VistA Imaging: An Update on IHS Activity and Directions Mark Carroll, MD; Janis Sollenbarger

1. VistA Imaging: An Update on IHS Activity and Directions Mark Carroll, MD; Janis Sollenbarger

2. Objectives • Overview of VistA Imaging • Current experience with VistA Imaging in Indian Health • Next steps/planning

3. Today’s Presentation • Overview of IHS Imaging Needs • Overview of history of VI in VHA • Brief history of VI in IHS • Possible architectural models • 7 Steps process to implement VI in Indian health • Question and Answer

4. Why VistA Imaging? • RPMS has no image storage capability • Implications for the IHS EHR and for diverse Telehealth activities

5. EHR “Image” Needs • Reports • Consults from Outside Specialists • Consents • Advance Directives • Patient Photos

6. Howard Hays, MD, MSPH IHS Technical Conference June 20, 2006

7. EHR Milestones and Status • RPMS EHR was certified January 2005 • 7 test sites participated in 2004 • Presently 53 facilities use EHR • Goal for all Federal sites to be using EHR by end of 2008 • Tribal sites encouraged to use EHR as well

8. EHR Sites as of 6/6/06

9. www.telehealth.ihs.gov

10. “Real-Time Telemedicine” • Mental health • Videoconference-based • Other specialist consultation

11. “Store-and-Forward” Telemedicine

12. IHS-AFHCAN Collaboration • National Telehealth Infrastructure • Offer a secure enterprise solution for telemedicine across Indian health

13. Large Scale • 248 Sites • 586,412 square miles • Multi-Agency • 43 Autonomous Organizations • Native/Tribal, Military, Veterans, State of AK • 3 Federal Agencies • Multi-Provider • Community Health Aide / Practitioners (CHA/P) • Nurse, ANP, PA • MD • Specialist • Native Health Corporations (36) • U.S. Army • U.S. Air Force (3 bases) • Veterans Administration • U.S. Coast Guard • Public Health Nursing

14. The “Classic” Cart Four Devices “Cart” Roadmap “Next Generation” Cart More Devices - Repackaged

16. ENT Tele-Consultation Center • Specialists at Alaska Native Medical Center • Patients at the Yakima Indian Health facility in eastern Washington • “Expert triage” model

17. Integrated System of Care • Integrated Health Enterprise architecture that includes: • Images and telehealth information with the IHS Electronic Health Record

18. The Chronic Care Model Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4.

20. Why VistA Imaging? • RPMS has no image storage capability • Implications for the IHS EHR and for diverse Telehealth activities

21. Why VistA Imaging? • Multi-faceted software program developed in federal sector for image capture, display, and storage of: • Scanned documents • Non-DICOM images • DICOM images

22. Strong Foundation • Build from existing successes

23. Please note! • VI is not a mandate • It is: • Part of IHS IT strategic plan • Part of ISAC priorities • But it is an Unfunded opportunity • Except for some support such as the IHS-VHA project agreement

24. Strategic Directions • VI is the multimedia component of VHA CPRS • VI is now offered as the multimedia component of IHS EHR

25. VistA Imaging in Indian Health • Permission to use VI • Proof-of-concept implementations • Proprietary license review • IT/IHS EHR integration issues • Architectural planning and roll-out

26. IHS-VHA Project Agreement

27. IHS-VHA Distribution Agreement • VHA is manufacturer of FDA regulated device • IHS cannot modify VistA Imaging code • Software is free (except for some embedded proprietary software) • IHS must install VistA Imaging on hardware configuration certified by VHA • Hardware configuration is “robust” • I.E. Expensive

28. Vista Imaging • Separate application • Separate hardware • Some proprietary software embedded within application

29. Why is the Hardware Expensive? • Storage redundancy and security • Image data is stored in 3 places – • RAID • Tape • Magneto optical discs (Jukebox)

30. Phase 1: Proof-of-Concept • Wind River as initial installation in Fall, 2004 • Earlier software version of VI • Portland Area regional installation in 2005 • To support all Portland Area sites • Warm Springs as initial site accessing VI via the IHS WAN • “Live” in January, 2006

31. Regional Hardware • Pros • Cost-effective • Opportunity for image sharing • Facilitates technical support • Capable of supporting teleradiology • Cons • Relies on Wide Area Network

32. Shared Hardware in the VHA? • Some VISNs are consolidating their Jukeboxes • The trend is to provide approx 7 years of on-line storage w/ the JB being accessed less and less • Some VISNs have consolidated VistA databases

33. VI – EHR Integration • VI Launches from EHR • Maintains patient context • Presently requires a separate enduser log-on • Other customization work under review • Annotation tool • Patient photo

34. Proprietary Licenses • Accusoft • Image Gear run-time license • 5 Regional server license purchased for first 5 installations • Nationally funded for license • Annual maintenance fee to be paid by Area or installation • Other possible • DICOM query and retrieve • DICOM compression

35. Phase 2 Implementations • Nashville Area • August 2006 Installation • Other Areas and facilities • Navajo Area • Phoenix Area • Billings Area • Bemidji Area • Oklahoma Area • Hastings Indian Medical Center

36. EHR Sites as of 6/6/06

37. Possible Deployment Model – circa 2005

38. Possible Models – 2006 • Different models are possible such as: • Cluster at every site(!) • Regional cluster • Option 1: Regional Jukebox • Option 2: National Jukebox or mirrored jukeboxes • Note: PACS • Hybrid blend with commercial PACS • Use of VistA Rad as PACS systems

39. Regional VI Clusters Ordered Under Review Installed

40. Integrated Radiology Services • Opportunity for standards • DICOM and HL 7 conformance statements • Transcription • Requirements at contracting re: • Reports integration into RPMS • Workgroup forming re: white paper

41. Tele-Radiology

42. Thank You mark.carroll@ihs.gov