What will the cardiology department look like in 2010? Health Imaging & IT sought expert opinions on what imaging technologies and applications are in the works, how demographics are changing and where cardiac care is headed over the next five years. The big picture may surprise you.
More patients and sophisticated imaging techniques as well as a shift to prevention of coronary artery disease will be cardiology hallmarks in five years. Patient data management will drive improved care as physicians located in multiple, disparate enterprises can provide optimal patient care with complete patient information—including images—at their fingertips. As we look at the demographic, clinical and technical factors that will converge to create the cardiology department of 2010, consider:
- In 2010, the first baby boomers turn 65. Stir in the epidemic of obesity and diabetes and the number of Americans at risk for cardiovascular disease reaches 100 million.
- CT and MR angiography will continue to gain acceptance in the market, changing the function of the cath lab. Look for the first 256-slice CT scanners to arrive by 2010.
- New tests could allow physicians to detect coronary artery disease earlier. "Today, we treat cardiovascular patients when they become symptomatic. By 2010, there will be a forward shift to the asymptomatic patient," says Frederic Pla, general manager for cardiology care, GE Healthcare.
- PET-CT and SPECT-CT may be deployed to diagnose medium to high-risk patients.
- Look for the advent of the lifetime patient record and technologies and structures to support its access and distribution.
The patient population
"The cardiology market is growing," sums Ronald Razmi, MD, director of cardiovascular MR/CT at The Heart Center of Indiana (Indianapolis). "We have an epidemic of obesity and diabetes that is projected to grow over the next 10 to 15 years. We'll see more vascular disease in younger people, and they will need imaging and stress tests to look at the coronary and peripheral vessels."
Technology will impact the patient population. Sixty-four slice CT presents a viable, non-invasive alternative to conventional cardiac catheterization. "A lot of physicians are reluctant to send a borderline patient for an invasive procedure. They will pull the trigger faster with a non-invasive option," predicts Razmi. This means more patients to be imaged and earlier detection of disease for some patients.
But 64-slice technology isn't the holy grail of detection. "There will be simple, non-invasive tests to stratify low-risk and high-risk patients," says Pla. Carotid IMT (intima-media thickness) ultrasound can be used to measure the thickness of the carotid and look at the morphology of the carotid wall to determine which patients are likely to have coronary artery disease and should be referred for additional tests like CT or MR angiography. John Elsholz, vice president of product development at Witt Biomedical adds, "We'll see increasing use of proteomics and genomics in both diagnostic and treatment regimens for patients who are at risk for vascular disease." And preventative therapies based on genetic markers may be used to treat cardiac disease before it occurs.
Cardiac CT revs up
Sixty-four slice CT screeched into the cardiology arena in 2004, providing a new option to evaluate some cardiac patients. Key questions to consider include:
- How will cardiac CT evolve over the next five years?
- How will the cath lab be impacted?
"CT will play a major role in the cardiology department of 2010," predicts Sudhir Kulkarni, director of strategic solutions, cardiology for Siemens Medical Solutions. Kulkarni says several factors will determine acceptance of cardiac CT; reimbursement, training for cardiologists and cardiac applications, availability of the technology, research to define and compare CT angiography to x-ray angiography and acceptance by surgeons. "The earlier these happen, the sooner CT will become more prevalent over x-ray angiography. But diagnostic catheterization will not be completely eliminated," sums Kulkarni. CT may grab invasive diagnostic procedures from the cath lab; however, it cannot be deployed for interventional procedures as pushing stents requires continuous streaming video.
In fact, cardiac CT may feed cath labs. "We're seeing a proliferation of cardiac-enabled CT scanners in the ER, and a lot of customers are building cath or electrophysiology labs in or adjacent to the ER," says John Desch, vice president, strategic business, North America for Philips Medical Systems. If CT detects coronary artery disease, the patient can proceed directly to the cath lab for treatment.
Toshiba America Medical Systems has taken on the task of determining the utility of 64-slice CT. An ongoing eight-center/300 patient CorE 64 trial aims to determine the sensitivity and specificity of 64-slice CT angiography vs. cardiac catheterization. Results are expected in 2006.
In the meantime, the question with CT is whether the next step will be a leap to 128-slice or 256-slice technology? GE's Pla foresees a pause and focus in the cardiac community as clinicians learn how to use 64-slice CT in the clinical setting. Robb Young, CT product manager for cardiology for Toshiba, agrees. Toshiba is running a 256-slice CT scanner in Japan, but Young admits it is not ready for prime time, citing computing speed as a prerequisite for the technology.
The primary clinical benefit of 256-slice technology is its ability to cover the entire heart in one rotation, which will facilitate the emerging applications of perfusion and infarct imaging. Young says Toshiba is completing research with the 256-slice scanner so that applications are ready when the scanner hits the market between 2008 and 2010.
MRI & cardiology: possibilities & barriers
"MRI could have a great future in cardiology," says GE's Pla. MR angiography is superior to CT angiography for cardiac applications other than coronary imaging, says Razmi of The Heart Center of Indiana. Plus, it involves no radiation or contrast. On the downside, there are some barriers to MRI's penetration of the cardiac market.
For starters, although MRI is a great tool for evaluating cardiac function and viability, echocardiography performs functional analysis reasonably well, and most cardiologists have decent access to echo. And cardiac MR has a fairly steep learning curve. What's more, 64-slice CT has gained fairly rapid acceptance and penetration in cardiology, which could negatively impact MR. Nevertheless, if a few factors converge, MRI could become a key tool in the cardiology department of the future.
"MRI could provide one-stop shopping for cardiac function and viability testing within five years - with improvements in computing power, speed, reconstruction tools and resolution," predicts Jonathan Elion, MD, medical director of Heartlab, An Agfa Company. Currently, MRI resolution stands at 1 millimeter compared to 0.4 millimeters for CT; the extra resolution is essential for coronary imaging.
"Theoretically, 3T should be able to achieve better resolution. If 3T fulfills its promise, coronary CT could be in trouble because MRI omits radiation," states Razmi. Moreover, MRI could become an interventional tool with improved resolution if open MRI could be combined with non-magnetic stents. A few labs - primarily pediatric labs - are placing MRI scanners in the lab, relying on the zero-radiation technology to get close to the target and swinging to x-ray to pinpoint the target.
Razmi points to a final factor affecting dissemination of both CT and MRI in cardiology - economics. "For CT and MRI to really take off, cardiologists must take ownership. A lot of cardiologists are heavily invested in nuclear cameras and complete studies in their office. If the nuclear camera yields adequate results, the bulk of the business may remain in the cardiologist's office.
PET-CT & SPECT-CT in the cardiac arena?
Although PET-CT and SPECT-CT bring some advantages to the cardiac arena, both types of fusion scanners face some hurdles. "Simultaneous imaging of the arteries and morphology [facilitated by PET-CT or SPECT-CT] would be a great advance," notes Kulkarni. PET-CT can measure ischemia with markers to show which areas of the heart are truly dead; however, only a smaller subset of the cardiac patient population requires ischemic benefits. Similarly, iodine can be used to mark pericardial effusion, and other cardiac markers could be developed by 2010.
One problem with both PET-CT and SPECT-CT is the cost of the exam. Their utility lies upstream of the disease in the asymptomatic population, but it is too costly to deploy either study for screening use, says Pla. The answer in 2010 may be to screen the 100 million at-risk Americans with a lower-cost screening tool and refer the 20 million intermediate risk patients for non-invasive imaging to better determine the extent of disease and appropriate treatment. Young foresees combining PET or SPECT with a 256-slice CT to gain perfusion data in both modalities, but admits the scanner will be quite expensive.
Gearing up for image & information management
The bottom line for cardiac image management is that cardiologists will be seeing more patients with more and larger images for a longer period of time, and images will need to be distributed seamlessly across and beyond the enterprise. "On the technical side, archive requirements will be substantially greater," says Elsholz of Witt. "Hospitals will need deeper archives and higher bandwidths to manage larger image studies." And as image sizes grow, vendors will need to develop new lossless compression algorithms to facilitate distribution of larger files.
Desch of Philips adds, "Generally cardiology won't be a department in 2010. Instead, cardiology will be a disease state. Hospitals of 2010 will treat patients in a disease path. They need to build governance and infrastructure to manage patients horizontally across the enterprise."
A key part of the horizontal infrastructure will be the combined archive. Elsholz says, "We will see further convergence of radiology and cardiology. Virtually every cardiology patient has a radiology record." On the technical side, the combined archive has fewer servers with no duplication of costs, management and maintenance.
Mosche Zchut, vice president of technology for OptiMed Technologies, Inc., describes the current state of affairs. "Today it is still a problem for cardiologists to access a chest x-ray. We will see improvements [in 2010] in workflow and patient care with a centralized solution that enables cardiologists to access images at their workstation."
The coming radiology and cardiology connection extends beyond PACS. Brian Fitzgerald, North American marketing manager for cardiology for Agfa Healthcare, relates, "Cardiologists interact with multiple disparate systems and modalities that aren't connected. Unlike radiologists, who primarily operate from a single workstation, cardiologists are mobile. The cardiology department may be on one floor, but the cath lab is on a separate floor. What is needed is a cardiology information system (CIS) linked with the image management system. The CIS should store cath and echo results and pull radiology and non-DICOM images like pathology images. The delivery mechanism should enable mobility. This requires a web-enabled image management system, providing the physician the option to review and report on images virtually anywhere."
Elion foresees the physician's portal becoming the access point for data from multiple systems with the distinction between images and other data diminishing. As storage costs continue to drop, it will become easier for images to co-exist with other data. The ability to view echocardiograms, cardiac catheterizations and lab data on one screen will improve both workflow and patient care.
Cardiology is and will continue to be a multi-facility specialty with patient data residing in multiple locations. Fitzgerald shares, "There is a disconnect between what happens in the physician's office and in the hospital [with physician's offices lagging behind in technology deployment]. One of the best solutions is for the hospital to take the lead and create a separate organization to provide IT infrastructure in a capitated environment."
"Over the next five years, CIOs need to create a cardiology information strategy that fits within their enterprise strategy," says Brian Nagle, global product manager for Agfa Healthcare. "An objective of that strategy will be to create a longitudinal patient record that aggregates measurements, treatment outcomes and other events over a long-term cardiology care plan." And the longitudinal cardiology record must be mobile.
Alphabet soup of the future
One of the enablers of the longitudinal patient record is the Integrating the Healthcare Enterprise initiative. The XDS (cross-enterprise document sharing) component will enable healthcare facilities to register the existence of a document with a repository. What are the cardiology implications? If a patient arrives in the ER with chest pain and a slightly abnormal EKG, XDS will allow the ER to tap into previous studies and perhaps eliminate the need for repeat exams. Plus, the information will be conveyed back to the primary physician's office, mitigating that disconnect between inpatient and outpatient care. "The infrastructure is building," confirms Elion.
One XDS enabler is the regional health information organization (RHIO), which will be in vogue in five years, says Elsholz. RHIOs are designed to permit healthcare providers access to patients' previous medical records. The lack of an enterprise master patient index presents another barrier; however, a bill to create a national patient identification system for use in any healthcare setting is before Congress.
Cardiology sits on the verge of numerous changes. Inpatient and outpatient healthcare providers need to create a plan to manage the onslaught of new patients, optimize identification and treatment and implement systems to facilitate inter-enterprise access to patient identification.
Clinical Snapshot: The Web-based EMR Meets Cardiology
"More than 10 years ago our medical group recognized the importance of a better documentation system than paper," says Ronald P. Karlsberg, MD, professor of medicine, University of California Los Angeles and director of IT and research for Cardiovascular Medical Group of Southern California (CVMG). That realization led to the development of NotesMD, a web-based cardiology patient record. The comprehensive IT solution enables the practice to capture 95 percent of patient data vs. the 40 percent captured in most practices. Data such as social history, outside consult notes and emails are available in one interactive location.
NotesMD has transformed the practice. Ten years ago, one transcriptionist served the four-cardiologist practice. Although the practice has swelled to 20 cardiologists, the lone transcriptionist still fills its needs. Karlsberg states, "Some of our physicians have doubled their efficiency [since we deployed NotesMD]. Plus we can provide better care because of these systems." Features like a single-click prescription refill shave up to 10 to 15 minutes from routine processes and, at the same time, reduce medical errors.
In addition to containing all records of patient contact, NotesMD provides evidence-based medicine to improve the quality of care. Embedded decision support will become increasingly key as 2010 approaches and cardiology evolves to a chronic care paradigm with an increasing portion of care provided by the primary-care physician. For example, a physician may query the EMR to quickly identify patient candidates for a particular therapy.
The browser-based program integrates with the practice's Medcon web-based PACS, so that all images are contained in the chart. Images and reports can be viewed in every exam room, and the integrated MDWeb-NotesMD application enables offsite availability and remote review for more efficient and accurate diagnoses and care. CVMG may be one of the first practices to implement a web-based cardiac EMR, but the model is likely to become much more commonplace by 2010.
Clinical Snapshot: The cath lab of the future
The Linda and Jack Gill Heart Institute at the University of Kentucky in Lexington, Ky., is banking that advances in CT and MR technology will grow its cath lab business. "The complexion of the cath lab is evolving from diagnostic functions to interventional procedures," states John Gurley, MD, director of interventional cardiology. Gurley describes the cath lab of the past as a quick diagnostic center with a limited menu of procedures and few, relatively inexpensive catheters and supplies on hand.
Fast forward to the present. The number of procedures and devices has exploded. Each case might require $5,000 to $7,000 in supplies, a dramatic increase from $50 in catheters and contrast 10 years ago. Scores of new stents and catheters including coronary stents, peripheral vascular stents and catheters, carotid systems and closure devices have been introduced. Procedures have become more complex, more time-consuming and pose greater demands on staff and the material budget. "The cath lab is more challenging to manage. There is the potential to generate or lose revenue depending on how efficient you are," explains Gurley. The Heart Institute aims to deploy RFID (radiofrequency identification) tracking tools to automate inventory and logging processes.
At the same time, Gurley says cath labs of the present and future need to concentrate on patient and operator safety as labs transition into the interventional world. "Vendors need to develop technologies to extract more meaningful information from the radiation we use, and cath labs need to modify techniques and dosing protocols to fit interventional (vs. diagnostic) procedures. For example, pulmonary vein isolation does not require the same frame rates or radiation doses as a diagnostic angiogram," Gurley continues.
He points to new x-ray equipment that can handle both coronary and vascular imaging as a step in the right direction, supporting multiple functions, including peripheral vascular, cerebral and congenital procedures in the cath lab.
The cath lab at Erlanger Medical Center in Chattanooga, Tenn., is poised to take advantage of the shift to invasive procedures. "We've built an invasive suite that can handle interventional procedures, and plan to equip the lab with diagnostic equipment to feed interventional procedures," explains Cath Lab Manager Craig Cummings. Cummings predicts an upswing in procedures like mitral valve repairs and aortic valve replacements in the cath lab in the next few years.
The 16,000-square foot invasive cardiology suite features a direct admit space and four rooms, with space to add two more rooms in the next five to 10 years. The new lab will incorporate a paperless charting and automated transcription system.
"Paperless charting will save at least $40,000 annually in transcription alone," calculates Cummings. The cath lab is laying the groundwork for paperless charting by scanning charts into lifetime clinical records; the scanned chart will translate directly into Witt Biomedical's Calysto solution when the cath lab deploys the system. The lab plans to implement digital imaging, including 64-slice CT, and share images over the medical center intranet. A one gigabit network will enable the lab to run large image packets through the hospital backbone.