Integrating Digital Imaging and Communications in Medicine (DICOM)-structured reporting into the hospital environment.

The Digital Imaging and Communications in Medicine (DICOM) Standards Committee has balloted and accepted a new class of objects dealing with the generation, distribution, and management of reports. The structured reporting (SR) objects bridge the traditional separation between imaging and information systems. The DICOM SR objects offer a higher level of integration of the medical enterprise, providing practitioners with an effective tool to cover all aspects of the medical process from admission to discharge. This report presents the technical challenges posed by integrating the concepts introduced by SR with a complete hospital information system (HIS).

Minimizing Digital Imaging and Communications in Medicine (DICOM) Modality Worklist patient/study selection errors.

Frequently when patient and study identification information (patient name, patient identification, date of birth, sex, and accession number) are manually entered at a modality, typographical errors occur that have to be corrected before the acquired images can be matched to the proper patient and study on a picture archiving and communication system (PACS). The Digital Imaging and Communication in Medicine (DICOM) Modality Worklist service alleviates these problems by automatically transferring this data from the radiology information system (RIS) to the image acquisition modality. The technologist then does not have to manually re-enter the data to place it into the image files. With modality worklist, precise patient and study data are obtained and placed into the image headers with no typographical errors. When the images are sent to the PACS, they match the corresponding patient and study records, and are immediately incorporated into the electronic patient record. While modality worklist does replace the manual keying of the data and virtually eliminates typographical problems, it introduces a new source of human error: the incorrect selection of the patient and/or study from the computerized worklist, and the resultant mislabeling of the images. When these mislabeled images are sent to the PACS, they are immediately associated with the wrong patient and/or study, where they potentially may cause serious harm. The goal of this report is to raise awareness to this problem, to identify the major causes of these errors, and to offer some practical suggestions on how to minimize them.

Challenges associated with interfacing computed tomography to a picture archiving and communication system at the Baltimore Veterans Affairs Medical Center--a historical perspective.

The interfacing of digital image acquisition modalities to the picture archiving and communication system (PACS) plays a major part in the conversion from a traditional film-based radiology practice to one that relies almost entirely on soft-copy reading. The Baltimore Veterans Affairs Medical Center (VAMC) is one of the first filmless hospitals in the world. Since 1993, it has used computed tomography (CT) scanners connected to a commercial PACS to provide digitized patient images for filmless reading. Over the years, the evolution of Digital Imaging and Communications in Medicine (DICOM) standards, advances in networking technologies, and enhancements in PACS and hospital information system (HIS) software have greatly improved this system's robustness and patient/study identification accuracy. The result has been a major increase in productivity.

The use of digital imaging and communications in medicine (DICOM) in the integration of imaging into the electronic patient record at the Department of Veterans Affairs.

The US Department of Veterans Affairs (VA) is using the Digital Imaging and Communications in Medicine (DICOM) standard to integrate image data objects from multiple systems for use across the health care enterprise. DICOM uses a structured representation of image data and a communication mechanism that allows the VA to easily acquire images from multiple sources and store them directly into the online patient record. The VA can obtain both radiology and nonradiology images using DICOM, and can display them on low-cost clinician's color workstations throughout the medical center. High-resolution gray-scale diagnostic-quality multimonitor workstations with specialized viewing software can be used for reading radiology images. The VA's DICOM capabilities can interface six different commercial picture archiving and communication systems (PACS) and more than 20 different image acquisition modalities. The VA is advancing its use of DICOM beyond radiology. New color imaging applications for gastrointestinal endoscopy and ophthalmology using DICOM are under development. These are the first DICOM offerings for the vendors, who are planning to support the recently passed DICOM Visible Light and Structured Reporting service classes. Implementing these in VistA is a challenge because of the different workflow and software support for these disciplines within the VA hospital information system (HIS) environment.

The VA's use of DICOM to integrate image data seamlessly into the online patient record.

The US Department of Veterans Affairs (VA) is using the Digital Imaging and Communications in Medicine (DICOM) standard to integrate image data objects from multiple systems for use across the healthcare enterprise. DICOM uses a structured representation of image data and a communication mechanism that allows the VA to easily acquire radiology images and store them directly into the online patient record. Images can then be displayed on low-cost clinician's workstations throughout the medical center. High-resolution diagnostic quality multi-monitor VistA workstations with specialized viewing software can be used for reading radiology images. Various image and study specific items from the DICOM data object are essential for the correct display of images. The VA's DICOM capabilities are now used to interface seven different commercial Picture Archiving and Communication Systems (PACS) and over twenty different radiology image acquisition modalities.

Providing a complete online multimedia patient record.

Seamless integration of all types of patient data is a critical feature for clinical workstation software. The Dept. of Veterans Affairs has developed a multimedia online patient record that includes traditional medical chart information as well as a wide variety of medical images from specialties such as cardiology, pulmonary and gastrointestinal medicine, pathology, radiology, hematology, and nuclear medicine. This online patient record can present data in ways not possible with a paper chart or other physical media. Obtaining a critical mass of information online is essential to achieve the maximum benefits from an integrated patient record system.

Integration of imaging functionality into the healthcare enterprise using DICOM.

The US Department of Veterans Affairs is integrating imaging functionality into the healthcare enterprise using the Digital Imaging and Communication in Medicine (DICOM) standard protocols 1. The VA's VistA Hospital Information System (HIS) is installed at all 170 VA medical centers across the country. Image management is supported by the VistA HIS in several ways. Some VA sites have commercial Picture Archiving and Communication Systems (PACS) interfaced to the VistA HIS, while other sites use the direct image acquisition and diagnostic display capabilities of VistA itself. By supporting a small set of DICOM services, VistA can transmit patient and study text data to the image producing modalities and the commercial PACS, and enable images and study data to be transferred back. Images can be displayed on low-cost clinician's workstations or high-resolution diagnostic quality multi-monitor workstations located within a facility or elsewhere on the healthcare enterprise wide area network. This is a US government work. There are no restrictions on its use.

The Department of Veterans Affairs integration of imaging into the healthcare enterprise using the VistA Hospital Information System and Digital Imaging and Communications in Medicine.

The United States Department of Veterans Affairs is integrating imaging into the healthcare enterprise by using the Digital Imaging and Communication in Medicine (DICOM) standard protocols. Image management is directly integrated into the VistA Hospital Information System (HIS) software and clinical database. Radiology images are acquired with DICOM and are stored directly in the HIS database. Images can be displayed on low-cost clinician's workstations throughout the medical center. High-resolution diagnostic quality multimonitor VistA workstations with specialized viewing software can be used for reading radiology images. Two approaches are used to acquire and handle images within the radiology department. Some sites have a commercial Picture Archiving and Communications System (PACS) interfaced to the VistA HIS, whereas other sites use the direct image acquisition and integrated diagnostic display capabilities of VistA itself. A small set of DISCOM services has been implemented by VistA to allow patient and study text data to be transmitted to image producing modalities and the commercial PACS, and to enable images and study data to be transferred back. DICOM has been the cornerstone in the ability to integrate imaging functionality into the healthcare enterprise. Because of its openness, it allows the integration of system components from commercial and noncommercial sources to work together to provide functional cost-effective solutions.

Extending the multimedia patient record across the wide area network.

The Dept. of Veterans Affairs is developing and testing a wide area medical network with multimedia capabilities for coordination and consolidation of medical services across locations. The system is composed of multimedia information systems at individual medical centers connected by a high speed wide area network. The DHCP Imaging System, which has been in clinical use for six years, provides storage management and workstation acquisition and display of the multimedia data. Teleconsulting capability using a variety of mechanisms' is being prototyped and tested to meet medical staffing and consultation needs.

Integrated clinical workstations for image and text data capture, display, and teleconsultation.

The Department of Veterans Affairs (VA) DHCP Imaging System digitally records clinically significant diagnostic images selected by medical specialists in a variety of hospital departments, including radiology, cardiology, gastroenterology, pathology, dermatology, hematology, surgery, podiatry, dental clinic, and emergency room. These images, which include true color and gray scale images, scanned documents, and electrocardiogram waveforms, are stored on network file servers and displayed on workstations located throughout a medical center. All images are managed by the VA's hospital information system (HIS), allowing integrated displays of text and image data from all medical specialties. Two VA medical centers currently have DHCP Imaging Systems installed, and other installations are underway.

Mechanisms for exchange of image data to support distant medical consultation.

The VA has developed an integrated infrastructure to support the exchange of medical data, including images and text report data, between medical centers. This capability is expected to support teleconsulting and meet a variety of existing medical staffing and consultation needs. Consultation from distant locations requires at least the same complete integrated patient record available to onsite physicians. Several mechanisms are being explored to support distant medical consultation. Multimedia extensions to the VA's electronic mail system have been developed to allow images and other data objects to be included in electronic mail messages. Another approach that has been prototyped is to extend existing local imaging networks to produce more widely distributed imaging systems. These approaches will be described and discussed.

A bidirectional ACR-NEMA interface between the VA's DHCP Integrated Imaging System and the Siemens-Loral PACS.

There is a wide range of requirements for digital hospital imaging systems. Radiology needs very high resolution black and white images. Other diagnostic disciplines need high resolution color imaging capabilities. Images need to be displayed in many locations throughout the hospital. Different imaging systems within a hospital need to cooperate in order to show the whole picture. At the Baltimore VA Medical Center, the DHCP Integrated Imaging System and a commercial Picture Archiving and Communication System (PACS) work in concert to provide a wide-range of departmental and hospital-wide imaging capabilities. An interface between the DHCP and the Siemens-Loral PACS systems enables patient text and image data to be passed between the two systems. The interface uses ACR-NEMA 2.0 Standard messages extended with shadow groups based on draft ACR-NEMA 3.0 prototypes. A Novell file server, accessible to both systems via Ethernet, is used to communicate all the messages. Patient identification information, orders, ADT, procedure status, changes, patient reports, and images are sent between the two systems across the interface. The systems together provide an extensive set of imaging capabilities for both the specialist and the general practitioner.

Integrating medical images into hospital information systems.

The effective delivery of health care has become increasingly dependent on a wide range of medical data that includes a variety of images. Manual and computer-based medical records ordinarily do not contain image data, leaving the physician to deal with a fragmented patient record widely scattered throughout the hospital. The Department of Veterans Affairs is currently installing a prototype hospital information system workstation network to demonstrate the feasibility of providing image management and communications functionality as an integral part of an existing hospital information system. The core of this system is a data base management system adapted to handle images as a new data type. A general model for this network-based integration is discussed and various alternative architectures are examined.