Table Of Content

dvard Number: DAMD17-03-2-0017 TITLE: Development of the Integrated Taformation Technology Syaten PRINCIPAL THVESTIGATOR: soit E. Gilatrap CONTRACTING ORGANFZATION: Pitteburgh University Pittsburgh, Pennoylvania 15213-2582 REPORT DATE: Januazy 2005 TYPE OF REPORT: Annual PREPARED FOR: U.S. Army Medical Research and Materiel Command Fort Detrick, Maryland 22702-5012 DISTRIBUTION STATEMENT: Approved for Public Release: Distribucion Unlimited The views, opinions and/or findings contained in this report are those of the author(e) and shoulé not be construed as an official Departrient of the Army position, policy ox decision unlesa so designated ny other docurentation “20050315. 013 Form Approved REPORT DOCUMENTATION PAGE _ OYE No. Or4-0108 Seema eee ier eee sdinigartiahen ties chasis a er a me, TAGICY Use OY ‘2 RePaRT bate TREO HIRE ARD DATES COVERED tiene te Samuary 2005 Annvsl (20 Doo 2900 ~ 49 Dee 20034 “SHORE AND SORE 7 ANS ORE Development of the Integrated Information Tesheology systan | OANDI?-05-2-0017 ATOR Seott &, 6L1stran 7 SREY ORARTERTION WAT AND ADDRESSES, 7 FERPORING DROATEATIT Bieeenurgn University, ‘sevonr Mimsor Pittsburg, Penaylvania 15213-2562 Fame gilstreoaetupm edu RONEN TROITFCRNE To SPONSORS TORRE ‘cency ames) ate ADDRESSES) ‘RaCucY AcPORT suheee® U.8. Amy Medical Roscerch and ateriel Command Pert Detrick, Marylang 21702-5012 "FBOPREOTARY BOE ER IS ATION TAVARABUEY STATE START COE Approved for Public Release; Distribution tninited TE ABETRATT oct OB WET No abstract provided. Th SURRCT TERE TER OF PRES Telenedicine, iformacicn teclmo“ogy, evalustion, celevsdiology, 2 telepatholog). tele-acheearcsogrephy FEE EE V7 SEEURITY CERBBOATON | 15 BEURITY CASSTRCATON | 79, RECURS CLASSACTION | EO TRTEATON OF ABSTRACT ‘or ncrow OF Fs PASE otaastascr Mncrsesitied Tuciaeet tied tuelecst fied Patiainea TT FREER ‘Randy ab er 25 Table of Contents Front Covet sn Standard Form 298, ‘Table of Ceuteats TIntoductin. Body. “Teleradiology “Telepathotogy Podiati Tele-eshocandiogeaphy. Ematyency Medical Ser e2%.5ess Tmengency Modicine ‘tinge Database BMEDS Wireless Demonstation Telemental Hoalth, Yeleradiation Oncolouy Major Bactiers Security Certification TRB Syproval Process, ‘Key Research Accomplistiments ‘Teleradiology ‘Tetepathology Pediurie Tete-rsliocardiography. Emergency’ Medical Ssviecs. ntergeney Triage Database EMEDS Wireless Demonsiration portable Outcomes. ‘Conclusioas Referen Appeniives A. Teleradiology Evafuation Timeliaa #8, Teleradiology Survey Findings. ©. Teleradiology Preliminary Findings. D. Dynamic Telepathulgy Vision and Scope Doct. EL 2 Teleputhalogy Survey Data F. 3 Tolopathology IRB Flow Chat G, Boho IRB Process, HE Revised SOW. Introduction ‘The Inyrted Medical Information Technology Systom (IMMITS) rogram is facused om implementation of advanced wechnology solutions duit elioinate inefficiencies, increase utilization and improve quality of vare fur acdive duty fouex. The work on this project hat focused on the development and implementation of protorype teleuedicive systems ud advanced technology applications at United States Air Force buses, Significant effort bas bosu. devoted to the DITSCAP security proces: for the applications developed Emphasis has been ‘Placed on the development of sound evaluation methodologies for each of the sub-projects with special aticarion to tho areas of cost effetiveness and end-user satisfotin within the AFMS, Body Teleradiology Implement a working Teleradiology system in the Air Foece leveraging the system already tt use aa Carlveesty af Pitburgh Fleath Syiem (CPC) ‘The Steatr iSite nd {Vault COTS products have beca installed a Weight Patterson APB in Dayton, Ohio since 2003, (Wright Panersou, Stentor aud UFMC began plonning und preparing for upgrading to Sesmor version 37.2 nate of te laner balf of 2004. Ta Novernher 2004 Stentor rescived DIISCAP ventitication for version 3.2.2 which will be iaualled and in praduction, at ‘Weight Patterson, in ealy 2005. Develop and implementa protoiype workflow model using a DTS enabled infraviracnure. ‘Requirement fr this project ware obtained ftom Wziel Patterson Air Force Buse Medict! Comer (WPBIC), Development ofthe DTS erubled infrastrucure prototype for WEMC Has Completed ia May 2004, The DTS inftustrciure provides the Radiologisis at WPM a moce ‘bust und efficient way to view radiological images. Create a protoayye intelligent DICOM dspatelen ‘Requireatents for this projec were oblaied from Wright Patterson Air Foree Base Medical Center, Developrnent of the ialelligent DICOM diqpetcher for WPMC was coupled in July 2004. The intelligent DICOM dispatcher inckadss the ability te display mucse wits and Atepartmental radiology study work ists to clinicians tuoughout WPM. Develop a procetype reporting and dictation infrastructure, ‘UPMC ia developing, for iatctnal purposes. a reporting and dictution infrastructure and plans to ‘use the base source code of the UPMC infasiructere for WPMIC, UPMC will atsist WPMC in developing requicements for x reporting and dictation nfastenceore during the development oF ‘the WPMC intelligent DICOM dispatcher prototype. WEMC will most Ikely he perusing the use of a COTS reporting and dictation product. Develop and evaluate a prototype Secondary Capture (SC) DICOM wrapper that wil attow incorporation of arblrary and visthle light datasets into the DICOM archive. UPMC has developed a Secondary Capture ($C) DICOM wnspper to inceeporute visible Bight dtasels into » DICOM archive, UPMC is beta testing the Secondary Cupture ($C) DICOM. ‘wrapper prototype intemally. Ac this time WPM has to need for this sevice, Develop and implementa systen for ransferving images toa c interpretiton This SOW teas not vontsined inthe eriginat proposal, The initial itn ofthe Teleradiology project was fo put the infrestractore in place ao thet Wight Pierson would become a hab ina ‘Teleratiology network aud provide interpretation ser-ives for hospital sol clinics with excess dousnd. In the spring of 2003, Wright Pttrsan faecd te loss of radiologists due to deployment ‘nd ation. The Diagnostic Imaging Flight Coeamander at Weight Pattersnm asked UPMC for assistance in establishing a Teleradiology link to Kettering Medical Contr in nearby Kettering, Obie fo ficliate entsoursing of ivlugy inlexpretalfnn. A secnre VPN connection Was «established nod o sysiem was put in place in Octobor 2003. Aan offsiteliviian Incation fiers management system wus developed and deployed by UPMC for the Weight Puterson Radiology Depurtmem and the Ketering Medical Center in uly 200. Radiologists at Kevoring Medical Canter ae now wading and dictaling Wright Putters studies, tan location for Evaluate the impact of inplementatton and usage of the prototype Stentor Image and Taformation Management Systeus ut Wright Patterson Medical Cenien, ‘Rescarl is focused on usce stistaction, system functionality, and changes in tmoliness, wurk ceffiioney and paticot care, The stdy consivts of aurveye, ntervicrs, sis Visits and diageoatie raging saints, Yioicet Delays ‘Mandatory DOD security compliunce requirements (DITSCAP) forced delys in system installation aud Jul functioning atthe Metical Center, Etfrtive December 2003, Stentor Sysiem 3.1 parsed al requirements and DOD approval was gram for operas. Progress Stentor 3.1 has been operatic ul Wright Patterson sinee Docetaber 2003. "hia syler ix undergeing additional system and scvutity upgrades in compliance wilh project objectives, By ‘mid February, the upgraded system (Stentor 3.2}is puyested to he opsratioual, This upgrade will bring the system imo compliance with general project objectives for system jastallaion at ‘WrighParerson Evolustion activtis have becn voaducted in allgnment with project development activites. Baseline surveys, interviews and ste visite were conducted prier to Stenfor's implementation and follow-up intermittent surveys an sits visits have beeu conducted to ack progress: Post survey os collected for Stentor 3.1 in January 2005 und will be compared with basaline findings as final survey dala fo be collected for Stentor 3:2, Fins] intarview and site vii dain will also contribute ta am understarding ofthe impact of Stentor at Wright-Patterson, ‘Teble, Surveys: Time Paints and Ose, bls Su ‘See aucchmom: A, Peleradiofogy Evabuntion Thmeline Surveys Baseline surveys were completed in conjunetion with Stentor aun runing conducted in May. 20K. Pulse surveys (Le, intermitnt ahravitedl surveys) weas-completed every few mows sneross a subset of sees Wo tack system acceptance an] polenlil urien to auption md use Tie | Time [Pine "Tims Polat Point 1 | point? | voiat 3 6 | Users F Basetine Sueveys Pale Surveys, Post Survey EIGES nok | GaN | ROOF Radiologie [4 ce Teclmologists_|[ 23 3 2 is Clinicians Hl 0 3 3 ‘Gites 2 2 @ 2 = * heise awe meagan Sev attachment: B. Teloradiatogy Survey Hindings Interviows ‘Fre-mplomentation interviews were uonduoted with u ubnct of radiologists (3), technologists (a= 4) and clinicians (n ~ 4). Informal interviews were also onnducted with twa Koy projent ‘Adunnisoaturs at Weight-Palterson wha were reiing fom the Ais Borco, Interviews are underguing comprehensive analysis and will conuibote to au uudcrstauing of bares, supports snd lesscos Jearned fram he projet Site Visits escarchers have made seven ste vss to Wright-Puttenon AT to conduct surveys and discuss vusage and satisfaction with ata thal routinely interfacen with Stentor, Ting Stisien Imaging Departmcat productivity is being tracked based on CHICS database statistics ‘This informacion wil parallel project implementation und system apgrades. “Workflow Analysis Site visits and intsviows contributed to a workflow analysis of stalTpracticer and interactions ‘vith the diagnoatic imaging syslems. Changes in eaff roles and aeapensibilitcs in process Aiugrantic images ars hing tracked! aerose systems, See atuchoent: ——C. Teleradiology Preliminary Findings IRB Approval Process ‘Ths reseatch is being planned ead conducted ima masmer consitent with th goals of the project. Bvalualion soalies are being conducted with tho fll approval of investigation zeview boutds ‘QNBs) at cach insttation and stedicat center imvulved in the enndust of the studies. The IRB review process hax proven fo be a tine-consuming process, Its significant to ne the work, ‘offor uv! Hime invelved in securing Full ARTE approval Telepsthotogy Iraplement a prototype sate telepatholony systew within the Ae Force leveraging the system sdreudy tase at UPMC Health Sytem, Design, develop and implement a prototype sclepashologg workflow application, Enniuate compliance of te protriypetoleparhotogy system withthe Common Criteria for Faformation Technology Security Evaluation {CD dats security requirements and perform the ‘neoded remedlation to subsatspstem fox C2 certification. Static Teteputhotoxy UPMC Static Teepathology System rossived DITSCAP caititcation in November of 200. Sinze thal time, the sllic system vias implemented at Keesler AFT und Eglin AH. Air Fore ‘persennel have used tho systom and buve identGied mimir operational difficulties Specitieally, thc adapter lens purchased and shipped war not the lens needed and that te OTC camera software proved hard to une. DPMC has ordeve the corsoct lena dnd will provide UPMIC imnge capture woftwate (vide infra). Additionally, UPMC will asia withthe use ofthe safhare that hey purchaned. Evaluate the willy of digital slide paohology i the Air Force eavlronmet ‘Au Aperio ‘WSI system wat instilled at Keoslor At was tested, and Keesler personnel were ‘nuincd to operate the device, UPMC ant Keesler personel implemented pathology teaching ‘material and examinations based on WS1 performed at Keesler, and plans arc being made to txt and wilize this teeluolopy inthe clinical environment At the sume time, PMC has unplemntod a research ad development team that has been ‘examining the wilty of WS inthe elinial environment. Four IRR approved clinial ‘evaluations of WS! in 1) Quality Assurance, 2) Primary Diagnnai 3) lntomaal Cousultation and 4) Extemal Consultation have been designe, upproved and underway. Formal relly uf the Fret study will be eealable by the end of February, andthe othcr studies will he eompleted by aly 2005. All studies will he co-publishod with Als Force personnel, Peliminary revlts indicate ‘uniformly diagnostic image quality and lite discrepancy wilh the ecsuls of dizost lass slide evamination pat six months, there has been a signilican imprevercent i image quality, speed and ‘The attached evaluation eport will help explain to sctvities involved with the WST Implement a protorype dynamic wlepathology rystem oi Keesler AFB, Eglin AFB and Travis AFB. Tn 2004, UPMC conducted a review of cummercially available products for robotic telepathology. The Nikon CoolScope wes shson forse in static rebate telephoto because of the avsiahiity ofthe source code from the mamfacturer and hecause of significantly lower cost, ‘The software was demonstrated at PMC forthe Air Eevee uring the sammee if 2004, Ais Force security isnues surrounded the CoolSeope product, and significant “work-around” bhuve heen roquited to isos tha CoolScape software from Ihe Sic Force network, system is im place, and a CoolScope is operational ut Travis Air Force Base ‘UPMC is curently affsmpcing to extend the DITSCAP certification for Static Telepstbology to include the Cool Scape based robot telzpatholugy. Additanally, the developed CoolSeape software is being modified to work with the Afr Faee’s move 6 Windows XP (it Was eriginally designed in Windows 2000). Tis expecied that CoolSeapes wil in impleusenred a¢ Keesler and Eglin ATB in 2608. See attachment: Di, Donaatio Felopatholoyy Vision and Scope Drcranent Design unt develop: iat cofoare to ident tnrage quatty. ‘A bright field image capeute system has been developed lo cupturehiyh-zeaohstion digital RGB imrges of histopathologival Ussue sample (The he owe hoing add to the static {clopathology system, vide supra). The softare provides a hisogram dialog box thal provides _mraphical representation of white balance and undcr/over oxposure tora given itaage. The sysfem asiss the user to capture an image of tho highest quality color ead fovua, ‘This eofbware will be included in UPN Ststic Telepathology ¥.2, Jn addition, UPMC bs developed software that evaluates imuge Focus in whole slide images. ‘Thi anftware i implemented in the UPMC WSI protovols and has heen portant in improving, image quality as discussed ubuve. hiv Fink nongs J ralepgchology spe ei ialesiclent ida finde. ots da a Gxplaing WSl inage guscily svalention e?Fo-h Evabuate the impact of implementatlon and wsope of State Image Telepathology at Keesler, igin an Travis Medical Centers, ‘The purpose of this esearch ia to evaluate usage snd acceprance paces for pathologies interfcing with statis image telepatholngy syskaas in pathology departments al Keesler, Fgtin and Travis AFR, The study has tee parts: 1) Surveys - conducted pre, intarmittort aad post ‘implementation, 2) Interviews - conducted pre and post implemaatatica, aud 3) User Actviyy ‘Reports of frequency and pattems of use arose system componeats, Project Delave ‘Maudatory DOD seouityvorplince requirements (DITSCAP) forced delays in sysean {nstattion, Effective September 2004, Static Image version 1.2 pasoed all requirements and DOD upgrval was granted for operations. Progiess IRB exempt approvel was obtained aud pre-implemeatation interviews were coudcted with [pathologists a Reosler and Kalia, Surveys were conducted in coujunction with applications ‘usining af each site allowing applications taining sessions. Steff at Keesler received training {ir Stutz Tmaye version 7.1 jn December 2003 and tor Static Image version 1.2 in September 2004, Staff at Eglin received training for Static Tage version 1.7m Soptenber 2004. Pathotogiss at Teovis will be interviewed and trained in 2005, Surveys Bascline surveys weve completel in vonjunction with Static age applications irining. Survey data fiom Time Points |? serves asa basclinc measure of perceptions of he eyetom's performance and potest impact on patient care. Time Poin 3 provides preliminary data on users carly acceptance and adoption of the system. A summacy of ital fading i eluded. ‘Table: Surveys! Time Point and User “ime Point | Tero Fach] Tae hago LT Seale mige ll ] Sti Tans V2 | Wate image 1 Then ‘ascine Post Bascine inteutent Kessler Reels __| Weslerac tin | _Keester tin jf 2a said [non 12005 Tatingaiy 3 a € ‘ess a ry a See atachonent: —_F, Telopushulagy Survey Duta Tserviows Presmptemematio interviews were conducted with subset of pattologisia(n = 53, Interview? ata ie curenly being snalyred aud will eouribute to baseline workMlnw analysis and user fanetionality and satisfaction information, Site Visits Researchers have mule lee ste visi to Korster APE and 10 10 Eoin AFD to conduct intecvivws an surveys and fo discuss porceprians of use and satinlucton with maf that aay interface with the Static koage systems. . User Autivty Slaites User autivity ishing tracked aud will uppleonent survey un interview ings. IRB Approval Proves ‘The reseurch is being plane and conducted ina examer consistent with the goals of the pscjent Evaluation studies are being cunductel with the full wymewal of investigation review bourde (CRBs; st each institution end medical centr involved ia the conduct ofthe mais. The IRB. feview provers has proven fo be a time-consucing process. Tes significant ro note the work, cffor and tine involved in securing full TRB anpravale, See aiuichments —_F. Telopatholingy IRB Flowchart Podiatric Tele-echocardiography Design, develop, implement and evaluate a prototype pedietrletelonechveardiography system for usein the Ais Farce. ‘Children’s Hospital of Pittsburgh (CHP) aad UPMC vondusted an evaluation of the COTS ‘deoconfetencing produels fur porenial use inthis projet, In consultation with tke DeD Viton [Netware Centar in San Antonio, ‘Texas a decision as made to use Polya equipmiet for this project, It was also determined thot MEDNet was the appropriate commmnwisations link. Eglin AFB and the Navol Hospitet Pensacola had a pro-cxiting node on MEDNet bul Keesler AFR did do. Thus devise that Keesler would use commercial ISDN for this preject until sueb te a8. ‘MEDNet noce becomes available, Installation of equipment oveurred in February of 2004 tut was complicated by ISDN connectivity fouer. fer working the issues through the Kessler Ceneamunivatione group, the systern went technically live in May 20M. Sevoral est cases were completed hetwoan Ressler and Children’s Hospital of Pitsburg ‘Changes in persoune! also had a significant impuctom thi project. tn he 2004 the Pedic Cardiologist at Keesler separated ftom the Air Force. A seplaccuieut was bot sate ual Sometime inthe fall 9f 2008. ‘tis projsct would be ile nal the new perwun arrived. 1 July 2004 the adult somograpr fra Bolin AFB Usveled o Pittsburgh fir oheervatonal ‘euining at Children’s Hospital of Piasburgh. She spent lhree days cheerving Podinticoches in the Ib ant ICU, For health reasons, the adullsorugrapher at Pensacola Naval was unable to stond this session and will be rescheduled ut a later date, ‘The new pediatric erdinlngiet arrived ip Noveusber 2004, Affe an oxientaliom period to Keesler she will begin outroach ctnis in eatly 2005 and wil be prepured to ieplement the pense olo- echacardiography program, Evaluate the ropional impact of « protowpe pediairte ule-cchocardiogvaphy sprtem in Tri Cure Reyion 4, A deisild evaluation study has been develope un gain inermation about pexceptions of the se of te tle-echocurliograpty equipment, This srudy bas three pais: (1) sutveys following each teleechocurdingraphy' season; (2) inleviews - conducted pee and post; and (3} monthly patio ‘ore stutistioal reports trom TRICARE Region 4, Project Deluvy Although equipment was installed ip Yaauury 2004, project implansatation was delayed pend resolution (0 ISDN iasuew. AL the time thatthe system Went olincaly ive in Muy 2004, the pediatric cardiologist wus raving ftom the Air Force and his replacement wauld not be on base ‘uti Tate 2004, 10