Wednesday, September 1, 2010

Anyone Missing Their Shoes?

When you're on the road as much as I am you learn to savor humor when it finds you. For example, the airport announcement I heard this past week that urged a traveler to return to the security checkpoint to collect their shoes. You'd think you'd notice that you were in your stocking feet (or barefooted) as you scurried off to the boarding gate, but I guess this traveler was in a hurry. My guess is that they simply boarded their flight (because the announcement was repeated more than once) before they noticed their shoes were missing. If you're in a rush and preoccupied with multitasking, unless you suddenly step onto wet grass, gravel, or hot pavement, you, too, might not even notice that you've left your shoes behind. 

There's an old saying that "the devil is in the details," which you might have the misfortune of experiencing if you get caught flat-footed by rushing into a PACS installation without taking the proper precautions. I've seen it happen at more than one facility: Institutions rip out their dark-room and hurry to go digital without recognizing their dependence on the new technology and its infrastructure. What if the network goes dark because someone accidentally cuts a cable? What happens if the PACS archive goes down? What's the operational plan for a software upgrade requiring the database to be down for a weekend? What if two or more RAIDs on the SAN simultaneously fail? 

All these scenarios can be analyzed, their risk assessed, and mitigation procedures put in place. These procedures, which should cover scheduled as well as unscheduled downtime, modality (CR, DR, etc.) failure, a RIS being unavailable, PACS down, network failures, and so on should be thoroughly documented. 

Operating procedures for technologists, radiologists, physicians, and PACS support personnel should be detailed in a step-by-step manner. Redundancy and back-up equipment and procedures have to be tested on an on-going basis so they are available when needed. This can be as simple as burning a CD at an acquisition modality for STAT cases (if, for example, a PACS or facility network is down) and walking the disc over to a radiologist for review. In fact, I worked on one RFP that that required a CD writer at each modality QA station (just remember to ensure that blank CDs are readily available). 

The message is simple: Prepare for the worst and strive for the best. That way, when the unforeseen and unexpected happens—which it will—you won't find yourself shoeless and unprepared for the elements; not in an airport and not when managing and supporting a PACS. 

VA Biomedical Engineers Receive PACS/EHR Training

The VA Midwest Healthcare Network (VISN 23)--covering veterans in the states of Iowa, Minnesota, Nebraska, North Dakota, South Dakota and portions of Illinois, Kansas, Missouri, Wisconsin, and Wyoming--is initiating training for its biomedical support staff on healthcare IT technologies, with a focus on Picture Archiving and Communication Systems (PACS) and Electronic Health Records (EHRs). An extensive four-phase training program will enable VA engineering staff to meet the increased demand for healthcare IT expertise in their facilities. 

The VISN 23 has recognized that developing in-house expertise is more beneficial to the facilities and their patients than relying on multiple vendors' service personnel. As such, VISN 23 is devoting significant resources to training its biomedical support staff on multiple modalities as well as PACS and IT systems. IT experts concur there is no substitute for an in-house expert that can deal with problems as they occur at a facility. 

A four-phase training program will take place over the course of one year. The syllabus was developed by Dallas-based Otech, in close coordination with the VA, but could be applied to any other institution or group of professionals. It uses a blended learning methodology, where students will use self-study based CDs and accompanying study guides over the course of two to three months to master each phase of training. The students will then meet at a central location to go over the materials and perform a comprehensive review prior to taking an on-line exam. 

The first phase is designed to bring everyone to the same level of IT and clinical expertise--as both knowledge domains are required to deal with the support issues. The Certified PACS Clinical and Technical Associate (CPAS) certification from the PARCA organization recognizes this level of expertise, and was achieved by all of students by August 27. Most of the VISN 23 students have an IT background, and focused their energies on mastering the clinical portion of the training—particularly in regard to medical terminology, which includes radiological positioning, modality knowledge, and anatomy. Knowledge of these terms is essential when dealing with physicians, as well as when performing any type of troubleshooting. 

The second training phase is similar in structure to the first: Participants self-study with CDs and study guides; meet in peer groups to review the material; and then gather for a comprehensive review prior to demonstrating mastery via an on-line exam. The second level trains students as PACS systems analysts where they will gain in-depth knowledge of the technology and its standards, such as DICOM and HL7. The students will also learn to interpret interface specifications--including conformance statements--for the purpose of preparing new installations, software changes and upgrades, and finding errors. 

Phase three of the training program will start in Spring 2011. The VISN 23 biomedical support staff will become proficient in advanced troubleshooting and techniques using sniffers, and validate connections and interfaces. The emphasis will be focused on healthcare IT technologies and integration at the "back-end." Upon completion of this training phase, the support staff will also have acquired sufficient knowledge to sit for the exams to become OTech DICOM Certified Engineers. 

The fourth and final phase of this round of training will focus on IT systems at the enterprise level. Students will gain mastery of many of the IT components in the healthcare enterprise, such as the EHR, as well as their related standards and will also acquire troubleshooting skills for quality related issues. 

This four-phase program may set the benchmark for other VA regions in educating biomedical support staff for the next generation of healthcare IT. These new systems are more complex, issues with integration and interfacing will become more trickier, and troubleshooting will require a greater breadth of knowledge. There is no question that these skills require a new level of expertise, which will be provided by the VA biomedical staff in VISN 23! 

Details about the four-phase phase, one-year training program: 

Level 1: PARCA Certified Technical and Clinical PACS Associate (CPAS): Students will acquire basic clinical and technical knowledge to allow them to troubleshoot and support simple PACS connectivity issues and diagnose hardware as well as software problems. This level is intended to bring professionals with a Clinical or IT background to the same base level, allowing them to grow to level-2, -3, and -4 support levels. 

Technical Component:Clinical Component:

  • Computer Basics

  • Medical Terminology

  • Operating Systems

  • Human Anatomy

  • Exercises OS

  • Radiology Imaging and Positioning

  • Databases

  • Modality Characteristics

  • Exercises DB

  • Imaging Characteristics

  • Networking Technology

  • Process Workflow

  • Security Concepts

  • Prior and Outside Exam Handling

  • The duration is 8 weeks of self study using the OTech study guides and CD's, followed by a three-day review/refresher face-to-face class. This level is equivalent to the PARCA CPAS level; an on-line exam will be taken upon completion on ( to become CPAS certified. 

    Level 2: Systems Analyst: Students will be able to configure PACS components, modalities, and other connections. Students will be able to troubleshoot basic issues and interpret log files and dumps of both DICOM and HL7 transactions and relate the information back to the standard specifications. Interpreting conformance statements and interface specifications will be taught in order to anticipate and resolve potential connectivity issues. The emphasis of this training is on the interpretation of interface specifications and logs. 

  • Introduction to PACS, Scenarios

  • HL7 Interface Specifications

  • PACS Components

  • DICOM, HL7 Set Up and Configuration

  • Acquisition and Viewing

  • Networking Basics

  • Workflow Methodology and Samples

  • Simulate DICOM Modalities

  • Introduction to HIT Standards: DICOM, HL7, and IHE

  • DICOM Verification

  • DICOM Conformance Statements

  • Send Images, Queries to Worklist and Database

  • Duration: 8 weeks followed by a four-day review/refresher class face-to-face as well as hands-on practices. 

    Level 3 Support Engineer: Students will be able to support mission critical components such as the archive, and resolve complex issues regarding connectivity using advanced troubleshooting tools and techniques. 

  • Architecture, Migration, and High Availability

  • Use of Sniffers and Active Test Tools

  • Security and Privacy Requirements

  • Most Common Errors Simulated

  • PACS Policies and Procedures

  • Validation of Images and Protocols

  • Integration and IHE Profiles

  • Adding new PACS Components

  • Advanced DICOM Services

  • Preventive Maintenance

  • Advanced Troubleshooting Techniques


    Duration: 8 weeks followed by a four day review/refresher class face-to-face and practical lab. 

    Level 4 Systems Enterprise Engineer: Students will be able to anticipate issues with regard to new standard implementations such as Structured Reports (such as for ultrasound and cardiology). Image quality issues diagnoses through proper use of tools and test images and issues with the pixel pipeline will be identified. 

  • Advanced Performance Monitoring Tools and Techniques

  • Use of Sniffers and Active Test Tools

  • Business Continuity/Disaster Planning and Techniques

  • Most Common Errors Simulated

  • Image Quality Troubleshooting

  • Validation of Images and Protocols

  • Pixel Pipeline

  • Adding new PACS Components

  • Using Test Images and Methods

  • Preventive Maintenance

  • Advanced DICOM Topics, SR etc.

  • EHR and EHR Standards

  • Other Specialties: Cardiology, etc.

  • Extensive Hands-On Lab Setting Up Test PACS

  • Duration: 8 weeks followed by a four-day review/refresher class face-to-face and practice lab. 

    For more information about this training, contact Kurt Finke at the VA ( or Herman Oosterwijk at OTech at