DICOM for the Clinical Specialties

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DICOM for the Clinical Specialties

• Peter Kuzmak
• Dr. Ruth Dayhoff

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Overview

• Applying IHE workflow to CPRS Consults
• Consult DICOM workflow details
• Clinical Specialties using DICOM
• Unread Study List and TeleReader
• Example Diabetic Retinopathy Surveillance
• Configuration
• Hands-on Interactive Session

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• In 1999, IHE Radiology defined the workflow for
  how image acquisition modalities interface to
  PACS.
• However, nothing was said about the Clinical
  Specialties. We decided to do something about
  that.

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DICOM for Clinical Specialties

• Interface CPRS Consult Request Tracking to DICOM
  image acquisition devices used in the
  non-radiology clinical specialties
• Dentistry
• Eye Care
• Endoscopy
• Dermatology
• Pathology

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IHE Image Acquisition Workflow
Picture Archiving Communication System
Imaging Modality
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Workflow in Clinical Specialties

• Consult Ordered
• Schedule Appointment
• Patient Arrives
• Images Acquired
• Patient Leaves
• Diagnostic Reporting
• May be done with Step 4.
• Follow up Visits

369x359 24-bit
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Workflow Messages
Order entered for a Consult or Procedure
CPRS Order Entry
VistA Appointment Management
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Workflow Messages
Order entered for a Consult or Procedure
CPRS Order Entry
VistA Appointment Management
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Workflow Messages
Order signed
CPRS Order Entry
VistA Appointment Management
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Workflow Messages
Message sent to DICOM Gateway
CPRS Order Entry
VistA Appointment Management
DICOM Gateway
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Workflow Messages
CPRS Order Entry
VistA Appointment Management
DICOM Gateway
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Workflow Messages
Patient scheduled for appointment
CPRS Consult Request Tracking
VistA Appointment Management
DICOM Gateway
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Workflow Messages
Patient scheduled for appointment
CPRS Consult Request Tracking
VistA Appointment Management
DICOM Gateway
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Workflow Messages
Message sent to DICOM Gateway
CPRS Consult Request Tracking
VistA Appointment Management
DICOM Gateway
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Workflow Messages
Patient arrives at image acquisition modality
CPRS Consult Request Tracking
DICOM Gateway
Imaging Modality
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Workflow Messages
Modality obtains patient demographics and study
info
CPRS Consult Request Tracking
DICOM Gateway
Imaging Modality
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Workflow Messages
Image acquired, sent to VistA
CPRS Consult Request Tracking
DICOM Gateway
Imaging Modality
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Workflow Messages
Consult put on Unread Study List
CPRS Consult Request Tracking
DICOM Gateway
Imaging Modality
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Workflow Messages
Image acquired, sent to VistA
CPRS Consult Request Tracking
DICOM Gateway
Imaging Modality
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Workflow Messages
Images verified on VistA
CPRS Consult Request Tracking
DICOM Gateway
Imaging Modality
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Workflow Messages
Patient leaves image acquisition modality
CPRS Consult Request Tracking
DICOM Gateway
Imaging Modality
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Workflow Messages
Images diagnosed on VistA (TeleReader used)
CPRS Consult Request Tracking
DICOM Gateway
Imaging Modality
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Workflow Messages
Images diagnosed on VistA (TeleReader used)
CPRS Consult Request Tracking
DICOM Gateway
Imaging Modality
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Workflow Messages
Images diagnosed on VistA (TeleReader used)
CPRS Consult Request Tracking
DICOM Gateway
Imaging Modality
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Workflow Messages
Images diagnosed on VistA (TeleReader used)
CPRS Consult Request Tracking
DICOM Gateway
Imaging Modality
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Workflow Messages
Report is entered
CPRS Consult Request Tracking
DICOM Gateway
Imaging Modality
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Workflow Messages
Consult removed from Unread Study List
CPRS Consult Request Tracking
DICOM Gateway
Imaging Modality
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Workflow Messages
Image icon appears on CPRS note
CPRS Consult Request Tracking
Image icon on CPRS note
DICOM Gateway
Imaging Modality
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Workflow Messages
Message sent to DICOM Gateway
CPRS Consult Request Tracking
Image icon on CPRS note
DICOM Gateway
Imaging Modality
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Workflow Messages
Request Complete
CPRS Consult Request Tracking
DICOM Gateway
Imaging Modality
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Workflow Messages
Request Complete
CPRS Consult Request Tracking
DICOM Gateway
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Workflow Messages
Request Complete
CPRS Consult Request Tracking
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Clinical Specialties using DICOM

• Dentistry
• Prior to 2001, dental IODs CDs existed, but no
  networking
• VA wanted dental IODs with MWL Storage
  networking
• March, 2001 VA Moratorium
• August, 2001 1st demonstration of MWL Storage
  for Dentistry
• ADA has picked up the effort since then
• Eye Care
• Initially no Ophthalmology specification in DICOM
• 2002 VA encouraged AAO develop new
  specification
• 2004 Ophthalmic Photography Image DICOM
  Supplement 91
• 2005 IHE Eye Care
• 2007 VA national Diabetic Retinopathy
  Surveillance program
• Future other specialties
• Pathology 2006 IHE Pathology
• Endoscopy 2006 IHE Japan Endoscopy
• Dermatology 2007 American Telemedicine
  Association endorsement

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Dentistry
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Dentistry
1024x1536 8-bits
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Dentistry
Cephalometric Image 2500 x 2024 16-bits
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Dentistry
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Eye Care
Slit Lamp Image 900x1166 24-bit
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Eye Care
Fundus Image 3072x2048 24-bit
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Eye Care
Fundus Image 3072x2048 24-bit
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Eye Care
Fluorescein angiography 1108x1016 8-bit
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Eye Care
Optical Coherent Tomography
Visual Field
DICOM Encapsulated PDF
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Pathology
Microscopic Slide 1520 x 1144 24-bit
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Endoscopy
1024x768 24-bit
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Dermatology
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TeleReader Application

• Used by doctors to identify and navigate to
  imaging consult studies that need to be read
• Generic application for all clinical specialties
  that supports both local and remote IFC imaging
  consults
• Can work over WAN - reading sites can handle
  multiple remote acquisition sites

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Topology of Remote Reading
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Reading Site

• Each acquisition site maintains its own list of
  studies to be read
• Doctor at reading site launches TeleReader
  application
• Doctor selects acquisition sites, specialties and
  procedures from a list of studies waiting to be
  read

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Selecting Acquisition Sites, Specialties, and
Procedures
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Reading Site

• Reading sites access Unread Study Lists at the
  reading sites
• TeleReader software retrieves the appropriate
  Unread Study Lists from the specified acquisition
  sites

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Unread Study List
Needs new list
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Selecting a Study
Needs new list
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CPRS/Clinical Display Launched

• CPRS and Clinical Display are automatically
  launched for the selected patient
• CCOW User Context synchronization
• CCOW Patient Context synchronization
• Study is locked while being read
• Remote Image View provides access to images at
  remote acquisition sites

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CPRS/VistA Imaging Display
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Interpretation Software

• Doctor reads images and enter results
• Full CPRS result entry capabilities are available
• IFC for remote reading
• Templates for structured result entry
• Completing the consult moves the study from the
  Unread Study List to the Read Study List

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Reading Resulting
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National Diabetic Retinopathy Surveillance Project

• Diabetic Retinopathy is leading cause of
  blindness in U.S.
• The leading cause of blindness in working-age
  population in the U.S.
• Treatable if detected at early stage
• Recommend annual retinal screening
• 750,000 diabetic veteran patients need an annual
  exam

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Image Acquisition
A skilled imager, a non-dilated patient, a 15
minute procedure
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Reading Site
Reading images acquired at a remote site.
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Retinal Images
Mild diabetic retinopathy
Image of a healthy retina
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Retinal Images
Frequently, ocular maladies are found needing
treatment.
Patients are often unaware of problems.
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Project Rollout (FY2007)

• Software field test 10/06 3/07
• Simultaneous training of imagers and installation
  of equipment
• 159 Retinal Camera Acquisition Sites
• 58 Reading Sites
• 37,236 studies read during this 6 month period
• Estimate 75,000 patients will be seen first year

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DICOM Configuration
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TeleReader Configuration
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Hands-on Interactive Session (1/4)
Overview

• Student places a CPRS Consult request for VeHU
  Imaging Consult Service
• Staff acquires DICOM images for study using a
  modality simulator
• Student verifies the images for their study
• Student uses TeleReader to lock a study, views
  the images,enters a result and completes consult
• Student displays completed consult with image
  attached to the result note

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Hands-on Interactive Session (2/4)
Ordering and Image Acquisition

• Start CPRS and Clinical Display
• Place a CPRS Consult request for VeHU Imaging
  Consult Service
• Staff acquires DICOM images for study using a
  modality simulator
• Use Clinical Display to view image for study
• Shut down CPRS and Clinical Display

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Hands-on Interactive Session (3/4)
TeleReader and Unread Study List

• Start TeleReader
• Display Unread Study List
• Lock/unlock some studies
• Can only lock unread studies
• Launches CPRS and Clinical Display
• Select/deselect Options - View All Studies
• Full list or only available studies are shown

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Hands-on Interactive Session (4/4)
TeleReader and Result Entry

• Lock an Unread study
• CPRS/Clinical Display should be directed to the
  patient
• Use Clinical Display and view images
• Use CPRS to enter result and complete consult
• Status should change to Resulted
• Study should now be on the Read List
• Use CPRS/VI to display image attached to TIU note
  under Consult tab

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Thank You!