When it comes to patient care, an image is often worth more than a thousand words. In government circles, nowhere is that more true than for users of the Department of Veterans Affairs’ Veterans Health Information Systems and Technology Architecture Imaging system. From its humble beginnings in a government worker’s basement more than 30 years ago, VistA has grown into a behemoth that supplies medical imagery to 156 VA medical centers and thousands of outside medical offices.
VistA is now a model for other government agencies, including the military services, the Indian Health Service (IHS) and the small Honolulu-based Pacific Telehealth and Technology Hui, a partnership between the VA and the Army’s Telemedicine and Advanced Technology Research Center. But some elements of VistA — such as its radiology system — must compete with faster, better, cheaper commercial alternatives.
In its early days, VistA had few visual elements. Dr. Ruth Dayhoff, national project manager for VistA Imaging, started to work on the system in 1969, when X-rays existed only on film and hulking mainframes defined computers.
Dayhoff started working in medical computing as a precocious high school junior after landing a summer job with the National Biomedical Research Foundation in Washington, D.C. She learned Fortran and programmed a CalComp plotter to draw outlines of teeth that could represent normal dentition at various stages of a child’s life. She said the tooth outlines in her program used average measurements of children’s teeth derived from X-ray films. The goal of her project was to replace charts that had been in use for two decades.
After graduating from high school, Dayhoff attended the University of Maryland, where she earned an undergraduate degree in mathematics. She then earned a medical degree from Georgetown University. She trained in clinical pathology at George Washington University and Johns Hopkins University and did her residency at the Washington VA hospital, which started her VA career.
By the mid-1980s, the VA had developed and started to field its Decentralized Hospital Computer Program (DHCP), the precursor to VistA, and its electronic health record, the Computerized Patient Record System (CPRS). With DHCP, the VA had a clinical management system but no way to integrate digital images with patient records.
Basement beginnings
In her basement office at home, Dayhoff set out in 1986 to merge digital images and patient records using PC technology that IBM had introduced just five years earlier. She built her first imaging workstation on one of the best PCs available at the time — a Compaq DeskPro with 640K of memory and an Intel 8086 processor.
To manipulate and display images, Dayhoff said, she connected an image capture board to the PC so she could display 65K images with as many as 32,678 colors. To store the images, Dayhoff obtained a pre-production loan of a 200M write-once, read-many drive from Tallgrass Technologies. The images stored in the database linked to DHCP patient records.
Two years later, VA doctors and IT experts recognized the potential of the imaging technology to improve health care for veterans. The VA decided to fund a test installation at the VA Medical Center in Washington, D.C. From that humble beginning, VistA Imaging has grown into a system used by all 156 VA medical centers. It handles, stores and presents a wide variety of medical images besides X-rays.
Originally functioning as a stand-alone system at VA hospitals, VistA Imaging now connects to a nationwide backbone that allows clinicians to access the 350 million images stored in the VA system via Remote Image View software, Dayhoff said.
VistA Imaging can also handle data from a wide range of medical devices that adhere to the Digital Imaging and Communications in Medicine standard, such as digital X-ray machines and sophisticated CT scanners.
VistA Imaging can also store and display nonradiology images, such as electrocardiograms; microscopy, endoscopy, skin and wound photography; and annotated diagrams in the VistA CPRS.
Dayhoff said the VA has developed interfaces for more than 250 medical devices in VistA Imaging. Clinicians can access those images through the desktop VistA Imaging Viewer. VistA Imaging also stores and indexes scanned documents, such as records from clinicians outside the VA system, so VA doctors can quickly access a patient’s medical history, said Lonnie Siebrandt, business manager at the VA’s Tucson medical center.
DOD eyes VistA Imaging
Carl Hendricks, chief information officer at the Defense Department’s Military Health System, announced in June that MHS wants to use the VistA Imaging Viewer to enhance DOD’s electronic health record system, called the Armed Forces Health Longitudinal Technology Application (AHLTA). Although DOD will not adopt the complete VistA Imaging system, it wants to use the viewer to boost reference-quality radiography for nonradiologists.
MHS wants to adapt the VistA Imaging Viewer module for image presentation on MHS desktop PCs, Hendricks said. Air Force Col. Anthony O’Koren, acting program manager for the MHS Clinical Information Technology Program Office in the Tricare Management Activity, said DOD is evaluating the VA’s image viewer “to see what parts we can use. It’s a work in progress.”
DOD is also developing a registry system for documents, files and images. “We need to start to build the registry, so we are able to find the images and bring them back to the viewer,” O’Koren said. The registry will also help MHS share images and other medical records with the VA when an MHS patient — or former MHS patient — receives care at a VA facility.
DOD expects the document, file and image management portions of its imaging system to be ready by summer 2007, O’Koren said. Northrop Grumman will work on the first stages of adding image and multimedia capabilities to AHLTA. The company declined requests for comment.
The VA and DOD will work together on future refinements of the VistA Imaging Viewer through an integrated product review team that “marks a new level of federal cooperation,” Hendricks said.
The imaging system work is “a model of cooperation, and we intend to leverage [the work] DOD does,” said Dr. Robert Kolodner, who was chief health informatics officer at the Veterans Health Administration before recently being named interim national health IT coordinator at the Department of Health and Human Services.
Indian Health VistA
IHS has also decided to adopt VistA Imaging. Dr. Mark Carroll, telehealth program director for IHS, said the service first tested VistA Imaging in its Billings, Mont., region about a year and a half ago and is ready to distribute the system servicewide.
Although IHS initially thought document scanning would be the only VistA Imaging application it would adopt, the service plans to also use the radiology and imaging packages because IHS has few federally employed radiologists in its nationwide network of more than 600 IHS and tribally managed hospitals, health centers and clinics, Carroll said. VistA Imaging is attractive because it offers many helpful functions for capturing, displaying and routing images for remote teleradiology uses.
Because the VistA Imaging hardware for one facility costs $70,000 to $100,000, Carroll said, IHS plans to set up regional imaging hubs. It already has one installed in Portland, Ore., and will add another in Nashville, Tenn., this fall. Many of the remaining 12 IHS regional areas are considering similar configurations.
Hawaiian VistA
VistA Imaging doesn’t stop at the ocean’s edge. Dr. Stanley Saiki, director of the Pacific Telehealth and Technology Hui, which uses VistA, said the decision by DOD and the VA to adapt VistA Imaging is a good example of parlaying government IT investments.
Because VistA Imaging was developed in-house, he said, the three federal health care systems will be able to share code and adapt it to their specific needs without needing to contact a vendor for expensive modifications.
