Cardiology PACS: Heart at Work

Cardiology departments are revamping their image capture and management systems with digital technology to combat growing patient volumes and enhance patient safety, efficiency and overall care. Radiology is the leader of the image management pack, but cardiology is gaining stride. More heart-care centers are implementing digital storage and retrieval systems to improve multi-site physician access to images.

Cardiovascular disease is a leading killer of Americans. All totaled, cardiovascular diseases including heart disease and stroke, still outweigh cancer deaths.

It is no surprise then that cardiovascular surgeries and procedures are steadily increasing. From 1979 to 2002, the number of cardiac catheterizations surged 389 percent, according to the American Heart Association; more than 1.4 million inpatient cardiac caths were performed in 2002. The average total charge for patients hospitalized for diagnostic caths increased from $11,232 in 1993 to $16,838 in 2000, according to the Agency for Healthcare Research and Quality. However, the average length of stay decreased from 4.7 days to 3.6 days.

Increased digitization of cardiovascular services may be a contributor. More and more heart-care centers are saying goodbye to film, CD and video - as well as manual workflow - and installing state-of-the-art digital acquisition systems. More recently, healthcare providers are implementing the digital storage and retrieval systems to manage them.

Research firm Frost & Sullivan estimates that cardiology PACS (picture archiving and communications system) sales will rise 20 percent a year, from $160 million in 2004 to $430 million by 2009 - a steady increase, seeing that only 17 percent of cath labs and 8.5 percent of echo labs reported using PACS in 2002.

There are a number of reasons for implementing cardiology image archiving and distribution systems, including:

  • One central, online location for cardiology data.
  • The ability to review multi-modality images on high-speed workstations, or non-diagnostic quality images anywhere, anytime.
  • Simultaneous review of images.
  • Better image quality and diagnostic tools.
  • Faster report turnaround time, out-the-door billing capabilities and increased revenues.

Multi-site access

"Digital imaging and electronic reporting allows HealthFirst to provide patient care in the timeliest manner," says Thomas Donahue, cardiology PACS administrator at HealthFirst in Florida, a consortium of three non-for-profit hospitals: Holmes Regional Medical Center, Cape Canaveral Hospital and Palm Bay Community Hospital. HealthFirst selected Heartlab's Encompass Cardiac Network to manage the enterprise-wide cardiology image and information management needs of the three hospitals.

Health Firsts' three hospitals perform more than 9,000 cardiac cath procedures and 21,000 ultrasound exams annually. Cardiac specialists perform more than 6,000 invasive procedures and more than 700 open heart procedures each year. "Being a multi-site hospital system, communication between IT, cardiology and our vendor is critical," says Donahue. "We move gigabyte studies back and forth between hospitals 20 miles apart. That much data over the network puts a lot of demand on our system. With our built-in resiliency, we don't have to worry about losing patient studies or delaying the doctor's access to images."

With the system, physicians do not have to go down to the cath lab or viewing room once an exam is done. Studies are instantly available for review on any of Heartlab's 21 workstations, located in the different cardiovascular departments of all three hospitals. A web tool enables users outside of the Heartlab system access to images over the organization's secure internet virtual private network (VPN). With Heartlab's results management modules, physicians can create electronic reports while reviewing studies on-line. Once completed, finalized reports can be retrieved instantly by doctors in the OR, ICU or at the patient's bedside.

The web tool allows authorized users access to HealthFirst's cardiology data in doctor's offices and remote locations. HealthFirst used to have a courier deliver its pediatric ultrasound studies to Orlando, which is a 45-minute drive away. Now the internet acts as an instant courier for the images.

Integration of information

Vascular surgeons, interventional cardiologists, diagnostic cardiologists and noninvasive cardiologists at MetroHealth System's Heart and Vascular Center are all accessing online images and information after the implementation of Medcon Telemedicine Technology's TCS Symphony. The digital storage and retrieval system provides a growing, integrated database for multi-modality images and patient data, all of which help physicians made quicker diagnoses.

MetroHealth's cardiovascular department performs 22,000 cardiac cath procedures, 12,000 echo studies and 8,000 vascular studies annually. They first implemented Medcon technology in 1999 to handle viewing, managing and archiving of cardiac images and information in the cath lab. Expanding the system in 2002, MetroHealth implemented PACS in the echo and vascular labs, which also included a reporting module for echo and stress. An interface to the hospital's Epic EMR system allows text reports to be exported into the hospital information system (HIS) for multi-physician access.

"From the Medcon system, physicians can access cath, echo and vascular digital images from one workstation," explains Gisela Nehring, project leader, information services. "The images also are available via the MDWEB [on MetroHealth's intranet] for any other physician who would like to view them." On the other hand, diagnostic quality radiology images can be viewed in the radiology department and the emergency department. Physicians can view them via the web in non-diagnostic quality. "If cardiology looks at the nuclear images, CT or MRI, it is via the radiology web," says Nehring.

MetroHealth cardiologists want six months of online, immediate data. Images saved for the long term are stored on a DVD jukebox, which Nehring says has a slower retrieval time. It still pales in comparison to the days when echos were stored on videotape and an offsite company was used to retrieve them. "Now the images are delivered with the click of a button," says Nehring. In addition, billing-out-the-door time has reduced from weeks to days, and the system significantly improves report turnaround time.

Faster out the door

Reducing report turnaround time for cardiology practices is a priority for any healthcare facility seeking to improve patient care, physician satisfaction and referrals. This can be accomplished once paper, film and videotape are eliminated and workflow is automated. Where reports used to take 24 to 48 hours to complete, they are finished within minutes. These types of "savings" can be spent however the department sees fit. In the cath lab, it may mean one more patient is treated daily.

Before implementing Witt Biomedical's Calysto for Cardiology, physicians at Alexian Brothers Medical Center dictated reports orally into the phone and someone else transcribed the report. Data on patients were collected manually by the nurses and documented via pen and paper. Imaging and data collection lacked organization.

In 2002, the Chicago-based, 473-bed healthcare provider streamlined its data collection processes in cardiology by installing Witt's PACS and nurse stations in the procedure rooms for paperless documentation. Calysto is used for the cardiac cath lab and non-invasive cardiology, but images are only half the equation, says Jennifer Beaumont, digital imaging administrator. The other half is the extensive database created from electronic documentation.

The database includes information such as charting and sedation monitoring collected using Witt patient care monitors in the holding area. At the patient's bedside, physicians can review cine images through built-in DICOM viewers. Referral cines from other institutions can be downloaded and archived on the Witt server to allow physicians anywhere access.

"After a [cath or echo] procedure, the images are sent to a Witt server and they are tied to the data files that were created by the nursing documentation and eventually, physician transcription" says Beaumont. "Reports are instantly available throughout the hospital for authorized users. For any physician or clinician looking at the documentation that we did, there is also a link for the images. Using a web product, information can be accessed over the internet. Every waveform we capture, every image we bank, all the nursing and physician documentation can be accessed depending on one's privileges."

Nuclear medicine is run by radiology, so those images are not on the system. Cardiologists who need to look at theses images, as well as CT and MRI, must DICOM query and retrieve them. Future plans include integrating Calysto with the hospital's information system. "This will create a single point of access," explains Beaumont. "For example, if someone is looking for pictures from a patient's angiogram, he or she will go through the Meditech system to retrieve it. As far as the reporting goes, if the doctor is looking for a cardiology, radiology or pathology report, he or she will look in the same location."


Cardiology has been a slow adopter of PACS technology. But once they implement PACS, the technology is phased in, typically starting in the cath lab. Patient care models differ greatly in cardiology, as do the dynamic nature of the images - and their size.

Healthcare providers must deploy enough bandwidth for the images - rightfully requiring that storage hardware be increased to handle the larger pipe. Secondly, cardiology images require more storage. Storage prices are coming down, but the amount of stored information is growing dramatically, and technology is changing exponentially. Sites may start out with a tiered storage architecture, but transition to more accommodating and cost-effecting spinning disc technology as they evolve. Plan for change.

Alexian's Beaumont suggests that end-users evaluate how the dynamic quality of cardiology data factors into the selection of storage and network requirements. "You have to make sure that the network can handle the file transfer between the server and the front-end PC," says Nehring. "You need to make sure that the PC has a sufficient enough RAM. You really just have to make sure that you have a robust enough network that can handle the large file transferring."

HealthFirst's Donahue says research is critical. "Know how much data you are going to produce, pay careful attention to storage and file transfer and the different technologies out there," he says. "Get outside help wherever it's needed, perhaps for your network. Get input on the clinical side that understands workflow. When selecting a vendor, you really need to find someone that is going to fit you architecture, design and environment."

As MetroHealth's Nehring contemplates, ensuring uptime is vital to the entirety of a PACS implementation. "When you tell someone that you are going to make that information available, that is a standard and that expectation is there," she says. "It's not that we can't do it, I think we do it very successfully. But for anybody starting out, this is a challenge that must be met."

Saint Thomas Hospital's cardiology department met the challenge by integrating its cardiology PACS [TCS Symphony] with EMC Corp.'s Centera. The storage system manages and maintains the integrity of fixed content, such as critical cardiac patient cath images and records.

The 541-bed tertiary care facility in Nashville, Tenn., consists of eight cath labs used to treat 12,000 patients annually, generating 4.2 terabytes of data. Each cath procedure generates approximately 500MB of data, consisting of both images and reports. "Radiology images are static in nature and single frame," says Ralph Ricci, technical coordinator for cardiac medical services. "In cardiology, our frame rate is about 15 frames per second, and a routine procedure can run 60 seconds worth of data."

The storage technology is reliable, secure and access time is in seconds versus minutes. "Patient data must not be lost and needs to be easily accessible," says Ricci. "Centera is an array of hard drives that stores digital data and is accessible without the use of robotics, tapes or DVDs."

"The PACS has streamlined the way hospitals store, view and access critical patient data," says Ricci. "They allow for clearer visualization of images and there for potentially better diagnosis. With proper storage of studies, redundant off-site data can be retrieved almost instantaneously for review. PACS integrate with inventory and reporting functionalities, produce greater costs and operational efficiency that was not previously possible."

The department & beyond

Where one door closes, another one opens - and another one after that. The tell-tale reality of life is the tell-tale reality of cardiology PACS. Moving away from manual workflow procedures and using digital technology opens yet another door of "what's next?"

For St. Francis Hospital, a 431-bed heart center in Roslyn, N.Y., it means integrating radiology's PACS with cardiology's PACS [Heartlab's Encompass] and moving toward a single review station and perhaps a single program for images from both departments. The ultimate goal is to permit the review of digital cath and echo exams, along with cardiac MRI, nuclear medicine, multi-slice CT images, and all radiology images from one workstation throughout the enterprise.

"Our goal is to have multimodality workstations throughout the enterprise, serving all cardiology and radiology images," says Alan Katz, MD, director of medical information technology. "Because of the inherent reviewing and off-line analysis, the multimodality station will save hardware costs and essential hospital office real estate."As PACS develop over time and alliances are built between vendors, an all-in-one platform will become a reality. More and more departments in the future will look for ways to integrate PACS to provide multi-modality review of images from multiple departments at one workstation.

According to Katz, there are several other factors driving PACS integration. "Integrating image information will make study review more accessible to clinicians, improving diagnostic skills and ultimately the quality of patient care," he says. "The primary goal is to accurately and efficiently diagnose and triage patients in the inpatient or outpatient setting. Clearly the federal government is moving towards a portable and secure electronic medical record and imaging will be an essential part. The availability of prior images to a physician treating a patient for the first time will improve decision-making and decrease unnecessary duplicate testing. Finally, there is great interest in fusion imaging where two different techniques such as PET scanning and CT images are superimposed on each other to provide insights into anatomical and functional pathology."



At this month's ACC, IDX Systems is launching its IDX Imagecast for Cardiology, which has been a works-in-progress for more than two years and was previewed at last year's show.

The system assembles all cardiology imaging modalities, including cardiac cath, echo, nuclear medicine, CT and MRI, with patient information and stores it in a web-based, single database for multi-physician access anywhere throughout the healthcare enterprise.

"It is designed to be used across all clinical service lines," says Jim Poehlmann, program manager for cardiology. "We built this as a module on top of our radiology system [it has the same database as IDX's Imagecast RIS/PACS system for radiology]. All the interfaces have already been built to different applications. There is a lot of hardware and outbound features that do not have to be rebuilt when the system is integrated with IDX's radiology PACS."

IDX Imagecast for Cardiology also can be integrated with multi-vendor PACS.

According to Poehlmann, key features include: a quick scheduling and display module built for cardiology; nursing documentation; billing and charge capture; clinical information window [snapshot of patient's clinical history]; specialized inventory module; automated national registry reporting; and a suite of management reports for the cardiology department manager.

"We also have some specialized reporting tools," says Poehlmann. "The cardiologist will have a choice of using traditional dictation and transcription. Or we are offering voice recognition for cardiology [ScanSoft Dragon NaturallySpeaking software]."

The system is entering its alpha phase and should be released in the third quarter, says Poehlmann.

Poehlmann adds that the system will be available in two flavors: CVIS that manages all the workflow processes, and the cardiology PACS that can be added to that.



Agfa Healthcare | IMPAX for cardiology
Provides the required image acquisition, storage, review and reporting capabilities needed for a digital cardiac care environment. It enables cardiologists to view various cardiac images simultaneously, whenever and wherever.

Cerner | CVNet
Automates functions across the cardiology department, from patient registration, and scheduling to management and outcomes reporting. In addition, charging and coding are managed automatically in the process.

DR Systems | Dominator RIS/PACS
Includes enterprise image management and distribution of radiology, cardiology and pathology images. A single sign-on system, it provides cardiovascular tools, including: image calibration based on catheter size; stenosis measurement; image subtraction; and cine tools.

GE Healthcare | Centricity Cardiology
Provides multi-modality support for digital x-ray, echo and nuclear imaging, enterprise-wide web access to images and waveforms, integrated physician reporting, and DICOM connectivity.

Heartlab | Encompass Cardiac Network
Employs a multimodality clinical reporting and image management system built on a single database foundation that gives users anywhere fast access to cardiac patient information.

IDX Systems Corp. | Imagecast for Cardiology
Using a web-based, single database CVIS/PACS solution, clinical staff throughout a hospital enterprise have continual access to complete patient images and information.

Medcon Telemedicine Technology | TCS Symphony
Assembles all cardiology modalities including cath, echo, nuclear medicine, CT and vascular ultrasound with patient information, data and measurements into one central database for LAN and internet access. All patient cardiology data are collected and stored in a single cardiac EMR.

Philips Medical Systems | Xcelera
Provides multi-modality image viewing and archiving, 2D and 3D quantification, measurements, advanced reporting for the adult and pediatric care. With the same system, users can analyze and report on a pediatric echo to include Z scores, a stress echo, a strain rate study and log a cardiac cath intervention with immediate physician reporting.

ScImage | PICOMEnterprise
Provides single server system for image and information management for the cath lab, radiology, echo, endoscopy and pathology. Built on a web-based foundation, the enterprise-wide data system integrates with existing HIS, RIS or clinical information system.

Siemens Medical Solutions | Soarian Cardiology
Allows users to build a dedicated EMR that includes lab results, images, ECG,
physiological waveforms, and documentation. Siemens' KinetDx Solutions Network, tailored for the echo department, allows institutions to implement a single department network or to integrate patient information throughout the enterprise.

Witt Biomedical | CALYSTO for Cardiology
Manages images and information. CALYSTO WEBDV is designed to function on a hospital intranet or the internet, allowing authorized users to access all data using standard web browsers. Xpresstation multi-modality review station is designed for the community hospital, clinic or physician office.