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VistA Integrated Medical Imaging System
Imaging Project, Technical Services, Department of Veteran Affairs
Silver Springs, MD

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.‚s 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

*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
The VA‚s 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 patient‚s 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 VA‚s 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 VA‚s 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
The Imaging System involves both technical innovations in hospital
information systems and innovations in the way physicians handle and
view their patients' data. The VA‚s 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 system‚s 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 VA‚s
hospital information system. Since October 1997, the Wilmington VA‚s
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 ( 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