Take Heart: PACS Streamlines Cardiovascular Care
Siemens syngo Velocity Vector Imaging technologyPACS has gone from a tool that only large, high volume organizations could afford to a more prevalent system for facilities of all sizes. Now, more and more facilities are installing a PACS in their cardiology and vascular departments to manage echocardiograms, cardiac catheterizations, CTs and other procedures. Selling the idea to physicians and administrators can be a challenge and it’s easy to underestimate how to get the most out of the system once it’s implemented. Inside Cardiac Imaging talked to several facilities about their experiences with implementing a cardiovascular PACS.

“PACS for cardiology is so important because we’re such a visual subspecialty,” says Peter Frommelt, MD, pediatric echocardiologist at Children’s Hospital of Wisconsin. Having studies only on a CD or videotape doesn’t allow for all of the important players to access the images. “We live and die by our images. The ability to have images that are widely available and easily accessible is really the lifeblood of a good program.” The hospital became the first all-digital pediatric echo lab in the country in 1998. “We’ve been so pleased with our early push to a PACS solution for cardiology,” he says. “Despite our pain and suffering, we’ve been well rewarded.” Eight years of digital information are invaluable for patient care and research purposes, he adds. Children’s uses syngo Dynamics from Siemens Medical Solutions.

“If you’re going to be a cutting-edge cardiology department, whether small or large, you have to have certain technologies,” says Mark Weber, manager of clinical services for the Health Alliance, a group of six hospitals in the Cleveland, Ohio area. “If you’re going to sell yourself in the community as a state-of-the-art cardiology program, you have to be a state-of-the-art cardiology program.”

Fight physician fears

Despite the benefits that physicians will experience, jumping the hurdle of obtaining their buy in can be a challenge. “In some cases, the physicians involved don’t want to make the leap,” says Weber. “They are content with burning CDs.” Volume, however, does have to be high enough to justify investment in a PACS, he says. “You really have to convince them that their workflow will be better. You are buying this because it will improve patient care, it will make information more accessible in more places, and consulting and referring becomes a lot more practical.”

CDI originally implemented a PACS from Camtronics, now Emageon, in 2000, and physicians at the Alliance hospitals have become passionate about it, says Weber. When upgrades are scheduled, “they get a taste of how it used to be,” he says. They don’t have full functionality and “realize that they don’t know how they did it before.” Some physicians practice at other hospitals that don’t have a PACS, which also garners appreciation for the system.

Frommelt says that his PACS provides a seamless recall of both current and archived studies of the same patient that videotape can’t begin to compete with. “That’s pretty well known but pediatric cardiologists are frightened of giving up tapes,” he says. “They want long sweeps. They want to tape everything that the technologist does.” However, he has been successful getting them to focus on one-beat clips for diagnosing even complex congenital heart disease.

Selling the benefits of PACS to physicians can help facilities get what they need from those physicians. “Our physicians practice at a variety of hospitals,” says Kelly Neal, director of cardiovascular services at Washington Hospital in Washington, Pa. “It’s important for us to be able to offer the ability to report on images remotely. One of the biggest gains is that physicians can remotely eyeball a catheterization as it’s being done.” Her facility uses Horizon PACS from McKesson.

Not all cardiologists have to be dragged into a new realm of technology. A small group of cardiologists chosen to be the first to go live with the Agfa HealthCare Heartlab cardiovascular product suite at Florida Hospital Waterman in Tavares, Fla., paved the way for their colleagues. “We chose a few to try it out and they loved it,” says Cynthia Lenninger, cardiodiagnostic supervisor. Other cardiologists saw the trials and wanted to use the system also. The facility was able to go live earlier than planned. “They didn’t want to wait,” she says.

Show me the money

Hospital administration holds the purse strings so selling the need for PACS is vital. Weber worked with the vice president of cardiac services and the head of medical services to sell the PACS. They offered meetings with all of the various stakeholders to find out their needs and reservations.

They created a budget that included their minimum and maximum recommendations. Since each of the six hospitals has a different volume of procedures, each could tailor a system to their needs. “We let them decide,” he says. While they pointed out how much could be saved on film, they also made it clear that ongoing investment was crucial. “We cautioned them that once you buy, it’s not going to be a static purchase. New technologies are very capital intensive.” With an average software interval of 12 to 18 months in medicine, the expense never goes away. “We really cautioned them and said, ‘When you think you’ve paid for the system, you’re going to have to reinvest.’” He says he’s been lucky that he doesn’t have to plead for more money every year. “They’ve been eager to reinvest.”

Lucretia Craig, chief of imaging services at Olathe Medical Center in Olathe, Kansas, says she and her facility’s cardiologists drove the push for PACS. Her administration gave her a set budget, so she could get a PACS as long as she stayed within her budget. Olathe started a heart program in 1998, essentially doubling its size to 300 beds. The center started out with film but when they talked about building a chemical darkroom, they decided it was a good time to get rid of that process. “That was the trigger to go filmless,” she says.

GE Healthcare already was Olathe’s primary vendor for its hemodynamics equipment, so Craig says shifting to cardiology PACS was simplistic. That didn’t come, however, until after two years of shopping around for a vendor that offered a PACS that would work for both radiology and cardiology. “No other vendor could do it,” she says. “A lot of vendors have pieces but you don’t see full integration. We won’t purchase anything and we won’t function in a way that lends to physicians using separate, disparate systems. Full integration has been our Bible.”

Getting final approval to go forward with the PACS required justifying every penny, Craig says. “Lots of people focus on fiscal responsibility,” she says. “We had the money but we wanted to spend it very wisely. The bottom line is patient care.”

Weber also says that a facility is “not going to get rich doing this. You do this because it’s best for the patient.” Others agree. “It’s a no brainer to me,” says Kenny Dukes, director of cardiovascular services at Natchez Regional Medical Center in Natchez, Miss. Dukes had used PACS from ScImage at his previous facility and when Natchez wanted to install a PACS for its cardiology department, he felt very comfortable recommending the same. Natchez installed ScImage’s PicomEnterprise last year.

Nurture, not neglect

Although PACS can simplify so much, users warn that getting the most out of the equipment is not so simple. “We were very naïve about thinking that we didn’t need a person to oversee implementation and maintenance,” says Neal. She thought she and her cath lab manager could handle that. “To do what the system is intended to do, you need someone paying attention to it, getting all of the bells and whistles out of it.” The software is good, she says, but someone has to “mother” it. “To spend the money and have the system not do everything it can is really a shame. If you’re going to invest in the technology, invest in someone to maintain it.”

There is a tendency to think that because PACS simplifies your processes, departments can get by with less staff. “It’s not true,” says Olathe’s Craig. “You’re attempting to put systems in place that need attention to detail very specifically.” And new steps in the process become more important, especially patient registration. “When you go to PACS, or any kind of computer system, there’s a tremendous amount of reliance on people you’ve never relied on before,” says Craig. Since registration is the starting point of an electronic process, those employees need training. “If registration gets something wrong, nothing is right from then on and it takes hours of recovery. Your education process is not just for the people using the PACS but also for the people who start the process of the electronic record.”

At the most basic level, the PACS is a database. So, Craig recommends hiring “highly qualified people to reconcile your systems so that as you grow the system you can manage it and keep it clean.”

Craig’s facility created a cardiovascular information systems manager position who is responsible for managing all the systems in the cardiology department, making sure that the database is clean and that all staff are trained properly.

Another potential challenge to getting the most out of a PACS is growing complacent with it, says Weber. He and his team try to regularly show users what the system can do for them, such as using dual monitors for side-by-side comparisons.

Having gotten PACS six years ago when the technology was relatively new, Weber says he was a little naïve also. “What I see that generates the most failure is that facilities have a tendency to under-staff their support. They don’t hire enough people in IT and clinical support to really work with the end-users.”

The workflow well

Considering department and facility workflow and how it will change can significantly impact the results of a PACS installation. You need to evaluate your workflow in-depth, and really understand it and how PACS will impact it, says Weber. Back in 2000, there weren’t many facilities he could reach out to and ask how PACS affected staff. If another system is installed in an Alliance hospital, Weber now has a process in place. He knows how to interview the department and map out the workflow, and he has detailed job assignments.

Weber also has considered downtime procedures because he knows there will be downtime. “People don’t think about that. They just assume that this stuff works 24 x 7.”

But many users say that the main impacts on workflow are speed and more speed. “Our workflow has changed dramatically,” says Lenninger. “We can get echos done in a more timely manner and they are ready for doctors to read as soon as we’re done with the study.” She says the PACS also has reduced paperwork down to the bare minimum.

Dukes has seen the same. “It’s just made everything a lot simpler,” he says. There are no images to file or CDs to burn. “Everything goes straight into the PACS so it’s already there. When we finish a case, we don’t have to do any extra work.” The technologists have had to learn a few extra steps but that was worth it, Dukes says, because the PACS has relieved them of a lot of their old duties. “It makes for less busy work for them so they can be more productive.”

Getting thorough reports

One of the most significant ways that PACS can help with patient safety is by helping users more easily create structured reports. Frommelt says his organization did not have a dictation template that gave a complete structured report of the heart — a segmented analysis of every aspect of the heart — which is a requirement now. The only way to get a thorough report was for the dictating physician to comment on each part of the heart. “People didn’t do that,” he says. “They just commented on the anatomy they saw.”

And, once the physician dictated his less-than-thorough report, the dictation went through a transcriptionist and then into a separate electronic system. Physicians had to go in and find their reports, read them and sign off within four to six hours. Then, the report was uploaded to the hospital’s EMR. That also triggered the report to be faxed to the referring physician. In reality, report turnaround time was closer to 24 to 48 hours. And, the technologist would handwrite a preliminary report in the chart — a system “fraught with patient safety and quality concerns,” Frommelt says.

The physician-dependent system was not good, he adds. “You always want airbags, not seatbelts.” With the Siemens PACS, a structured reporting system is married to the images. The report provides a template so that all segments of the heart are described, and when the physician is done with the report, with the click of a button that study is autofaxed and autouploaded into the EMR. Turnaround time is now about two hours.

“Having this system has allowed us to completely eliminate preliminary reports,” Frommelt says. Only one report is generated from each study. “Our consumer physicians love it and other noncardiologist consumers have been very happy with the ability to get complete and final reports so quickly.”

Pick your people

Often the people you work with are just as important as the equipment. “You can buy the best and greatest equipment but what really matters is the service,” says Lenninger. She and her team are very happy with the quick response she gets from Agfa HealthCare Heartlab to problems and questions.

Washington Hospital’s Neal has had a “phenomenal relationship” with McKesson. The company sent a team to the facility that took the workflow and translated it into fixes and additions to their PACS. “We couldn’t have asked for a better relationship. They listened to how we wanted our reports structured and put that information into templates.” Neal had two existing systems — RIS and HIS — that the PACS had to feed to. In less than two weeks, the McKesson team made it possible for Neal’s users to get a “beautiful, very robust report.”

Your vendor relationship is worth a periodic review, PACS users agree. “When looking at any PACS, continually look at your partnership,” says Judy Smith, PACS administrator at Florida Hospital Waterman. “That’s not only sales and hardware, but the service side, including upgrades and the future vision of upgrades.” She has been impressed with Agfa Heartlab, and their interest in her thoughts. “They have let us be a voice. They have valued our input where some vendors don’t quite want to listen to users.”

Ongoing challenges

The cardiology PACS market has grown but there are still some gaps, says Frommelt. Working with two proprietary systems that don’t communicate, he had to create a patch that did not previously exist. “This system was not in any way designed to do what we’re currently doing,” he says. The solution includes other builds generated from his facility. “There should be solutions that you can purchase and have been functional, but the industry still is not to that point.”

The improvements in treating pediatric congenital heart disease patients are starting to require more from vendors. “The industry has not supported pediatric structured reporting for echocardiography,” Frommelt says. “That’s a huge deficit in a small market. It doesn’t have the same priority as the adult market.” But, adult reporting is impacted as pediatric congenital heart patients become adults.

At this point, creating a report can be time-consuming. “You can dictate even a complex lesion in one or two minutes, but it can take 10 to 15 minutes to create a complex congenital structured report,” he says. “Part of that is because Siemens’ pediatric congenital reporting system is still in its infancy. That work up-front is invaluable in providing timely, efficient and complete results reporting which dramatically impacts both patient safety and physician satisfaction.”

PACS for cardiology is offering a wealth of benefits to many organizations. The time may not be right for everyone but as vendors fine-tune their offerings and more standardization is in the works, the right time may be approaching quickly.