O Pioneers! Cardiovascular Information Systems Workflow & Integration
Image courtesy of Agfa Heartlab

As a big boom in cardiovascular information system (CVIS) adoption approaches, vendors are gearing up with new offerings, and cardiology departments slightly ahead of the pack install the systems as would-be pioneers in a new frontier.

Like the way of paper charts and VHS tapes for viewing cardiac images, the old way of managing images in a cardiology department are beginning to vanish. But just beginning, for sure.

About “15 to 16 percent of cardiovascular departments have adopted cardiovascular IT systems, if you look at the averages,” says Jeremy Bikman, director, Imaging & Advanced Technology, KLAS Enterprises, which released two CVIS-related market reports in 2005. “That means that they’re storing images electronically and doing documentation electronically,” Bikman adds.

But there can be some confusion as to what exactly they are installing — a cardiology PACS that manages cardiac imaging or a cardiovascular information system that adds tools for patient management and admin tasks. In comparison, radiology PACS adoption rates are much higher — with almost all of large 500+ bed hospitals having shifted to PACS, about half of 200 to 500 bed facilities, and slightly less than half of 200 or less bed hospitals having installed systems.

The adoption gap between cardiology and radiology can be blamed on a number of likely reasons, some of them having to do with the unique culture of cardiology departments which are often much like powerful and influential micro-hospitals themselves. For instance, there are often communications issues between different specialists, and it also comes down to a question of expertise in IT.

“While vendors are struggling to completely live up to their promises, some of it is because cardiologists have not wanted to change the way they’ve done things. We’ve seen the cath lab not really caring or wanting to do what the echo lab guys do,” says Bikman, as an example.

Some departments have to sort out the conflicting approaches and lack of cooperation between each segment of their department in order to move forward with technology. Historically IT has not been that involved in cardiology, and cardiologists themselves do not necessarily have a high level of expertise in IT. The same might not be true of radiologists who are generally pretty IT-savvy.

“Wherein radiology you have people who are somewhat technically savvy, you’ve got radiologic technologists and systems administrators who can become PACS administrators, if needed. In cardiology there really aren’t too many corresponding people within the department” which makes the shift all the more difficult, says Bikman.

A mix of different solutions is another problem. Cardiology departments looking to go digital have to confront the integration of a great number of legacy systems, as well as the struggle of integrating even the newer systems, some of which don’t want to work together either.

“We were surprised by how standalone many cardiology departments are from an IT perspective,” says Bikman. “A lot of the departments were not connected to other systems within the hospital, not even [administration] for patient demographics. They communicate largely by fax or other slower means.”

Yet, despite these hurdles, the cardiovascular information system (CVIS) market is set to boom. KLAS was pressed by a number of organizations and vendors to study the market, which shows the urgency and interest. Meanwhile, large companies are buying up smaller CVIS companies — such as Agfa’s purchase of Heartlab, McKesson’s acquisition of Medcon and Emageon buying Camtronics’ line.

Making it work with few bells and whistles

At the very least, a cardiovascular information system will do a lot to improve a department’s management of digitally acquired images. Comprised of five metro hospitals, and a number of smaller rural facilities, Alegent Health in Nebraska pushes as many as 19,000 cardiology images to its cardiology PACS each year — comprised largely of non-invasive cardiology images such as TEEs (transesophageal echocardiograms), vascular, and x-ray angiography studies, and cine cath lab images.

Since February 2004, they have been gaining many of the advantages from this system that have been seen by countless radiology departments, using Siemens’ KinetDx Cardiology PACS (since renamed syngo Dynamics) to manage images, automate basic reading and reporting of studies, and to allow for enterprise-wide access through a 1 GB network connection.

“Things are generally more efficient. There are four cardiology groups that we serve and they travel around campus to campus. They are able now to read images at any campus they want,” says Jeffrey Bro, cardiology IT administrator.

The average file size for most of the images being sent to and fro is about 70 megabytes (MB), says Bro, although the range can stretch from 19 MB on average for vascular images to upwards of 250 MB for cath lab cases.

Although the KinetDx system is more basic than some, it is set up to feed reports to a Siemens Soarian HIS (hospital information system) once complete and checked for approval by physicians at a KinetDx workstation. Physicians do reporting at these workstations for everything but cath lab reports which must be dictated into a separate system.

One big benefit of KinetDx is speedier report distribution to referring physicians, Bro says. The reports are not electronically sent, but rather faxed. Compared to generating a hand-written chart, the reports are printed from the PACS and faxed which is a big improvement.

To connect KinetDx to the operating room, Bro rigged together an automated routing system to help surgeons and physicians there gain access to cardiac images. This type of distribution was not included in the system’s basic design but has been adapted nicely. Modality Worklist — which is not connected to KinetDx — is used by the department for demographic information and to smooth workflow.

Alegent’s piecemeal approach is probably typical of many cardiology departments as they shift to digitize their operations. It’s an ongoing process which requires an inventive approach to assure each piece fits and illustrates the need for dedicated IT personnel as part of any cardiology staff.

Expanding and speeding operations, and teaching too

A CVIS — that includes information management as well as image management — can be a powerful ally in confronting a great number of the conundrums facing cardiology departments. Winthrop-University Hospital in Mineola, N.Y., purchased and installed a Heartlab Encompass in January 2004. In one swoop, the facility addressed a laundry list of its cardiology department’s biggest woes: HIPAA compliance, the need to store cath lab studies on non-volatile media, lack of a data repository for statistical analysis, and a means by which to customize electronic reports, says Gina Berrent, technical supervisor, Department of Cardiology.

Winthrop is a large 591-bed hospital that acts as a tertiary cardiac referral center throughout Long Island and parts of Queens. Cardiology provides both in-patient and outpatient services, including all areas of invasive and non-invasive cardiology. Winthrop also is a teaching hospital and thus host to an ongoing set of cardiology fellows.

“It’s great because this is a teaching hospital, and the system dramatically improved how we train cardiology fellows rotating through invasive and non-invasive areas,” says Kevin Marzo, MD, chief, Department of Cardiology. “And it helps in outpatient care because it enables residents and fellows who are seeing patients who might have been in for inpatient care to have immediate access to their in-hospital studies,” adds Marzo.

The cardiology department at Winthrop is acquiring a wide range of images and pushing them to Encompass, and the workstations add a great deal of value as well.

“With the exception of 3D, the workstations do everything. There’s multiple case modality review at a single workstation; Dr. Marzo can sit down and view an echo that was done three years ago and pull up cath images from two years before that, along with the current images,” says John Gaetani, physician's assistant. “There are multiple tools provided for measurements and analysis, and image enhancement. You can print color copies of the images which some of the doctors like. A doctor can even take the cine runs and put them in a common video format for a PowerPoint presentation,” Gaetani adds.

Yet if there is any area that the people at Winthrop seem the most jazzed about, it’s probably the speed at which they are able to produce reports — which they custom built with the assistance of Heartlab — and pass them on to advance a patient to the next level of care the patient requires.

Moreover, Winthrop has as one of its hospital quality initiatives the completion of medical records. Marzo says that because of Encompass, their compliance level has hit 99 percent. Practically speaking, having a legible report from the cardiology department does have a big impact on patient outcomes. And, of course, having an illegible report is downright dangerous.

“What’s nice about the reports are that they come immediately following a physician going to a workstation and electronically signing off and are placed on the chart before a patient even goes to the recovery room,” says Berret.

Although reports from Encompass are currently paper-based, nurses can, for example, go to a workstation and via the web look at the electronic report if needed as soon as it’s complete.
Heartlab often uses Winthrop as a beta site for new components of the system. One of the upcoming offerings will allow for the secure distribution of reports via email, along with other new functionalities.

CVIS + EHR: Starting to really get somewhere

Cardiology Associates PC (CVA) based in Birmingham, Ala., is in the midst of tackling the integration of their ScImage PicomEnterprise with an Allscripts TouchChart EHR (electronic health record) system.

It’s a big job. Cardiology Associates has multiple facilities throughout Alabama, one of which in Montclair has nearly 30 cardiac exam rooms. “We’re like a small hospital, and there are actually more patients coming in compared to most hospitals,” says Eric Two Bears, CIO, CSO, director of information systems.

For example, every day the group produces as many as 15 PET/CT, five cardiac cath, 25 nuclear cardiology, and 30 echocardiography studies — which are handled by the 300-plus users on the network, many of which are physicians and PAs.

Currently they have two duplicate sets of patient demographics, one is held in PicomEnterprise while the other is in the EHR. This represents a big task in cleaning up inconsistencies in the data, but that is just one of many big tasks.

What Two Bears expects is a “lifestyle change” for the physicians in their group. At home they will be able to connect through a VPN (virtual private network), to read images, and access the EHR and sign-off on charts electronically instead of facing a pile of paper-based charts at the end of the day. The goal is to have physicians do their clinical notes as they go — working through a fully integrated system including the PACS and EHR to make everything completely paperless and completely automated.

Another component in the game plan is integration of PicomEnterprise with an IDX Practice Management system which is already interfaced with the EHR. This way the group also will be able to do appointment scheduling through the CVIS. Billing is done through the IDX system, and although the ScImage system does have some charge passing functionality, they do not plan on bringing in any of the IDX functionality in billing over to the cardiology system. For the most part, system integration is handled in-house at Cardiology Associates, with a helping hand from the vendors when necessary.

Running the whole shop

Some cardiovascular information systems are becoming the hub for patient management within cardiology departments, beyond image management, patient demographics, and even scheduling. At Community Hospital — part of a three hospital system in northwest Indiana called Community Healthcare System — a Witt Biomedical Calysto for Cardiology system is being completely integrated with inventory and billing as well.

Community Hospital made a commitment about a year and a half ago to move towards the system with all of their cath labs. As part of this process, Witt came in and evaluated every cath lab room and recovery area and connected to Calysto. Each interventional radiology room is using the system for documentation, measurement, and monitoring. In addition, it is connected within their Community Cardiology Center (CCC) both in the cath lab proper and a nine-bed recovery unit area for documentation and monitoring. It’s also in the cath lab recovery unit within the Community Hospital. All told, they perform about 2,500 cardiac cath procedures and 1,100 coronary interventions each year.

The CVIS “allows us to do the documentation of the case, it allows us to do inventory control, billing, and it allows us to complete our ACC [American College of Cardiology] data collection,” says Brian Decker, director of Cardiovascular Services. “It allows us to have a continuous document from the beginning of the care of a patient to the time when the recovery phase is over. So we have a document we can refer to for that entire timeframe,” adds Decker.

Calysto also performs hemodynamic measurements. Beyond that, the system performs image management for their peripheral lab, EP lab, interventional radiology lab, CR portables, and cardiac cath lab peripheral, each with Philips or Siemens acquisition systems. The system also handles the archiving, which Decker says has been a big step forward for them because prior to that they had no choice but to burn a CD for each case and store it.

Community Hospital plans on taking advantage of many of the advanced features the system offers, such as web-based viewing throughout the hospital including the operating room, from cardiology but also radiology and beyond.

Decker describes this enthusiastically as the golden standard they’ve been reaching for. “We’ve interfaced with our non-invasive system so that an echocardiogram also can be pulled up, or from our Philips radiology PACS a chest x-ray or CT scan, for example, can be looked up,” says Decker. “Physicians can access medical records, they can dictate, or produce a report. They can do just about anything they need to do at the workstation with the click of an icon.”

The level of integration also is illustrated in Community Hospital’s initiative to integrate the CVIS with business and administrative systems. Huge amounts of time (and paper!) will be saved by hooking up the Calysto with an ADT interface for registration information. Other benefits will likely come by interfacing with the business office through which Calysto will complete part of the bill via point-of-use charging for equipment and supplies.

“Inventory control is key. We will be responsible for our own inventory as opposed to the hospital system which wasn’t very good at it,” says Decker. “We feel we’ll be able to keep the department better stocked if we have more control.”

Levels of integration such as this look easy on paper, yet Community Hospital is no different than any other facility that would probably say that “challenging” is probably not a big enough word for how difficult it can be.

Regarding integration of cardiology and radiology PACS, perhaps Decker says it best: “We put Philips and Witt together in a room and said ‘Don’t come out until these systems can work together.’ And they did.”

Know your workflow

UCH (University Community Hospital) is a private, not-for-profit healthcare system based in Tampa, Fla. Pepin Heart Hospital is to be the fifth hospital in the group, a freestanding facility that has grown from within UCH’s flagship tertiary hospital. Active in cardiovascular services since 1989, about five years ago a plan was born to consolidate these services into a single building that is mostly filmless, paperless, and wireless.

It’s a huge undertaking, making this switch, with myriad diagnostics, cardiovascular and patient monitoring systems which will cover Pepin’s whole facility, including a 52-bed pre/post cardiac unit, 16 cardiovascular critical care beds, a 20-bed cardiac surgery recovery unit, five surgical suites, 10 cardiac cath/invasive procedure labs, and training facilities. GE is supplying its advanced cardiac cath lab suite, including the Innova 2100 and Innova 4100, Mac-Lab hemodynamic monitoring technology, pre/post workstations, and a Centricity Cardiology IT DMS system as a hub feeding into an enterprise archive.

To help, the hospital information system department includes a clinical informatics group that helps with implementing the systems which also cover pharmacy, billing, financials, HIS, and others.

To manage the undertaking, understanding workflow is essential. The process has included simultaneously redesigning multiple workflows as the new building was being constructed.

“We’ve been doing rollouts of a lot of these new modalities in our existing environment, so that when we move into our new building it will be a fairly smooth transition with everyone already having been trained,” says Bridgett Shaw, CEO of Pepin Heart Hospital. “It takes months to train people on these new systems. If you do not put the time into doing the appropriate time and training, then the project will not ever be successful. This is not an overnight endeavor; we have a lot of integration issues, a lot of interface issues, and there are redundancy issues you’ve got to think about as far as the healthcare is concerned,” adds Shaw.

Because they have a staff that is already pretty technically adept, they can use that as a springboard to take Centricity across the hospital, says Shaw. There’s a lot of training involved for Pepin’s 30 cardiologists and other staff who have been doing things a certain way for the last 25 years.

Therefore, beyond evaluating and adjusting your workflows as needed, which is crucial to success, gaining commitment throughout the organization is every bit as important because it impacts everyone, says Shaw.


In preparation for the shift to digital, cardiology departments will be wise to recruit IT personnel as allies when it comes time to install a CVIS and integrate it with legacy technology — both clinical devices and existing IT systems. An IT presence will be required long-term, as a channel of communication to vendors, or between multiple vendors. Simultaneously, a thorough review of workflow and expectations will radically improve the outcome of adoption. Finally, the support and input of cardiologists — especially with regard to the structure and content of automated reports — is essential.