Building the Ultimate Healthcare IT Infrastructure

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Database consolidation streamlines the enterprise

Consolidated healthcare IT infrastructure promises to help fix the system—providing clinicians streamlined access to multiple datasets to make timely, informed clinical decisions and removing artificial barriers between departments, physicians and hospitals. “As healthcare evolves and [artificial IT] barriers break down, physicians can respond appropriately, which, in turn, improves patient care and increases patient throughput and capacity,” says Mike Smith, CIO of Lee Memorial Health System in Fort Myers, Fla.

Healthcare IT’s results are impressive. Hospitals deliver better care, faster—and IT helps to saves lives. It’s a fact that patient mortality rates drop 15 percent during hospitalization when computers replace paper, according to a recent study in the Archives of Internal Medicine. Researchers found that healthcare facilities in Texas that used IT-based medical notes and records, test results, CPOE and decision support have fewer patient complications, less mortalities and lower costs.

Beyond patient care, charge capture is more effective with clean, complete claims the first time around. And we can’t forget staff productivity, efficiency, operational workflow, clinical workflow and better quality outcomes measurement.

Cutting-edge organizations with vision and set goals are working toward connecting and consolidating various imaging and clinical databases. The Southwest Ontario Digital Imaging Network in Canada, for example, is deploying a consolidated image database in one of North America’s largest digital image management projects. Ultimately, the project will provide users at 19 hospital corporations and scores of healthcare organizations the ability to share images regardless of the native PACS. Other healthcare organizations are taking a different approach and consolidating clinical datasets in a single source to streamline clinical care. Some are developing a single enterprise image management structure that houses radiology and cardiology datasets and provides an ubiquitous enterprise imaging workstation geared to the clinical needs of the exam.

Images everywhere

Southwest Ontario Digital Imaging Network (SWO) is one of the first steps in an eHealth Canada initiative to create a pan-province longitudinal patient view, making digital images available to physicians across the province, regardless of the native PACS. The project initiated in 2002 as the first of three hospital corporations deployed PACS, with each site selecting a separate vendor. Over the next several years, the project expanded to include additional sites and different PACS.

The network launched phase 2.2 of its project in December 2008. The DI-r (diagnostic imaging repository) is designed to bridge the various PACS throughout the geographic region. SWO invested in GE Healthcare Centricity Enterprise Archive and Centricity OneView—a PACS connector of sorts—a web-based clinical information and workflow management system designed to connect multiple discrete RIS and PACS solutions. The investment was made to complement the local PACS and provide radiologists with the ability to view broader patient information including all orders, patient demographics and results. All physicians in the Grey Bruce site, which consists of one hospital and two health services organizations, access patient images through Centricity Enterprise Archive. Other hubs across Ontario will follow in the next few years.

Planning for the massive centralized project has been complex. When it is complete, seven distinct PACS/RIS will feed into the repository. SWO established a Regional Shared Service organization; decision-makers from regional hospitals and health services corporations met regularly prior to the launch to tackle issues such as patient privacy, equitable cost sharing and appropriate service level agreements. On the IT front, Smart Systems for Health, an Ontario-based non-profit, assessed network readiness, boosted security and increased bandwidth from the hubs to the data center as necessary. 

A few months into the initiative, the DI-r/eHealth project is making an impact on patient care, says Stephane Ouellet, director of Regional Shared Service, Information Management and London Health Sciences Centre. Consider the recent case of a man who presented to a local hospital with symptoms of a massive stroke. A CT at the local hospital confirmed the diagnosis, and the patient was whisked to the regional academic medical center. “Upon his arrival, neurologists at the academic medical center had viewed the CT via OneView to confirm the diagnosis and administer TPA (tissue plasminogen activator). If the neurologists hadn’t had access to the images, the three-hour window for TPA would have closed,” shares Ouellet. The clinical and economic ramifications are clear. Without access to PACS images, physicians would have ordered a second study. Without TPA, the patient’s recovery would have been compromised.

Ouellet predicts other benefits as the single archive rolls out. “We expect to reduce patient transfers because physicians can make more informed diagnostic decisions by accessing images on OneView, limiting transfers for patients who can be treated locally.” In addition, the PACS connector enables virtual access to sub-specialists. For example, sub-specialists can render a treatment plan for remote cancer patients without a face-to-face visit.

Early into the project, Ouellet reports than DI-r has changed radiologists’ workflow. The ability to view images remotely allows them to work from multiple hospitals. “This helps mitigate the effects of the radiologist shortage,” sums Ouellet.

Future phases in the DI-r project include expanding capabilities to cross-regional reading of images and may extend to integrating cardiology datasets into the archive.

Toward an enterprise image management solution

Lee Memorial Health System aims to integrate its legacy Agfa HealthCare HeartLab PACS in the cardiology department with a newly deployed Agfa Impax digital image management system in the radiology department. The rationale for the complex, multi-phase process is clear, says Smith. “The lines between radiology and cardiology modalities are blurring,” he says.

Lee Memorial is the fifth largest public health system in the United States and the largest community-owned health system in Southwest Florida. With more than 8,500 employees, it is made up of five acute-care hospitals and two specialty hospitals.

In more and more cases, imaging modalities and procedures are neither radiology nor cardiology. They are multi-ology. Caregivers in both departments. Distinct digital image management systems create artificial barriers. Although cardiology and radiology are uniquely co-mingled, the issue extends to other departments as well.

Lee Memorial Hospital’s new endovascular suite has a digital bi-plane imaging system, which neurologists use for imaging studies and brain stenting. The neurology images wind up in the cardiology archive—even though they are not cardiology images. Consequently, neurologists contend with two imaging workflows and two distinct image management systems in their regular workflow. Cardiac CT angiography (CCTA) poses additional problems. CT is a radiology modality and exam, but both radiologists and cardiologists read the datasets, creating an archiving dilemma. Storing the images in the radiology PACS can frustrate cardiologists, who have to adapt to the radiology workflow and system to complete their review of datasets. The same is true for radiologists in facilities that store CCTA datasets in cardiology PACS or CVIS. “We want to use technology to remove these artificial barriers,” explains Smith.

The challenges continue downstream and impact the ultimate imaging customer—the clinician at the bedside. For example, dual reading of CCTA studies results in two reports, but the caregiver wants only one report. Currently, Lee Memorial Health System links the two reports, but linking them requires mechanical intervention.

The facility plans to combine radiology and cardiology image management in a single Impax PACS. Phase one—integration into a single database—began early in 2009. The end goal is an enterprise workstation that tailors toolsets to clinical needs. That is, when a physician logs on to read a cardiac CT study, the appropriate toolset will launch, whether the user is a cardiologist or a radiologist.

Smith foresees significant benefits when the hospital finishes integrating the two systems into a single database. The technology will balance workloads, leverage physician expertise and improve turn-around time and patient care because physicians will not be hampered by artificial restrictions created by various image management applications. The new system will serve clinical end-users by linking images to the EMR, providing them with critical data in a timely, convenient manner.

The IT department will continue to work with its PACS vendor to manage clients and toolsets. For example, as it deploys digital mammography, it will embed this client on the PACS workstation. The strategy also tackles referring physician workflow by providing access to images for (non-diagnostic review) via the clinical portal.

A real-time EMR

Several years ago, MedCentral Health System, a mid-sized regional hospital in Mansfield, Ohio, faced the prospect of several IT systems concurrently sunsetting. The organization assessed its goals and drivers to inform its next IT investments. “We decided we wanted to deploy a real-time [vs. historical] EMR,” shares Fred Crowgey, IS project director. “Our focus is on pulling the right information at the right time and presenting it in the right place to support clinical care.”

Siemens Medical Solutions Soarian Clinical Access clinical data repository proved to be the right solution for its needs. MedCentral deployed the system late in 2004 as an online data warehouse for data originating in various systems. Soarian interfaces with the laboratory information system, RIS and other clinical systems to capture nursing and physician documentation and longitudinal patient data. Images are stored in a separate database, but Soarian provides streamlined, one-click access to images.

Soarian Clinical Access impacted MedCentral almost immediately after deployment. “Sixty to 90 percent of all clinical decisions are based on lab and radiology data,” estimates Crowgey. More efficient access to the data translates into accelerated decision-making. Six months after going live with Soarian, MedCentral saw its average length of stay decrease from above the national average to benchmark rates.

The reduction benefits both patients and finances. Consider, for example, Medicaid cases. Every inpatient hospital stay that extends beyond the DRG-reimbursed rate means the hospital loses money. Prior to Soarian, results for a Friday afternoon chest x-ray might not be posted in the patient chart until Monday. Soarian integrates into the RIS, pulling the data and making results available to inform decision-making. Because results are immediately available in the electronic chart, the turnaround time associated with the paper-based chart is drastically reduced.

MedCentral also taps into the system to create workflow rules that improve patient care. For example, Soarian checks nursing assessments and documentation to determine whether a patient smokes. If a patient is a smoker, Soarian alerts respiratory therapy, so the department can share smoking cessation information with the patient.

Ultimate improvements

The writing on the IT wall is clear. Distinct, disconnected systems further fragment patient care. Consolidating data—either in a single database or in a clinical or image repository—is essential to streamlined workflow and patient care. Healthcare enterprises that have started to tackle the challenge warn that the process is complex as it entails multiple specialties, systems and sites. It is also necessary. The gains associated with consolidated infrastructure are essential to high-quality, knowledge-based 21st century healthcare. Consolidated systems provide caregivers with the clinical data they need in a convenient, efficient manner, to optimize patient care while maintaining cost-effectiveness.