the social security number (much easier for all involved and more reliable).

10. Workflow Messages When images are acquired by the modality and sent to VistA, they are then associated with the corresponding CPRS consult or procedure request and are stored on VistA. The images are attached to the most recent TIU result note for the request. IF NO TIU result note exists, the images are placed in a temporary file until the result note is entered.When images are acquired by the modality and sent to VistA, they are then associated with the corresponding CPRS consult or procedure request and are stored on VistA. The images are attached to the most recent TIU result note for the request. IF NO TIU result note exists, the images are placed in a temporary file until the result note is entered.

11. Workflow Messages Once the images have been associated to the proper consult via TIU note, the study is now available on the Unread Study list for reviewOnce the images have been associated to the proper consult via TIU note, the study is now available on the Unread Study list for review

12. Workflow Messages Once the study is completed, the images are then verified by the imager by viewing the study in VistA Imaging Display. (NOTE: the images ICON is NOT present at this time because a result has NOT been entered yet). As per protocol, it must be verified that all images that were acquired are present on VistA, that they are displayed properly, that they are the correct images, and that there are no unexpected additions (images from another patient). It is for this reason the patient should only be allowed to leave after the imager has successfully verified all of the images. A patient safety issue of improper image handling by the TopCon device has been identified regarding improper image transfer by the TopCon device when its hard drive gets too full. Alll sites utilizing this device are required to apply the fix (contact your TopCon representative or local Biomed Service for assistance if this has not been completed). This is the Patient Safety Alert AL08-15, published by Central Office on May 15, 2008.Once the study is completed, the images are then verified by the imager by viewing the study in VistA Imaging Display. (NOTE: the images ICON is NOT present at this time because a result has NOT been entered yet). As per protocol, it must be verified that all images that were acquired are present on VistA, that they are displayed properly, that they are the correct images, and that there are no unexpected additions (images from another patient). It is for this reason the patient should only be allowed to leave after the imager has successfully verified all of the images. A patient safety issue of improper image handling by the TopCon device has been identified regarding improper image transfer by the TopCon device when its hard drive gets too full. Alll sites utilizing this device are required to apply the fix (contact your TopCon representative or local Biomed Service for assistance if this has not been completed). This is the Patient Safety Alert AL08-15, published by Central Office on May 15, 2008.

13. This is the Patient Safety Alert AL08-15, published by Central Office on May 28, 2008. At the end of this session, we will go into more detail regarding deletion of images. The deletion specified here is particular to the TopCon systems. As indicated, Operator instructions for proper deletion of images from Topcon systems are available at: http://vaww.carecoordination.va.gov/store-forward/teleretinal/docs/Acquisition-TeleretinalDeletingImages.pdf This is the Patient Safety Alert AL08-15, published by Central Office on May 28, 2008. At the end of this session, we will go into more detail regarding deletion of images. The deletion specified here is particular to the TopCon systems. As indicated, Operator instructions for proper deletion of images from Topcon systems are available at: http://vaww.carecoordination.va.gov/store-forward/teleretinal/docs/Acquisition-TeleretinalDeletingImages.pdf

14. Workflow Messages Once the verified images have been uploaded, the specialist responsible for performing a diagnostic interpretation of the images will enter a TIU result note and complete the consult by electronically signing it. These two steps are necessary for the proper operation of the interface. The images are permanently linked to the TIU result note so that they can be viewed from the CPRS consult tab. Completing the consult removes the request from the Modality Worklist (next slide). The success of the teleretinal project has been great*****MARY FOSTER’s UPDATED INFO HERE???Once the verified images have been uploaded, the specialist responsible for performing a diagnostic interpretation of the images will enter a TIU result note and complete the consult by electronically signing it. These two steps are necessary for the proper operation of the interface. The images are permanently linked to the TIU result note so that they can be viewed from the CPRS consult tab. Completing the consult removes the request from the Modality Worklist (next slide). The success of the teleretinal project has been great*****MARY FOSTER’s UPDATED INFO HERE???

15. Workflow Messages

16. Workflow Messages Note that now the image icon appears on the CPRS note. (until the TIU result note is entered, this icon will not be present)Note that now the image icon appears on the CPRS note. (until the TIU result note is entered, this icon will not be present)

17. Workflow Messages The consult completion send the message to remove the request from the Modality WorklistThe consult completion send the message to remove the request from the Modality Worklist

18. Workflow Messages And the sequence has gone full circle. Now, follow-up visits may occur and additional images may be needed. In order to accomplish this, an unsigned TIU result note to re-open the request can be done. Images that are then acquired are associated with this new TIU result note. The unsigned TIU result note allows a new modality worklist entry to be recreated for the additional images to be entered, and signing the TIU result note “completes the request again” and removes it from the worklist. This process can be repeated as needed and the images that are acquired are always associated with the most recently opened TIU result note. And the sequence has gone full circle. Now, follow-up visits may occur and additional images may be needed. In order to accomplish this, an unsigned TIU result note to re-open the request can be done. Images that are then acquired are associated with this new TIU result note. The unsigned TIU result note allows a new modality worklist entry to be recreated for the additional images to be entered, and signing the TIU result note “completes the request again” and removes it from the worklist. This process can be repeated as needed and the images that are acquired are always associated with the most recently opened TIU result note.

21. Reading Sites, Specialty, Procedures The assigned sites for reading are viewable in the Specialties window after logging into the TeleReader. The window opens by default. You can choose to view all sites by checking the box next to the location, or you can check the box of the site for the studies you would like to read at that particular time. Clicking the specialty will automatically check the site and the procedure. Clicking the procedure will automatically check the site and the specialty. Clicking the site will automatically check specialty and procedure. Note: Site and Specialty are checked in this example and are gray, it is because not all procedures are checked for the specialty. The hash/plus mark removes the procedure for now. On your workstations you will not see a procedure called Miscellaneous. This was early coding to get ready for other specialies/services to take advantage of the TeleReader. The pluses and minus signs allow easy enabling or disabling of an entire site or specialty quickly. Clicking the specialty will automatically check the site and the procedure. Clicking the procedure will automatically check the site and the specialty. Clicking the site will automatically check specialty and procedure. Note: Site and Specialty are checked in this example and are gray, it is because not all procedures are checked for the specialty. The hash/plus mark removes the procedure for now. On your workstations you will not see a procedure called Miscellaneous. This was early coding to get ready for other specialies/services to take advantage of the TeleReader. The pluses and minus signs allow easy enabling or disabling of an entire site or specialty quickly.

22. TeleReader Unread List The Unread List displays 4 types of studies: Black: unread and unlocked, can be resulted by the current user. Blue: locked by the current user. Red: urgent/stat. Gray: the study is not available to be resulted. When a study is selected, the bottom of the TeleReader window provides details about the study. There is a padlock next to the blue/locked study. To lock a study, click once and click the lock button, or to to the study menu and select a drop down choice, or double click the item. The color changes from black to blue. color If someone else at your site who was reading opened up the TeleReader the study you locked will be gray for the other reader. Gray colored studies that appear when you open the TeleReader mean that you can not read them. Stat/urgent is created by the imager at the time of creating the IFC. What does waiting mean: Gray studies are studies which have been cancelled, completed, or are waiting, are locked by another user, or studies which cannot be resulted at your reading site.There is a padlock next to the blue/locked study. To lock a study, click once and click the lock button, or to to the study menu and select a drop down choice, or double click the item. The color changes from black to blue. color If someone else at your site who was reading opened up the TeleReader the study you locked will be gray for the other reader. Gray colored studies that appear when you open the TeleReader mean that you can not read them. Stat/urgent is created by the imager at the time of creating the IFC. What does waiting mean: Gray studies are studies which have been cancelled, completed, or are waiting, are locked by another user, or studies which cannot be resulted at your reading site.

23. TeleReader Not in Context Notice CCOW, CPRS v26 implements user context. In its simplest terms, this allows “simplified” secure sign-on to multiple VistA applications, in the same server account, from the same desktop. Applications are CCOW enabled and provides for a secure single sign-on structure. Not in Context: For example, instead of opening CPRS from the TeleReader you opened it via the CPRS icon on the desktop earlier in the am and you have one patient’record active in CPRS and a different patient’s study selected in the TeleReader. CCOW, CPRS v26 implements user context. In its simplest terms, this allows “simplified” secure sign-on to multiple VistA applications, in the same server account, from the same desktop. Applications are CCOW enabled and provides for a secure single sign-on structure. Not in Context: For example, instead of opening CPRS from the TeleReader you opened it via the CPRS icon on the desktop earlier in the am and you have one patient’record active in CPRS and a different patient’s study selected in the TeleReader.

24. It would be in your best interests to probably lock your studies rather than view. View does not lock a study and has the potential to have 2 people looking at the same study. Although stat consults are possible, it is another step for the imager and at this time the preferred method is that the imager contact the reader by phone with his or her concerns.It would be in your best interests to probably lock your studies rather than view. View does not lock a study and has the potential to have 2 people looking at the same study. Although stat consults are possible, it is another step for the imager and at this time the preferred method is that the imager contact the reader by phone with his or her concerns.

25. TeleReader Read List The lists refresh every 2 minutes. A study may take longer to move from unread to read based on speed of connection. You can click on the options menu and click on Refresh to move the study if so desired. Studies remain on the read list for 7 days, this is software specific and not site specific. You don’t want to display the entire read list as it will get too large. At this time it is not user or site configurable. There is discussion that on a future patch to be determined there could be an administrative tool that will allow removing of unnecessary items fro the unread list and the ability to view however much of the read list the user wants. Do you think the read list days should be a user/site specified value? There are 2 ways to move studies from the unread to the read list: automatically the telereader refreshes every 2 minutes, or manually going to the options menu and clicking on refresh. You will also have canceled consults appearing on the read list. Just to note that nothing can be done with the read list other than view, the lock button does not function.The lists refresh every 2 minutes. A study may take longer to move from unread to read based on speed of connection. You can click on the options menu and click on Refresh to move the study if so desired. Studies remain on the read list for 7 days, this is software specific and not site specific. You don’t want to display the entire read list as it will get too large. At this time it is not user or site configurable. There is discussion that on a future patch to be determined there could be an administrative tool that will allow removing of unnecessary items fro the unread list and the ability to view however much of the read list the user wants. Do you think the read list days should be a user/site specified value? There are 2 ways to move studies from the unread to the read list: automatically the telereader refreshes every 2 minutes, or manually going to the options menu and clicking on refresh. You will also have canceled consults appearing on the read list. Just to note that nothing can be done with the read list other than view, the lock button does not function.

27. Radiology Viewer

28. Radiology Viewer-Angle Tool

29. Radiology Viewer-Page Control

30. Radiology Viewer-Stack & Layout View

31. Radiology Viewer- Gray Scale Tools

32. Hands-on Interactive Session Student places a CPRS Consult request for VeHU Imaging Consult Service Staff acquires DICOM images for study using a modality simulator Student verifies the images for their study Student uses TeleReader to lock a study, views the images,enters a result and completes consult Student displays completed consult with image attached to the result note

33. Hands-on Interactive Session Start CPRS and Clinical Display Place a CPRS Consult request for “VeHU Imaging Consult Service” Staff acquires DICOM images for study using a modality simulator Use Clinical Display to view image for study

34. Hands-on Interactive Session Start TeleReader Display Unread Study List Lock/unlock some studies Can only lock unread studies Launches CPRS and Clinical Display Select/deselect Options -> View All Studies “Full list” or only “available studies” are shown

35. Hands-on Interactive Session Lock an “Unread” study CPRS/Clinical Display should be directed to the patient Use Clinical Display and view images Use CPRS to enter result and complete consult Status should change to “Resulted” Study should now be on the Read List Use CPRS/VI to display image attached to TIU note under Consult tab

36. Hands-on Interactive Session MAG DELETE KEY Who should have key – limited number of users Privacy Act Officer/Chief, HIM or authorized designee Imaging System Manager/Imaging Coordinator Local Policy Check site’s policy on deletion Use an addendum to note or make note Error Note Need to delete images before deleting note *********************************************************************************** * This document has linked images. You must "delete" the Images using * * the Imaging Package before proceeding with this action. * * The images will be hidden from public view, but will remain * * indefinitely discoverable to HIMS. * ********************************************************************************** This year, we will be deleting an image. Remember, local policy may dictate exactly who has rights to “delete” an image. At our facility, the HIMS Chief, Privacy Officer (HIMS Chief Backup), and the Radiology Manager (and her backup) delete images. This may be different at your site. Just remember to have a policy outlining the process. Only users assigned the MAG DELETE security key can delete an image. Only the Privacy Act Officer/Chief, HIM or authorized designee should have this security key. However, in some situations, facilities may have a need for other or additional authorized personnel to have this key. The National HIMS website has recently published some Imaging Scanning FAQ’s (http://vaww.vhaco.va.gov/him/faq.html) that can assist you in determining local policy. In that FAQ, there is a reference This year, we will be deleting an image. Remember, local policy may dictate exactly who has rights to “delete” an image. At our facility, the HIMS Chief, Privacy Officer (HIMS Chief Backup), and the Radiology Manager (and her backup) delete images. This may be different at your site. Just remember to have a policy outlining the process. Only users assigned the MAG DELETE security key can delete an image. Only the Privacy Act Officer/Chief, HIM or authorized designee should have this security key. However, in some situations, facilities may have a need for other or additional authorized personnel to have this key. The National HIMS website has recently published some Imaging Scanning FAQ’s (http://vaww.vhaco.va.gov/him/faq.html) that can assist you in determining local policy. In that FAQ, there is a reference

37. Hands-on Interactive Session This is the deletion placeholder that can be used from the HIMS FAQ Scanning guide. You may add to this if you’d like to ensure that proper identification is followed. We make sure that the patient’s name, the date and title of the document and/or a short description of what was removed is present. This assists in keeping a trail as to what has been removed from the patient’s chart. If a progress note must be removed (made non-viewable), then any images attached must be deleted first.This is the deletion placeholder that can be used from the HIMS FAQ Scanning guide. You may add to this if you’d like to ensure that proper identification is followed. We make sure that the patient’s name, the date and title of the document and/or a short description of what was removed is present. This assists in keeping a trail as to what has been removed from the patient’s chart. If a progress note must be removed (made non-viewable), then any images attached must be deleted first.

38. Hands-on Interactive Session Here is a screenshot of the VHA HIM FAQs page. As you can see, there are several selections that also may be of use for you in creating local scanning policies (ROI/Scanning/Telehealth, for example).Here is a screenshot of the VHA HIM FAQs page. As you can see, there are several selections that also may be of use for you in creating local scanning policies (ROI/Scanning/Telehealth, for example).