2005 Computerworld Honors Program

	VistA Integrated Medical Imaging System Imaging Project, Technical Services, Department of Veteran Affairs Silver Springs, MD USA Year: 1998 Status: Laureate Category: Medicine Nominating Company: Digital Equipment Corporation
	Consolidated storage and retrieval of medical images and text reports allows clinicians to view them together from any workstation in the hospital, improving doctor productivity and patient care.
	Effective health care delivery depends on a wide range of medical images, such as xrays, CT scans, microscopic slides, endoscopic views, dermatologic and surgical photos, and ultrasound scans. Manual and computer-based medical records ordinarily do not contain image data, leaving the physician to deal with a fragmented patient record scattered throughout the hospital. The Integrated Medical Imaging System developed by the Dept. of Veterans Affairs (VA) makes multi-specialty medical images available directly to clinicians as an integrated component of the computerized patient record. Radiology images are directly acquired from instruments via standard DICOM interfaces and can be interpreted using diagnostic quality reading workstations. This means that a hospital can operate without xray film (filmless radiology). Images can also be captured by clinicians during medical procedures. Diagnostic quality reading workstations are available for radiologists and clinical workstations are located in clinical care areas throughout the hospital. This innovative system integrates inexpensive off-the-shelf hardware (workstations, servers, networks, image capture hardware, cameras, scanners, and optical disk storage technology) with an existing hospital information system to improve service to patients, simplify information retrieval procedures, and improve communications among clinicians. Specific technical accomplishments include: development of windows-based, low cost, high resolution imaging workstations suitable for use by clinicians throughout VA hospitals development of high-resolution diagnostic quality radiology workstations for reading studies capability to capture and display the full range of medical images in an integrated manner integration and networking of these workstations into the VA's existing hospital information system (VistA) and wide area network. support for medical consultants to examine images originating at another medical center as part of the online patient multimedia record using the V.A.âs wide area network. As a result of these accomplishments, comprehensive data including both images and text can be effectively examined by hospital physicians without film or paper. System benefits to care providers and patients include: it improves the quality of patient care by providing all patient data it reduces the possibility of error based on lack of data or nonstandard terminology used to describe images; it increases communication among clinicians, improving continuity of care when multiple specialists are involved its reduces physician time spent searching for data; it aids patients in understanding their problems; it allows consultation with physicians at other sites; it assists in physician education; it may ultimately change the patterns of medical practice; it reduces costs by avoiding film printing
	The VAâs Integrated Medical Imaging System has proved extremely helpful to the clinicians it was designed to help. Physicians using the system have suggested new applications and a wider variety of data to be handled. It is used routinely when physicians meet together to discuss patients' diagnoses and plan their treatment courses. One physician user said "There's not a single GI case we do these days without the Imaging System. It makes a tremendous difference. We know what's there, like the tumor size. We can plan the operation. We can decide not to operate if it's a marginal case." The system allows easy, rapid and immediate storage of image information, often at the time of the procedure. This is important in saving physicians time and also because a patient's lesions may disappear or change quickly. Images are continuously available to multiple users at a time. The system makes communication between physicians more objective. Clinicians say "images provide more and better information than reports because it is so difficult to describe visual images in written form." A picture really is worth more than a thousand words. Radiologists get more information from an xray or CT scan because they can manipulate it to enhance different structures. Some find they tire less quickly reading from a workstation. Others feel more confident about their interpretations. Because of the enhancement capabilities, studies can be read that would require another exposure of the patient if film were used. The system helps VA physicians provide better care for their patients because decisions are based on a more complete picture of the patientâs condition. The need to repeat procedures is greatly reduced. Images can be viewed simultaneously for treatment reviews and conferences. Images are available for immediate viewing at times when patient decisions must be made rapidly. Second opinions and consultations by physicians at other sites will soon be possible using transmitted images and text. Physicians are better trained because the system's images provide a form of online continuing medical education. The VA's state-of-the-art information technology makes it easier to recruit good physicians. In addition, the system can be used to show patients their condition and allow them to make a better decision regarding their own treatment.
	The Medical Imaging System was created to meet the needs of physicians in treating patients. All hospitals currently have an unsolved problem of handling the many and varied images used in patient care. These are stored in many forms, including xray films, glass microscopic slides, and video tapes, which are bulky, exist in only one copy and often suffer loss or deterioration. Treating physicians need comprehensive patient data including images and text to provide patients with high quality care. Information must be delivered in a user-friendly, straight-forward and simple-to-learn manner so that clinicians can get their data quickly without losing valuable patient-care time. This project combined existing information technologies to meet these needs with an emphasis on integration of functionality. Prior to the initiation of this project, imaging systems were separate from database systems. Text and images were very different types of data with different technical needs in terms of management. Imaging technology and hospital information system (HIS) software technology were integrated by this project, for the first time. This combination provided far more functionality than the components could separately. The availability of information technology, advances in workstation displays, network capability, and mass storage devices were critical to the development of this application. The VAâs integrated imaging system has had an impact on the work patterns and thinking processes of physicians and has attracted worldwide recognition. In the past, clinicians have tended to be reluctant to use information technology. The VAâs Integrated Imaging System is so clearly beneficial to medical care that it has overcome the traditional reluctance on the part of physicians to use computers. The availability of images combined with report data meets a need and has made them eager to use the technology. Information resource staff at V.A. medical centers also recognize the potential impact on medical care and have shown enormous enthusiasm and dedication in the setting up equipment for their users. They know that this system integrates with their existing information technology and will fit with the VA care providers way of doing business. The integrated imaging system helps break down barriers between medical specialties by making all images available to every clinician, regardless of specialty. Recently, healthcare reform has emphasized the increased use of primary care providers. The integrated imaging system enables these providers by giving them access to all data needed to treat their patients. The technology also breaks down distance barriers because all patient information is available to the provider, independent of their physical location
	The Imaging System involves both technical innovations in hospital information systems and innovations in the way physicians handle and view their patients' data. The VAâs Integrated Medical Imaging System was the first of its kind and is still unique in the world because: the integrated system has routinely handled a wide variety of digitized medical images used by all medical specialties and has been operational for seven years; Image data management and communication capabilities are available within an existing hospital information system; the system has been expanded to meet the needs of radiology departments in reading and managing xrays, CT and MR scans, and other radiology images in a filmless environment Use of DICOM to communicate between HIS/RIS and image producing devices or PACS systems and obtain all radiology images the system is designed for use by treating physicians and allows interactive communication of images among all users; Incorporation of wide variety of types of images from all medical specialties Availability of all electrocardiograms in integrated fashion Ability to access online multimedia medical record over wide area network all images are available at workstations throughout the hospital Availability of both clinical viewing stations and diagnostic quality radiology reading workstations *First large-scale capturing of non-radiology images, performed by clinicians This application was originally based on the need to store images in a database management system so they could be easily retrieved for image analysis. A prototype system was developed in 1988 by Dr. Ruth Dayhoff, a physician with computer experience, and shown at various scientific meetings. Daniel Maloney and Dr. Ross Fletcher of the VA recognized immediate uses for this integrated technology for patient care. In 1989, with the help of Dr. Barclay Shepard, funding was obtained for a feasibility study to demonstrate that a workstation could be designed to integrate with the VA's hospital information system, accessing both shared text and images from central servers. The working prototype including workstation and servers was demonstrated to a wide range of individuals within the VA. A group of perceptive physicians in the VA's central office saw the potential benefits of the system and provided funding to install the system in a prototype site, the Washington DC VA Medical Center. Mr. Timothy Williams, Director of the Washington DC VA Medical Center, enthusiastically supported the project. It was recognized that many additional benefits of such a new technology would become apparent when the system was put into practice and users could assess its use in practice. In 1990, Peter Kuzmak and Avi Sadan joined the project staff. In 1993, in collaboration with Dr. Eliot Siegel, the system was installed in a second hospital, the Baltimore VA Medical Center where it interfaces to a commercial radiology image storage system, and provides radiology and other images to clinicians working in a "filmless" environment. In 1995, Gerald Perry at the Wilmington VA Medical Center recognized the systemâs potential to meet the needs of the radiology department for image management. Additional funding was provided to develop basic capabilities for radiology that would complement the existing system. Mr. Peter Kuzmak recognized the potential of the DICOM standard in the acquisition of images, and has been working since 1995 to integrate DICOM capabilities with the VAâs hospital information system. Since October 1997, the Wilmington VAâs radiology department is acquiring all computed radiography, CT, angiography, and ultrasound images digitally using DICOM interfaces and studies are being read on diagnostic quality workstations. There is enormous interest within the VA in DICOM interfaces to pass patient information to radiology systems and to acquire images for display on workstations within the hospital.
	The project is exceeding its original goals of providing images to clinicians as radiology image management capabilities are added. The Imaging System has been operational at the Washington DC VA Medical Center for almost seven years. Additional capabilities continue to be added as clinicians suggest new desirable functionality. The latest addition is digital radiology image acquisition and filmless reading. The system has been received with enthusiasm by its users beyond our highest expectations. This has been seen in three groups of people: clinicians, regular hospital staff, and administration. There have been industry-wide problems getting clinicians to use medical information systems, and we are interested in the reasons for this high level of acceptance of the Imaging System. One suggestion is that a portion of the medical thought process has a visual basis. Patient diagnosis and treatment involves localization of the patients problem, often using anatomic knowledge models. This process is aided through visual data; textual descriptions, which are forced by current record-keeping methods, may be counterproductive. Regular staff at V.A. medical centers also recognize the potential impact on medical care and have shown enormous enthusiasm and dedication in the setting up equipment for their users. They know that this system integrates with their existing information technology and will fit with the VA care providers way of doing business. Administrators tend to be more hesitant to accept new technology until its benefits are proven. They have responded to the enthusiastic reports from clinical users of system benefits in patient care and in provider satisfaction. They are also looking for technology which will allow them to reduce staffing and costs without negative impact on patient care. Currently the patients, clinicians, and staff at about ten V.A. medical centers benefit from the system. The future beneficiaries of the technological advancements of the Integrated Imaging System are the other 160 VA medical centers where the VistA hospital information system is currently installed. Secondary beneficiaries will include the Indian Health Service and Dept. of Defense hospitals and other facilities worldwide that use derivatives of the VA's hospital information system software. The concepts pioneered by this project and the innovative approaches for integration of state-of-the-art technology are applicable to projects in other institutions for integrated storage and retrieval of image, text and other multimedia data. This project has contributed to the state-of-the-art of image storage systems, and attracts a steady stream of visitors from around the world. Because of targeted use of appropriate technology, system development has been rapid. It was described by an individual doing a review of imaging systems as a "10-year project" accomplished in 2 and 1/2 years. At a recent scientific meeting, it was noted by a well-known session chair that others have been talking about building this sort of a system for a long time; the VA has already installed it and gathered data that will be useful to others. The system has the potential to change the practice of medicine, especially in its current "cost control" environment. It allows physicians to be involved in all aspects of the patient's care; a goal which has become more and more difficult due to specialization. Users say it "improves a physician's sense of dealing with the whole patient as a person" and "having the images available during rounds brings the patient back into medicine." They say the "Imaging System makes you more cautious. It makes you a better doctor... You can see what really was going on." Another user said that "Suddenly, the practice of medicine has become as exciting as it was when I was a medical student looking at pictures in books. The availability of electrocardiograms in the emergency room means that it can be quickly determined whether chest pain is due to new cardiac conditions. As a result, fewer patients need to be admitted to the hospital. A resident at the Wilmington VA hospital commented that he had sent a patient with an injured foot to have an xray done. He was able to see the resulting images in his office before the patient had returned. He was ready to prescribe a course of treatment and had the splint prepared by the time the patient returned. The teleconsultation capability will allow specialists to contribute to patient care who would not otherwise be available because of their distant location. Future plans for the system include (1) installation at all VA medical centers, (2) further development and implementation of the remote teleconsultation capability, (3) inclusion of additional data types (e.g.audio data, motion video). There is enormous interest within the VA in DICOM interfaces to pass patient information to radiology systems and to acquire images for display on workstations within the hospital. DICOM is a cornerstone in the ability to integrate imaging functionality into the Healthcare Enterprise. The use of DICOM has the potential to reduce costs by allowing open systems solutions consisting of in-house and commercial multi-vendor offerings. It reduces costs within the individual hospital be eliminating duplicate efforts.
	The Imaging System design required comprehensive analysis of the needs of the VA and imagination in devising a solution. Most people thought of images and text as fundamentally different data. Until the imaging system was developed, no one clearly saw the need. In particular, software developers did not recognize the importance of images to medical care. Medical users did not recognize the possibilities for creating a system that integrated both text and image data. The Integrated Medical Imaging project has treated images as a new data type, and added them to the VA's existing hospital database management system. The images are directly indexed by the text data that is entered anyway. There is no duplication of effort, and the text and image data becomes automatically associated. In addition to recognition of agency needs and imaginative use of emerging technologies to meet those needs, the development of the prototype image workstation network required a full range of technical abilities to integrate the various different parts of the prototype. The project required the writing of software to address the image handling hardware, the interfacing of programs written in different languages, and the selection and optimal utilization of compatible networking software. The software and languages used for image handling are normally very different from those used for hospital information systems. Finally, the DICOM standard is complex and required the selection of the optimal software and hardware environment for development. The standard is new and in some areas untested, and the VA contributed by identifying specifics that needed to be added or modified. The components used in the project were all at the cutting edge of technological development, which means problems were uncovered that others had not yet solved, requiring ingenuity and perseverance. Project development required a team of individuals with a variety of backgrounds. Medical credibility of the project was critical to physician acceptance. Design and development required both physicians and biomedical engineers, all with backgrounds in information systems. Installation, support and user training required technical staff with medical backgrounds and experience in medical operational system support. In medical care, reliability of data and systems are critical and demand a much higher level of response than has been previously found with administrative computer systems. The Project has received support at all levels, however support does not always translate to funding. The project staff is small, and at this time is only six people. Funding has been on a year to year basis which makes research work difficult because a considerable effort must be expended each year to obtain the next year's funding. Downsizing and reorganization makes it more difficult to complete complex projects. Decentralized decision making that is a part of reinventing government means there are more organizational components to communicate with. Hardware was required to be low cost and standardized. The project team had to adapt the project design to the hardware available and take advantage of hardware breakthroughs as they occurred. VA funding is limited, but the overall effect is that the system is much less expensive than projected. In the same way that it is difficult to describe medical images in words, it is difficult to describe this system verbally. In convincing people of the system's potential, it was necessary to demonstrate the system to them. Initially, we created a video tape so we could show the system in actual use. More recently, communication has been done with system demonstrations, site visits, and newer screen capture software technology.