Challenges of Automating Radiology with an Open Source Solution

Webinar: http://www.medsphere.com/infinite/Voice: (888) 346-3950Participant code: 1302465

Challenges of Automating Radiology with an Open Source Solution

November 2008 Community Call

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Presenters

� Ben Mehling

� Kathy English

� Janine Powell

� Loyd Bittle

� Adam Waterbury

� Jon Tai

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Agenda

�OpenVista’s Capabilities today– Radiology Worklist

– Autofax Introduction

– Autofax: Under the Hood

�OpenVista’s Radiology challenges

� Introduction to PACS

� VistA Imaging

�Market need

� Today’s VA progress with VistA Imaging

� Community Discussion

�Medsphere.org Tip of the Month

Radiology Automation with OpenVista in the Non VA Market

VistA Imaging/PACS for OpenVista®

Prepared by Kathy Doub-English, VP Product Management

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OpenVista Imaging Today

� VistA Radiology Information System

� Inbound image interface (document or picture) – from third party software to a CPRS

and CIS note & the demographic patient banner (.jpg, .png, .bmp, .tif, .pdf)

� Upload of images – from a file on the local computer or

network to a CPRS note or the demographic patient banner (. jpg, .png, .bmp, .tif, .pdf)

� Integration with commercial PACS/Radiology vendors (GE, Kodak) has been delivered– outbound orders and accessioning– Inbound transcribed result– Link (url) to the specific patient

study through the PACs image viewing software to view the image from CPRS’ orders and reports tab

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OpenVista PACS Interface

OpenVistaDatabase

CIS/CPOE OV Radiology

Mirth

RAD Work-List

PACS

ADT

Orders/Exam Status/Results

URL Link to Image

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Outgoing Messages to PACs

� Registration– A message is sent to the PACs system whenever a patient

is registered in the OpenVista radiology system. This registration creates the Case number which is sent to the PACS in an OBR message

� Examined/Images Collected– The OpenVista software allows the site to determine the

exam status that will trigger an update message. This is frequently done when the patient reaches the “examined”status but can occur at other statuses

� Cancellation/Deletion– If an exam is cancelled or deleted in the OpenVista

software, the cancel message can be broadcast.

� Verified/Released Report– The report message is triggered when data is entered into

the findings that causes the report to move to a “verified”(final) or Released/Unverified (preliminary) status. Sites can determine if Released/Unverified status is allowed.

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OpenVista Imaging Today

� Automated faxing of result to one or more physician offices using an open source technology named Hylafax

� Radiology Worklist and tracking board depicting department workflow & workload in real time

Radiology Work ListOverview by Adam Waterbury

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� Dashboard View of Radiology Workload

� Configurable– System Level

� Status Display

�Number of Days For Status To Display

– User Level

�Columns Are Re-orderable and Re-sizeable

�Columns Are Sortable

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� CIS Platform

�Utilizes OpenVista Security

– Display Based on Access ID and Patient Image Type

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� Features– Auto Refreshing

– At-A-Glance View Of Workload

– Customizable To Match Work Flow

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� Benefits– Eliminates Need To Run and Print Status Reports

– Up To The Minute Information

– Can Be Run Remotely

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� Beta– Completed

– 30 Day Beta At Century City Doctors Hospital

– Is Now GA

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� Phase II– Visual Indication Of Stat Orders

– Inpatient/Outpatient Indicator

– Ability To Select Patient

�Opens Terminal Emulator

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Auto Fax IntroductionOverview by Adam Waterbury

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Auto Fax

� Automatically faxes verified laboratory results to ordering physicians

� Faxes all Inpatient and Outpatient Results

� Automatically faxes completed signed radiology results to all physicians on the patient record

� Physicians who wish to receive faxes must be set up in advance

� Physicians must be active users in the system and have ordering capabilities

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Requirements

� Scalable and Flexible – One solution for all sites

– Can be used by other systems

� Low Cost– Open source solution preferred

�HIPAA Compliant– No ‘on the fly’ faxing

– Uses OpenVista security

– Customizable coversheet

– Secure displays

– Log of what information was sent where, when and by who

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Auto Fax Work Flow

HylaFAXServer

CIS

Lab

ModuleRadiologyModule

OpenVista

Fax1

Fax2

Fax3

Fax4

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Auto Fax Server

�Offered by iFAX, provided by Dell

� Tower, 1U and 2U configurations

� Port sizes range from 2, 4 or 8 ports

� Turnkey systems

– CentOS

– HylaFAX Open Source

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Product Features

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Auto Fax Features

�No additional steps for technicians

�HIPAA compliant

�Web based interface

– Controls the Auto Fax server

– Faxes can be resent, failed faxes resolved, server rebooted, and provides system state

– Uses OpenVista security module

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Auto Fax Console

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Auto Fax Queue Management

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Beta Testing

�Midland Memorial Hospital

– Completed

– Laboratory Package

– 28 docs

– 275 per week

�Memorial Hospital Sweet Water County

– In Beta

– Radiology Package

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Benefits

�Reduced Turn Around Time

– Physicians receive results faster

� Saves Paper

– No printing of results to fax

� 275 * 1 minute = 4.5 Hours a week

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Phase II

� Batch Faxing By Physician

� Patient Type Parameter By Physician

– Location inclusion exclusion

� Fax on demand

– The ability to override the phone number

� Anatomic Pathology Reports

�Rx Orders

� Coversheet Option By Physician

� Automated Transmission Report

Autofax: Under the Hood

Jon Tai

Design Goals

� We tried to design a solution that would...

– Support both Windows and Linux OpenVista deployments

– Leverage as many existing Open Source components as possible

– Only require “regular” off-the-shelf hardware

�Our expertise is in OpenVista, not hardware

– Be easy to maintain

�Beyond the initial setup, the impact to the IT department should be minimal

– Allow lab/rad techs to manage fax queue themselves

� The user interface should be user-friendly

– Scale

� Solution should work for small and large facilities

– Be HIPAA compliant

Architecture

� Hooks in OpenVista trigger faxes

� Faxing handled by a separate machine, the “Fax Appliance”

– Appliance acts as a network (JetDirect) printer

– OpenVista prints reports to be faxed to the appliance

� Report contains XML metadata

– Fax number, physician name, priority, etc.

� If Appliance cannot be reached, the OS printing mechanism on theOpenVista server queues the print job

– No data is kept on the fax appliance except for the outgoing faxqueue

– Allows flexibility and scalability

� Does not matter what OS OpenVista is running on, as long as it can print to a network printer

� Can add additional fax appliances if fax volume increases

� Appliance provides a web interface for end users to view fax queues

Fax Appliance Software

� CentOS 5

� HylaFAX 4.4.4

� xinetd

– Listens on port 9100 (JetDirect port)�

– Calls custom Python script that parses XML metadata out of the incoming report from OpenVista and submits the report to HylaFAX

� Apache / mod_php

– Custom web interface written in PHP

� Authenticates users using OpenVista RPC broker

– Secondary Menu Option controls access, much like CPRS

� Directly inspects HylaFAX queues on disk

– Presents faxes by status - outgoing, sent, failed

� Can be configured to allow end users to view fax contents

– PostScript to PNG conversion uses ImageMagick

Architecture Diagram

PhoneNetwork

Lab

Rad

OpenVista Server

OSPrint

Queue

xinetd+

pythonscript

HylaFAX

Modem

Modem

RPC Broker Web Interface

Fax Appliance

Fax Appliance Hardware

� Modem: Mainpine IQ Express

– PCI Express

– Supported under Linux >= 2.4 and Windows >= 2000

– 1, 2, 4, and 8-port configurations

– Scalable and relatively inexpensive

� Test hardware: HP desktop PC

– Used for internal development

– 2-port IQ Express

� Production hardware: 1-2U Dell PowerEdge servers

– Hardware is purchased from iFax Solutions, Inc.

�CentOS and HylaFAX pre-installed and supported by iFAX

– Exact hardware and number of modem ports depend on anticipated fax volume

Fax Appliance Hardware

� Example Configurations

– Dell PowerEdge R200 with a 2-port modem

� Planned fax volume: 200 faxes per day

– Dell PowerEdge 2950 with a 4-port modem

� Planned fax volume: 300 faxes per day

� Testing under ideal conditions, we were able to send about 66 faxes per hour on one phone line

– No busy signals

� You should do your own estimates based on

– Number of hours during the day that you can send faxes

– Average number of pages per fax

– Receiving modem speeds

– Anticipated percentage of busy signals

XML Metadata Format

<fax>

<from>Medsphere Hospital</from>

<from-fax-number></from-fax-number>

<from-voice-number></from-voice-number>

<to>TAI,JONATHAN</to>

<to-fax-number>17605556789</to-fax-number>

<to-voice-number></to-voice-number>

<priority>63</priority>

<regarding>Laboratory Results</regarding>

<comments>MRN: 12345</comments>

</fax>

� JetDirect protocol doesn't allow sending out-of-band metadata, so this XML is included in the body of the report and is stripped out before submitting to HylaFAX

XML Metadata Format

<fax>

<from>Medsphere Hospital</from>

<from-fax-number></from-fax-number>

<from-voice-number></from-voice-number>

<to>TAI,JONATHAN</to>

<to-fax-number>17605556789</to-fax-number>

<to-voice-number></to-voice-number>

<priority>63</priority>

<regarding>Laboratory Results</regarding>

<comments>MRN: 12345</comments>

</fax>

� Passed to HylaFAX using sendfax -d flag

– Required; sendfax won't accept faxes without the -d argument

XML Metadata Format

<fax>

<from>Medsphere Hospital</from>

<from-fax-number></from-fax-number>

<from-voice-number></from-voice-number>

<to>TAI,JONATHAN</to>

<to-fax-number>17605556789</to-fax-number>

<to-voice-number></to-voice-number>

<priority>63</priority>

<regarding>Laboratory Results</regarding>

<comments>MRN: 12345</comments>

</fax>

� Passed to HylaFAX using sendfax -P argument

– 63 means “high” priority; 127 means “normal” priority

– HylaFAX adjusts priority after failed fax attempts

XML Metadata Format

<fax>

<from>Medsphere Hospital</from>

<from-fax-number></from-fax-number>

<from-voice-number></from-voice-number>

<to>TAI,JONATHAN</to>

<to-fax-number>17605556789</to-fax-number>

<to-voice-number></to-voice-number>

<priority>63</priority>

<regarding>Laboratory Results</regarding>

<comments>MRN: 12345</comments>

</fax>

� Used to generate cover sheet

– From/to fax/voice numbers are configured in OpenVista

XML Metadata Format

<fax>

<from>Medsphere Hospital</from>

<from-fax-number></from-fax-number>

<from-voice-number></from-voice-number>

<to>TAI,JONATHAN</to>

<to-fax-number>17605556789</to-fax-number>

<to-voice-number></to-voice-number>

<priority>63</priority>

<regarding>Laboratory Results</regarding>

<comments>MRN: 12345</comments>

</fax>

� Shown in web interface to help lab/rad techs identify faxes

HylaFAX Configuration Considerations

� Options to accommodate the web frontend

– JobFmt: "%-9j %3I %3i %1a %5P %5D %-96.96s %-14.14e"

� Fixed-width fields are more easily parsed

� Include more information about the job

– Append “:14” to lines in hosts.hfaxd

� Forces spool files to be written with group id = 14 (uucp) so that web interface can read them

�Requires that you add apache to the uucp group

� If your appliance needs to dial a prefix to reach the outside

– ModemDialCmd: ATDT9,%s

�Dials “9”, then pauses before dialing the number given by OpenVista

Additional Considerations

� If your OpenVista server runs Linux, it should be technically possible to run everything on one server

– May be good for small deployments

– Lose some performance/scalability/flexibility

�OpenVista OS must be Linux

– HylaFAX only runs on Linux

�Cannot scale as easily

�Hardware platform must support your modem

� The web frontend is optional

– If your end users don't need it, you don't have to run it

– You can use the regular HylaFAX commands to manage your queues

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OpenVista Gap Today

� Acquisition of static & multimedia images through DICOM

� Ability to review, manipulate and drill into images with direct access within OpenVista product line

� Modality integration and Worklists

� Storage solution for images (Jukebox, SAN, etc.)

� Load balancing of work across Radiologists

� Results inbound from medical devices to clinical procedures (Will be delivered with clinical flowsheet initiative using HL7 for cardiac monitors, ventilators)

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What is PACS?

� In medical imaging, picture archiving and communication systems (PACS) are computers or networks dedicated to the storage, retrieval, distribution and presentation of images. The medical images are stored in an independent format. The most common format for image storage is DICOM (Digital Imaging and Communications in Medicine).

� Most PACS handle images from various medical imaging instruments, including ultrasound, magnetic resonance, PET, computed tomography, endoscopy, mammograms, etc.

http://en.wikipedia.org/wiki/Picture_archiving_and_communication_system

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VistA Imaging

� Goal: To facilitate medical decision-making by delivering complete multimedia patient information to the clinician's desktop in an integrated manner (Cardiology, Radiology, Ophthalmology, Pathology, GI, Pulmonary, Hematology, etc…)

� Modules:– Clinical Display Station – Standalone GUI application for the clinical user

outside of Radiology to view & manipulate static & multimedia images– VistA Rad – Standalone GUI application integrated to VistA Radiology for

use by the technicians and Radiologists for image review & manipulation, worklist management & capturing of diagnostic interpretation

– Core Infrastructure – Set of background clustered Windows Servers (Caché) with a proprietary HSM communicating to an optical jukebox

– DICOM Gateways� Acquisition Gateway - waveforms/images from machines to GUI

applications� Text Gateway – data to and from machines to applications support

ADT, demographic data acquisition and modality worklists � Routing Processor – Routes data within and external to a facility with

associated rules to determine who would interpret a study (load balancing). Picks up where DICOM leaves off

– Telereader – Originated in ophthalmology supporting a teleradiology concept for non-radiology departments (remote access to images and multimedia)

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Medical Imaging and PACS Market

� Medsphere community hospital customers are asking for an open source solution to view, manipulate and interpret Radiology Images and support modality worklists

� Medsphere prospects are asking for Medical Imaging and Picture Archiving and Communication System (PACS) automation

� The United States has more than 60% of the acute care hospitals using PACS systems today

� Access to the complete medical record from the point of care provides real time informed decision making which leads to care transformation

� Other points?

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Initial Findings

� In 2006, VistA Imaging was not ready for the commercial market for the following reasons:

– There was a dependency on two proprietary software components that were no longer available for purchase or distribution

�DSM: acquired by Intersystems

� Accusoft: older version of commercial toolkit no longer available for purchase. VistA Imaging is dependentupon this for compiling and distribution

– Strategy for posting to FOIA related to FDA requirements was not fully vetted

– VistA Imaging was in the early deployment phases of its evolution and was not well proven

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Today’s Progress

� Proprietary Software Dependency– DSM has been moved to Caché on a Windows Server platform eliminating

the dependency on a no longer available Mumps server.– The VA has rewritten the software to eliminate the dependency on Accusoft

� Patch 72 which was due to be ready 9/15/2008 for VA deployment� FOIA postings have followed as much as one year later than the

availability

� Strategy for posting to FOIA related to FDA requirements has been determined– Anyone that requests VistA Imaging through the FOIA channels (formal

written request & $15.00) will be reported to the FDA– The FOIA software is distributed as source code and must be compiled by

those intending to install and distribute– Use intent will determine FDA regulatory requirements for the providing

vendor� Document images only: no FDA requirement� 2 Dimensional image review without Mammography: Class I device

with less rigid certification process and follow on reporting and, in some cases requires 510K premarket notification

� 3 Dimensional image view with Mammography: Requires certification as a Class II device with 510K premarket notification and 2 yearreviews for design review and validation of safe use under GMP

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Community Discussion

� Is there a need to incorporate VistA Imaging into an open source solution?

� Has anyone had any experience with FDA registration in an open source manner?

� Should Medsphere sponsor the FDA certification for the community? If so why?

Medsphere.org Tip of the Month

Jon Tai

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