The saying 'time is of the essence' pertains perfectly to the time-constrained healthcare environment that physicians, nurses and hospital staff deal with on a daily basis - particularly in the realm of cardiac care. Many cardiovascular patients receive initial care in the ER and need immediate intervention. Others have had numerous tests - echocardiography or vascular exams and cardiac cath procedures - and cardiologists need quick access to these images and reports.
With PACS, cardiology departments deliver this pertinent information to caregivers wherever, whenever within seconds. Cumbersome videotapes and hardcopy film are being phased out and replaced with digital imaging and high-speed networks for their transmission. Cardiology PACS are improving workflow, speeding up report turnaround time and allowing more informed decisions to be made at the point of care.
Cardiology is swiftly moving into the age of digital image acquisition, storage and transmission. With the implementation of complex computer networks and PACS, diagnostic cardiology units are replacing videotapes with digital cine loops and cardiac catheterization labs are storing their images to a centralized, electronic data repository immediately after procedures are completed.
The PACS-related workflow benefits cardiology departments experience include:
• Quicker access to images
• Rapid transfer of images within and outside the hospital
• Simultaneous viewing of images at multiple locations
• Simultaneous viewing of images from various modalities
• Elimination of misplaced, damaged or missing film or videotape
For cardiologists, interventional cardiologists and vascular surgeons, digital images and patient information are accessible from any workstation that is connected to the system whether it's within the hospital building or at a remote location.
The cardiology department at NorthEast Medical Center, a 425-bed facility in Concord, N.C., recently implemented Witt Biomedical Corp.'s Calysto for Cardiology PACS. The enterprise-wide cardiology imaging and information management system serves as the hemodynamic system in the cath lab, is used in the electrophysiology lab for patient monitoring, and does image archival and review - as well as report generation - for cath and echocardiography studies.
With the elimination of film, some steps in workflow that are conducive to an analog-based environment have been eliminated. "In a busy [analog-based] lab, it may be 30 minutes to a couple hours before physicians have access to echo and cath lab images and reports," says Richard Strickland, cardiology PACS administrator at NorthEast. "Now, [with the PACS,] our cardiologists can actually come out of the procedure room, sit down at the computer, review the images, make their notes in the electronic record and generate a report immediately."
An interface with Meditech [hospital information system] enables the completed report to be distributed throughout the whole hospital in 15 minutes, as well as emailed out to referring physicians.
In emergency situations, patient information and images are available at the point of care. "Before in an emergency situation, patient information and images had to be pulled from medical records," says Strickland. "If that was in the middle of the night, it could take a while. Now, the medical staff just has to walk over to a computer and type in the patient's name and they have access to everything the patient has had done."
Strickland says physicians agree that workflow in echo is much more rapid in the digital world than having to load individual VCR tapes and fast forward or rewind backward to find something. "[With the PACS], physicians can display up to 32 different loops at a time on a computer screen," says Strickland, "which is much faster for them."
Oscar Munoz, MD, interventional cardiologist at Del Sol Medical Center in El Paso, Texas, exemplifies the benefits of a cardiology PACS using the following clinical scenarios: "We were performing an emergency cardioangiogram on a patient. During the middle of the test, we saw two vessels occluded and the EKG was equivocal. We were not certain which vessel had the new occlusion to intervene. Using the PACS and a workstation in the control room, we referred to the patient's prior cath images and quickly determined which vessel was previously occluded.
"In another situation, a patient had a replacement of an aortic valve," Munoz continues. "Soon after the surgery, the patient had an echocardiogram and the images were stored on the PACS. The patient returned to the hospital with acute shortness of breath. An echocardiogram was performed to check the valve again and we saw that the pressure across the valve had increased significantly compared to the prior echocardiogram. Something else was preventing the appropriate movement of the leaflets of the new valve, and the patient required a second operation."
When cardiovascular images are managed digitally, Munoz says physicians can conveniently search for and retrieve images. "The patients benefit because the doctor is able now to retrieve the images right away," says Munoz.
Del Sol Medical Center is using Heartlab Inc.'s Encompass Cardiac Network (Agfa Healthcare acquired Heartlab in June) for the digital image management of cath and echo studies. Structured reporting is being used in echo, and reporting for cath and vascular is slated for this year. In addition, the medical center installed Heartlab's Encompass Web Viewer to increase access to patient images and information from any computer on their secure network.
"A doctor may be in the clinic in the afternoon and receive a call because a patient is in the ER with acute shortness of breath and hypotension," says Munoz. "The technologist in the ER can put the images on the computer, which the doctor can access remotely in the clinic or office. The doctor may see a large pericardial effusion and know that they have to return to the hospital."
For the cardiologists in the hospital, Del Sol installed high-end diagnostic workstations in strategic areas, including the intensive care unit, critical care unit, echocardiography/vascular diagnostic department, cath lab, the dictation room and the ER. "A large percentage of cardiovascular patients receive their initial care in the ER," says Vic Rulli, RT, director of cardiovascular services at Del Sol. "Doctors do not make a trip to the ER to look at patient images, but rather, retrieve images from the workstations installed in a number of areas."
Physicians do not have to leave the CCU to locate a patient's film and put it on a cine projector. Even though the patient had three different exams performed on the same day, the physician can look at all three of them via PACS without having to find two videotapes and a cine film. Patient information is literally at the doctor's fingertips.
Improved access to images is a PACS-related workflow benefit, as well as simultaneous viewing of patient images. "If the patient had a cath a couple months ago, doctors can pull them up and look at them side by side [next to the new images]," Rulli says. "Let's say the patient has a poor injection fraction on their LV [left ventricle] and the physician is trying to see if the patient has a leaky valve. If the patient had an echo three days before and then had a cath, the physician can pull up the echo on one screen and the cath on another and compare the two injection fractions.
"It's streamlining workflow," Rulli continues. "It's letting the physicians get information quicker. It's letting them make decisions quicker. Everything is on the PACS and they can pull it up."
Integris Heart Hospital, part of the Integris Baptist Medical Center in Oklahoma City, Okla., is utilizing the Camtronics Medical Systems' Vericis PACS to expedite treatment processes. Cardiologists, vascular surgeons and interventional cardiologists access echo, cath and nuclear cardiology images from high-end workstations for clinical review and to structure clinical reports. The studies and final results are accessible via the web from standard PCs to authorized users inside the hospital and at many of Integris Baptist's 25 outreach clinics.
Workflow has changed now that images produced at the clinic can be uploaded to a central server and accessed by cardiologists at the Heart Hospital. "Instead of couriering images to the Heart Hospital from remote clinics, images are now sent electronically via network connection," says Aimee Tebow, director of Integris's heart cath lab. Physicians read cases in a more timely manner - increasing report turnaround time by at least two days, and an entire week in some cases.
Medical Center utilizes the internet and their cardiology PACS for their pediatric echocardiography program. "We do not have an onsite pediatric cardiologist," says Strickland. "We have an agreement with a radiology group that is about 20 miles away that has pediatric cardiologists. Rather than having them come over to the hospital to read echo films, they can see the cases immediately over the web. We get their [diagnosis] more quickly than if we had to wait several days for them to drive over to the hospital. The PACS impacts the speed in which the decision can be made and the care that is delivered to the patient."
Sending images over the web is a growing PACS-related trend and workflow booster. "The radiologists who read for us never step foot in the hospital," says Doug Colburn, CIO of Nebraska Heart Hospital in Lincoln. The radiology group, which is located in Omaha and about 50 miles away from the Heart Hospital, does all of their readings over the internet via a web application on diagnostic-quality monitors. "The cardiologists are most interested in echos, CT scans and cath images, but we also take a lot of chest x-rays and some CTs that are non-cardiac related," says Colburn. "We do lots of different care here even though we are focused on cardiac."
Nebraska Heart Hospital partnered with Siemens Medical Solutions to help make it a progressive and comprehensive filmless and paperless cardiovascular care center when it opened its doors in May 2003. Siemens' Soarian Cardiology, Soarian Clinial Access and Invision ChartAssist IT systems provide the technological backbone for the facility's electronic health record. Cardiac CT, x-ray, echo, cath and cardiac nuclear medicine images are all stored on PACS. To access the various clinical and business applications, physicians and medical staff use single sign on smart card technology.
"Eventually cardiac MRI and cardiac PET studies will be stored on the PACS," says Colburn. "Nearly 160 PCs and flat panel [displays] are located throughout the hospital. There are probably at least one or two computers located in each patient room. Diagnostic workstations are located in reading rooms and the cath lab."
Colburn says the hospital deployed a "dashboard" product that is a web-based portal that gives clinicians access to various ancillary systems as well as the lifetime clinical record. "All of the ancillary systems, including PACS, feed their data into this application. It's accessible via web browser from any PC in the hospital as well as externally."
Everything pertaining to the care of the patient is information available to the clinicians at their fingertips: the EMR, assessments, vital signs, dictated reports and electronic images. "Physicians love having all of the imaging modalities on the computer because they can access them anywhere they want to or need to," Colburn says.
Although he says that Nebraska Heart Hospital is on the "bleeding edge" with the implementation, combination and utilization of IT systems specifically designed for cardiovascular care, it's a constant works-in-progress. Speed and patient data presentation are two areas the hospital strives to improve.
"If you don't throw up exactly what the physicians want to see as soon as they want it, they loose interest quickly," says Colburn. "The two things to refine our system has been increasing the speed to access and better presentation and summarization of the data physicians want to see. We have created a summary screen that has all pertinent patient information on it. We also created this clinical kiosk that reduces the time to access to about 10 seconds."