Information is the heart of the clinical enterprise. When it comes to cardiac care, immediate access to complete patient information is key to improving both patient care and workflow. But providing that access can be a complex process that hinges on integrating multiple systems. What’s more, integration isn’t the only challenge. “It’s very difficult to find superb imaging and reporting in a single system,” opines Jeffrey Breall, MD, director of cardiac catheterization laboratories and interventional cardiology at Krannert Institute of Cardiology in Indianapolis, Ind. On the flip side, facilities that have taken the plunge into state-of-the-art cardiovascular information systems report significant benefits including:
- immediate access to current and historical images and reports
- simplified, speedy and consistent reporting
- data mining galore to facilitate clinical trials and drug eligibility notification
- the ability to view images and data in multiple locations in near real-time, which facilitates ‘virtual cardiac care’
- reduced costs and improved workflow
This month, Health Imaging & IT visits with a few pioneers to uncover the benefits and challenges of implementing and integrating cardiovascular information systems.
“Deploying a new cardiovascular information system provides a hospital an opportunity to create and build a system based on ideal workflow,” says Lucretia Craig, RN, BSN, director of imaging services at Olathe Medical Center in Olathe, Kansas. Olathe Medical Center has been tackling the IS-driven workflow process since 1997 when it deployed GE Healthcare’s MUSE ECG database.
MUSE is one component of Centricity, the hospital’s fully integrated cardiovascular information system. “MUSE provides online serial ECG access, enabling physicians to pull up previous studies for comparison to immediately note any changes,” explains Craig.
The next step of Olathe’s staggered deployment was to implement Centricity DMS in the echocardiography lab. One of the primary benefits of the data management system is structured reporting. Rather than dictating a report, the physician responds to a few questions in the system to create a report. “Prior to Centricity DMS it might take five days before an echocardiogram was turned around and [the report] available on the patient’s chart. Today, it’s on the chart in an hour or two,” reports Craig. In addition, Centricity eliminates variability in reporting styles. The consistent format makes for easier reading by referring physicians, says Craig.
The Centricity database also streamlines other clinical processes. The medical center can create reports and notify patients as they become eligible for certain drugs or clinical trials. For example, Centricity can pull the names of all female patients under 45 years of age with a certain diagnosis so staff can notify them of drug eligibility. “There’s no more [time-consuming] retrospective chart review,” sums Craig. Olathe Medical Center also deployed Centricity DMS in the nuclear and cath lab departments to provide the same results across the board.
St. Elizabeth’s Regional Medical Center in Lincoln, Neb., improved its cardiology workflow when it deployed McKesson Corp.’s Horizon Cardiology in 2004. On the physician side, the system provides rapid access to images and information, facilitates serial comparisons of studies and enables anytime/anywhere access through MDWeb, says Bruce Couillard, director of cardiovascular imaging.
Physicians, however, aren’t the only staff members to improve workflow and efficiency. The workflow gains extend to the entire cardiology team. Horizon Cardiology streamlines clerical and administrative tasks; paperwork is minimal and the time-consuming, workflow-busting chore of delivering studies is eliminated with autofax/autoprint features, Couillard says.
A final benefit comes on the financial front. St. Elizabeth’s reduced its direct operating expenses by eliminating the need for transcription with Horizon Cardiology’s reporting tools.
The integrated clinical information system
The goal at the Linda and Jack Gill Heart Institute of the University of Kentucky in Lexington is ambitious — an integrated clinical information system. The cardiac cath and electrophysiology labs rely on Witt Biomedical Corp.’s Series IV (which is now owned by Philips) and Philips Medical Systems Xcelera Cath Lab Management. The lab systems will connect into the hospital’s Eclipsys clinical information system.
The Heart Institute has realized benefits from its Philips/Witt solutions at the departmental level, says Linda Holtzclaw, RN, MSN, patient care manager for cardiac catheterization and electrophysiology laboratories. Both systems are Windows-based, which enables users to start working with minimal training. Series IV helps users build intuitive documentation menus; as users complete one step they are prompted to the next step, which saves time and improves workflow, says Holtzclaw.
Although Xcelera was conceived and planned as a cardiac system, other departments — OR, vascular medicine and pediatric echocardiography — have asked to join the system. “This will allow us to group patient files, select a patient and find all of the relevant data,” explains Holtzclaw. To date, pediatric echo has been added to Xcelera. The institute plans to review storage, use and security before expanding the archive and connecting to other user groups such as vascular and OR. The OR, for example, is clamoring for Xcelera as the workstation enables both reporting and image viewing. The workstation provides a better solution than other options like an OR dataport, says Holtzclaw. A dataport would allow users to download images but does not enable reporting. Despite the demand and demonstrated benefits of a wider deployment, the Heart Institute is proceeding cautiously. “Security is an issue as we add connections. We need to move away from local management of security to medical center management,” says Holtzclaw.
To keep up with rapidly increasing demands for information, Linda and Jack Gill Heart Institute placed Xcelera workstations on cardiac floors and in clinics and OR suites. The Eclipsys integration project will extend the reach of cardiac data. The first step focuses on order entry, tracking and results retrieval. The next interface will let users click tabs to look up procedures and reports on the Witt server and view images online. “It’s cost-effective. We won’t need to build expensive workstations for viewing images,” notes Holtzclaw.
Other benefits will accrue as the institute adds satellite clinics in outlying areas. Physicians will be able to access all patient data with a single University of Kentucky password. The web-based images will be high quality, but not diagnostic; users will need to go to an Xcelera workstation to view diagnostic images.
Integration also is the name of the game at Methodist Medical Center of Illinois in Peoria. The hospital began multi-phase deployment of Heartlab’s (An Agfa Company) Encompass Cardiac Network in 2004 and has implemented image management and reporting in echo and vascular and image management in the cardiac cath. The next phases of the project will tackle cardiac cath reporting and nuclear medicine image management. The system integrates with ADT, SoftMed reporting, long-term storage, mobile echo carts and a physician portal.
The advantages of the solution are significant, says CVIS Project Leader Merry Bassi. Physicians can pull up images and reports from any computer in the hospital and outside of the hospital through the portal. In fact, an off-site cardiologist recently viewed a live stat echo from his office an hour away. “He didn’t have to drive in in a rush or ask someone else to handle the case,” explains Bassi. Another plus of the system is near-instant report turnaround.
Bassi identifies interfaces as the primary challenge of digital information systems, but the nature of the challenge is human resources, not technology. Hospitals need to commit staff and time to working on interfaces and lure multiple vendors to the table to develop the interface, says Bassi; however, the patient care and workflow advantages of the integrated approach outweigh the minor challenges.
Reports & Images: A match made in heaven
“I’ve spent 14 years looking for a solution that incorporates superb imaging and reporting in one system,” admits Breall. The cardiologist’s search concluded when Indiana University deployed ProSolv CardioVascular a few years ago. The single solution improves patient care, says Breall, because it allows users to pull up all patient information at the laptop. “There’s no need to run to one place for images and another for the report,” he continues. That easy availability of images means clinicians are more likely to view images rather than rely on the report alone.
On the reporting side, ProSolv streamlines the process. For example, during a cardiac catheterization, a nurse or tech collects and inputs data on the fly during the procedure. When the case is done, the report is 90 percent complete, says Breall. The physician can select items in the system’s log to populate a structured report to complete the report and facilitate rapid report turnaround.
Cardiology & Radiology: A single solution
Dayton Heart Hospital in Dayton, Ohio, is a 47-bed specialty facility where radiology and cardiology operate as separate tracks with radiology handling non-interventional imaging procedures and cardiology managing interventional procedures. At the same time, the two specialties have common needs. Digital imaging is essential, says Radiology Team Leader Mark Cooper. “Both radiologists and cardiologists need all images, exam data and reports in one place.”
The hospital started to explore digital imaging a few years ago. One of the first tasks was an enterprise needs assessment. The core of patient care, says Cooper, is images and information. Improving turnaround time and time to diagnosis depends on the availability of both types of data. Cardiologists also realized that off-site viewing capabilities could enhance patient care and workflow. Finally, both radiology and cardiology wanted certain diagnostic tools as part of the information system package, and the small, thinly-stretched IT department lobbied for a single system to maintain. The single solution was attractive from a financial point of view as well, says Cooper.
After gathering input from users, the hospital began researching vendors and opted to deploy ScImage PicomEnterprise earlier this year. The entire hospital and its patients benefit from the solution, says Cooper. Although the cath lab was digital prior to ScImage, images were not available outside of the department. Now physicians can view images from anywhere. Surgeons appreciate ready access to images and are no longer requesting hard copies of some peripheral studies, which had been difficult to view digitally prior to ScImage.
In the new digital world, a cardiologist can view all types of images — CT, echo and cath — without visiting multiple departments. “This informs the physician and expedites patient care,” sums Cooper. It also eliminates duplicative orders as physicians can see if another clinician ordered a certain study or test.
The virtual enterprise
Miami Children’s Hospital/Arnold Palmer Children’s Group in Miami and Orlando, Fla., is a two-site pediatric cardiovascular facility. Emageon’s (formerly Camtronics’) Vericis cardiac image management system replaces videotape with digital clips for improved efficiency and patient care, says Leo Lopez, MD, director of non-invasive imaging. The Vericis EchoIMS reporting solution organizes information and speeds report turnaround. Under the old style dictation system it might take up to a week to finish a report; with EchoIMS clinical data are available almost immediately and reports are immediately edited and corrected and available within one day.
Another significant advantage of the approach is that it enables the two sites to function as a seamless, single enterprise. The two hospitals are linked by a dedicated T3 line that facilitates data transfer. If an echo study is completed at one site, physicians at the other site can view diagnostic quality images within seconds. The benefits are apparent during surgical echo studies. Lopez completes the impossible and is “present” in two places as he views an echo completed in the OR in Orlando from his office in Miami and recommend changes if necessary.
The virtual presence of an expert improves patient care and workflow, says Lopez. “Other sub-specialists are forced to commute the 250 miles between sites more frequently,” reports Craig Fleishman, MD, director of non-invasive imaging. The echo labs, however, video conference on a near-daily basis, which maximizes staff time and optimizes information and resources.
The distributed outpatient enterprise
South Carolina Heart Center is a seven-office practice headquartered in Columbia, S.C. The group relies on Siemens Medical Solutions Soarian Cardiology for cath lab reporting, syngo Dynamics PACS and plans to implement Siemens/NextGen ambulatory electronic medical record by the end of the year. Siemens Open Link serves as the interface for the information systems.
Like other digital facilities, South Carolina Heart Center has realized gains in efficiency and accuracy. “We’ve eliminated redundancy in documenting patient demographic information. Scheduling and billing information is transferred and automatically available, and we know when patients arrive,” explains CIO Sherry Shults. Insurance information is readily available, too, so staff can complete pre-authorizations or inform patients of their financial responsibilities upfront. The practice also relies on Allscripts Healthcare Solutions Impact.MD for document storage and Captaris’ RightFax for autofaxing. Impact.MD stores all dictations online, which allows physicians to view documents electronically, and RightFax automatically sends reports transcribed at the hospital to the center and to Impact.MD. “We don’t need to call medical records to request information. Anytime you can remove manual processes, you save time and reduce errors,” Shults says.
Cardiologists, perhaps more than other specialists, require information from a variety of sources in multiple formats. Soarian Clinical Access links into all of the programs at South Carolina Heart Center; a physician logs in once, searches for the patient and the system pulls data from multiple servers so it can be viewed from one location. Single location viewing is an essential feature of the 21st century cardiac enterprise, says Shults.
Expert Advice: Workflow, integration & IT
Digital image management does drive results, but getting there can be a trip. Cardiovascular information systems are expensive in terms of time and money; it’s important to choose and implement wisely, says Breall.
The first consideration is workflow. “Before you begin looking at systems, map workflow and document what you think is important. You don’t want to purchase a system and negate workflow. The system and workflow should meld together,” says Craig. Cooper adds, “Understand all of the steps of workflow and what they mean in digital terms.”
For example, some systems produce proprietary data that cannot be completely translated to or used on another system. Dayton Heart Hospital solved the issue with software, but proactive awareness helps minimize workflow busters.
Craig used a workflow map to inform the decision-making process at Olathe Medical Center. She did solicit staff input, but placed limits on its power. Physicians, for example, tend to base their opinions on their workflow rather than the entire workflow. “If you make the tech more efficient, physicians will be more efficient, too,” she says. Although Craig gathered advice from other users, she did not rely too heavily on user perceptions. “Opinions and perceptions aren’t always accurate. Workflow doesn’t lie.”
Holtzclaw recommends that buyers consider other imaging services across the enterprise. “It’s important to understand how they might fit into your plan,” she explains. For example, Linda and Jack Gill Heart Institute anticipated that it would take five years before the archive needed to be expanded; however, the cath lab is a victim of its success. With multiple users elbowing their way into the archive, the hospital is exploring expansion options just two years into the process.
Integration, not surprisingly, is another critical factor. An integrative solution provides an ideal starting point. The more integrative a system is, the better it will work for you, says Breall. “Think like a visionary,” adds Couillard. “The system should complement and work with the radiology PACS to facilitate the growing synergy between radiology and cardiology and interface with any equipment you might bring on board in the future.” Even the most integrative system, however, requires some IT tinkering.
In fact, the IT department is an essential member of the cardiovascular team. “It’s a myth that you need less staff to run computer systems,” says Craig. Olathe Medical Center created a cardiac information services team for rapid, urgent response to problems and to ensure full integration to other systems. Whether or not cardiology hires its own IT staff, IT involvement is critical. IT involvement helps cross barriers, meet enterprise IT standards and connect into other systems, says Holtzclaw. Miami’s Fleishman adds, “It’s important that IT buys into the system early in the process.” An engaged and involved IT department can remove a significant burden from clinicians.
Holtzclaw, however, does not advocate turning complete system control over to IT. “You need capacity to work locally. With some local control, the department can complete and store cases if the hospital system goes down,” she explains.
Finally, training is essential. Clinical specialist support helps users get started and continue to build skills so that the department squeezes all of the functionality from a system, says Holtzclaw. Cooper adds, “Buy twice the recommended training so that you can optimize the system for maximum patient benefits.”
Peeking into the future
Cardiovascular information systems are in a state of evolution. “In five or six years, everyone will look back and ask why an integrated deployment was so difficult,” opines Bassi. Ease is only part of the equation; integration between reporting and image management solutions will deepen. “I’d like to include pictures in my reports or complete measurements while I’m reporting,” says Lopez.
Other items to look forward to include faster speed and falling prices. “Memory is getting cheaper and computers are becoming faster,” affirms Lopez, who predicts that accessing serial historical studies will be even faster in five years.
“More testing and ancillary services will be performed outside of the hospital,” predicts Shults. Private practice physicians will want information in an electronic format and will need solutions tailored to their needs, she says.
The heart of the matter
“Digital [image and information management] is the way to go. Any short-term pain is outweighed by the long-term benefits,” concludes Miami’s Fleishman. Images and information are available in near real-time and in multiple locations to enhance efficiency, workflow and patient care. Reporting is streamlined and consistent with turnaround time measured in minutes and hours versus days. Cardiologists, radiologists, other specialists and clinicians have ready access to images and reports across and beyond the enterprise for rapid, well-informed clinical decision-making, improved workflow and reduced costs. The upshot? Integrated, digital cardiovascular information systems are an essential component of 21st century cardiac care.