752 VistA Imaging: Image Routing, Telerad , & Remote Image Display

1. 752 VistA Imaging:Image Routing, Telerad, & Remote Image Display John Di Lorenzo

2. VistA Imaging Routing Terminology • Routing is the combination of methods and software used to identify and transmit exams produced at one site to a storage location at another site. • Routing takes two major forms • VistARad • DICOM • Routed images are triggered in one of two ways: • Autorouting • Route on demand

3. Workload sharing between institutions or service providers Rapid access of exams at remote clinics or other facilities Remote specialist interpretation or consultation Off-hours, holiday, or emergency “WET” reads Off-site contract radiology services for primary interpretation Film printing Specialized viewing stations, CD burners Peer Review Routing Uses

4. Autorouting • In autorouting, automatically selected images are transmitted to one or more destinations. • Images are selected based on a predefined set of routing rules. • Autorouting functions are managed using the Routing Gateway.

5. Autorouting • How Autorouting Works

6. Autorouting Set up the rules for autorouting in the “route.dic” DICOM("ARC") when MODALITY="DX" SOURCE="AUGUSTA UPTOWN“ NOW={FRI 07:59AM to 17:00PM } PriorStudy YES SEND("ARC") when MODALITY="DX" SOURCE="AUGUSTA UPTOWN" NOW={FRI 07:59AM to 17:00PM } PriorStudy NO

7. On-Demand Routing manually selected exams are transmitted to one or more destinations. Exams are selected using the VistARad client and are transmitted by the Routing Gateway. On Demand Routing

8. On Demand Routing • How On-Demand Routing Works

9. On Demand Routing • In on-demand routing, manually selected exams are transmitted to one or more destinations. • Exams are selected using the VistARadclient and are transmitted by the Routing Gateway.

10. On Demand Routing Displaying Routed Exams and Demand Routing In VistA Imaging, the VistARadmanager is used to route exams as well as display which exams have been routed. A routed exam is available for display when the RC (Remote Cache) column in a VistARad exam list contains the destination name established for your site.

11. On Demand Routing

12. On Demand Routing • Remote Cache Indicator

13. DICOM VS VistARad Routing • VistARad Routing • Network Location File • Images Remain in the same format as in Archive • Uses routing transmission Processor • DICOM Routing • SCU_List.DIC File • Images converted to DICOM • Sends DICOM files to remote SCP

14. How it all Works • Routing Gateway locates routable images, determines where the images are to be routed to, and sends copies of those images to other locations. • Depending on workload, routing gateway can be set up: • On a standalone gateway • Co-hosted on a text or image gateway

15. How it all Works

16. How it all Works

17. Routing Prerequisites Administrative Technical

18. Routing Prerequisites • An executed Site Agreement must be filed with the VistA Imaging development group. • A contingency plan must be implemented at all sites in the routing system and filed with the VistA Imaging development group. • The contingency plan must include information from the clinical and IT side of the house.

19. Routing Prerequisites • Reporting / transcription requirements for routed exams • Bandwidth utilization guidelines and priorities • Management of patient confidentiality and privacy issues related to routed exams • Methods for addressing performance issues and/or misuse of the routing system • Documentation used for Auto Routing: • VistARad User Guide • Routing User Guide V.3.0 Patch 54

20. Routing Prerequisites • Security • Background Investigations on Contractors • Privacy & Security Course Requirement • www.ees-learning.net • Encryption is required once it leaves the VAMC LAN • Data should be encrypted on devices that it lives on once it leaves the VAMC • Access • VPN Accounts • Radiologist • Transcriptionist • Administrative Support

21. Routing Prerequisites • If remote interpretation is being performed, one or more VistARad diagnostic workstations for the display of routed exams. • An operational VistA Hospital Information System, an operational Image Gateway, and an operational Routing Gateway, configured as described in the routing documentation. • An operational Local Area Network (LAN). • An operational Wide Area Network (WAN) with sufficient bandwidth to manage the anticipated volume of routed exams. • Windows-based servers to provide exam storage at each routing destination, configured as described in the routing documentation.

22. Routing Prerequisites • Connection Options & Requirements for routing outside the VA Network • Business Partner Gateways • Site to Site VPN Tunnels • LAN Extension http://vpnportal.vansoc.va.gov/

23. Challenges • Challenges • Access Control List – Firewalls • Bandwidth – “Your best friend or Worst enemy” • Equipment – “ Who pays for it and where does it go.”

24. Routing Optimization Technical Optimization Use compression Evaluate bandwidth Autoroute prior exams Logistical Optimization Defined schedules Contracts/MOUs Standard Operating Procedures

25. Routing Compression Works with “VistARad” routing Reduces file size before sending images Will not compromise image quality Aware JPEG 2000 proprietary software Routing Optimization

26. Routing Optimization

27. Routing Optimization

28. Routing Optimization

29. Routing Optimization

30. Evaluate bandwidth Is all bandwidth being used? Routing Optimization

31. XRAY DR images Routing Optimization

32. Evaluate bandwidth Is all bandwidth being used? Routing Optimization • Yes • Get more • Change routing rules • Lower expectations 1.5 Mb (T-1 speed) per radiologist

33. Ultrasound images Routing Optimization

34. Evaluate bandwidth Is all bandwidth being used? Routing Optimization • Yes • Get more • Change routing rules • Lower expectations • No • Autoroute more • Send less files • Send images simultaneously 1.5 Mb (T-1 speed) per radiologist

35. Ultrasound images Routing Optimization

36. Routing Optimization

37. Routing Optimization

38. Simultaneous sends to single site Routing Optimization

39. Routing Optimization

40. Routing Optimization

41. Simultaneous sends to multiple sites Routing Optimization

42. Autorouting prior exams Saves time & frustration for user Uses more bandwidth Routing Optimization

43. Routing Optimization

44. Routing Optimization

45. Editing prior exam logic VistA MAG RAD PRIOR EXAMS LOGIC file (2006.65) Used for identifying priors for both routing and JB prefetch Critical fields for routing: AUTO-DISPLAY (should this be routed?) DAYS LIMIT/AUTO-DISPLAY (max. date range to route) VERSION LIMIT/AUTO-DISPLAY (how many?) Routing Optimization

46. Logistical Optimization & Telerad Business Practices Routing Optimization

47. Defined schedules Radiologists PACS Admins Support staff Routing Optimization

48. Memorandum of Understanding or contract How many employees? Recurring expenses Changing scope of work Equipment failure and replacement Contingency plan Routing Optimization

49. Standard Operating Procedures Monitoring transmission of images Contact lists in place Image quality issues Routing/technical problems Significant clinical findings Modifying routing rules Productivity and QA measurement Routing Optimization

50. Common Routing Problems and Solutions Routing Troubleshooting