Cardiac Images in the EMR: Just a Click Away

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 Commercially available or homegrown software allows cardiologists to access images and videos within an EMR environment.

In 2007, the number of electronic medical record system installs jumped 22 percent over the previous year. Approximately one-third of U.S. physicians now have an EMR system, while cardiology EMR adoption is estimated to be 8 to 9 percent, ranking high among specialties, according to the Medical Records Institute.

That number is sure to blossom along with the growth in cardiac care needs and the national push for EMR adoption. With that, integrating cardiac information and images into the record for easy physician access is critical to quality healthcare.

Finding a solution to integrating cardiac images into the EMR can take a couple courses: Provide a representative image directly in the report or provide everything with a click. At Duke Health System in Durham, N.C., and St. Peter’s Hospital in Albany, N.Y., they both wanted it the easiest way possible and went with the click.

Having it all

“We made a decision we wanted to have complete access to all of the image information. We did not want to put them in the electronic health record per se. We created a report and associated with that report a link that connects you to the images,” says James E. Tcheng, MD, professor of medicine and medical knowledge architect for Duke Health System.

Their clinical data repository contains data for nearly 3 million patients. Within the repository are 60 to 70 million individual records, from something as simple as a finger stick blood glucose lab result to a complete patient history. The hospital-wide EHR was custom-designed and implemented by Duke. On the cardiology end, they chose Philips Xcelera cardiovascular information system (CVIS) to collect patient reports and cardiac images. Radiology images are stored on a GE Healthcare Centricity PACS.

“We wanted to be able to access the text-base report [dictated reports or structured reports] relating to all the tests. We also wanted to be able to view the video. So we have created a system where we launch a separate viewer to view the images at any time we would want to do that. We do that inside the EHR so we don’t have to go searching for the patients to access their record,” says Tcheng. “It’s simply a click away.”

To launch the video, they use a web-based browser, a program they wrote internally. “By launching the separate application, physicians are able to see video, 15 to 30 frames per second video, which native Internet Explorer isn’t well designed to do,” says Tcheng.

The benefits of having the cardiac images available in the EMR most greatly impact the physician and the patient. “When you are trying to take care of the patient to make patient care decisions, you need all of the data available to you. And that is when you would work inside the electronic medical record,” says Tcheng.

He points out that workflow is changed at the level of decision making. “Most physicians in the cardiology sector when they are faced with a critical decision—for instance, revascularization or management of heart failure—they want to look at the study themselves, and based on that, want to make that next recommendation or decision.”

Two points of entry

Aside from having the integrated solution in the EMR, studies are available in a stand-alone solution, which Tcheng calls their parallel DICOM-compatible universe for echocardiography and cardiac cath lab. Using the Xcelera CVIS, physicians can easily access a lot of studies by modality for interpretation and reporting. “In essence, we have created parallel universes trying to marry the information that is returned to the environment that the physician finds himself or herself in for maximal efficiency,” says Tcheng. “It’s a matter of time and convenience which universe you work in.”

Smooth integration

St. Peter’s Hospital has integrated Lumedx cardiology EMRs with the hospital’s Siemens Medical Solutions hospital-wide EMR system. Stephen Cameron, RCIS, RCS, program director for cardiac and vascular, says Lumedx is “internally interfaced with the clinical information system. So if a physician logs in in-house, he has access to lab values, discharge summaries, physician consults and pharmacy information. He also gets cardiology, EKGs online, graphics and motion. We also have cath reports, and we also have the actual film online and in motion.”

Each year, the staff at St. Peter’s perform 3,000 cardiac catheterizations and transcatheter interventions (TCIs), 6,000 echocardiograms, 2,000 electrophysiology (EP) procedures and 900 heart studies. Cardiac images are stored on a Lumedx CardioPACS. CardioPACS uses the St. Peter’s storage infrastructure, which is an EMC Centera. While St. Peter’s recently acquired a FujiFilm Synapse PACS, it continues to use CardioPACS for acquisition, storage and review of images in cardiology.

Integration and upgrades are an ongoing process for St. Peter’s. Cameron says they began integrating cardiac information and images into the EMRs first with cath and then echo over the past few years. The transition was painless using “canned” integration from Lumedx. The information from the cardiology unit captured using Lumedx CardioDoc is automatically sent to referring physicians and integrated into the Siemens EMR. Images are available through a link in the record.

Anywhere, anytime

Access until recently was internal only when they began using Lumedx web access to provide physicians with offsite access to reports and images. “What we do differently from most other places is that a physician can line-in externally and internally using a single sign-on and get all the information from multiple systems and the patients,” he says. “We use RSA SecurID Token so the security is unquestionable.” Right now, physicians are accessing images and reports, but not yet generating reports offsite.

Competitive necessity

When it comes to implementing EMRs in cardiology, Cameron says jumping on board is essential. “If you don’t do [it], you will not be competitive in the future. Physicians are not going to have the luxury of going to three hospitals to read three different echos or angiograms.”

He says, “If you are not planning on doing this, you are putting yourself at a marketing disadvantage.”


Q&A: On the Record
As CEO of the Medical Records Institute, C. Peter Waegemann leads the organization’s mission to promote EMRs and to help physicians make the transition from “traditional medicine as an art” to computer-guided and computer-based healthcare. “EMRs are just tools in achieving major change in delivering care,” he says.

Q: What are the benefits of EMRs in cardiac care?
A: In cardiac care, there are seven benefits from EMR implementation:
  • In the most successful cases, practices have increased the number of referrals substantially by establishing a policy that reports are sent to referring physicians within an hour of the patient’s visit.
  • Substantial money can be saved by eliminating or decreasing transcription costs.
  • Remote computing improves the quality of life
  • of providers.
  • Emailing and digital health companions can help by providing new business models and revenue.
  • The quality of care improves as medical errors are reduced, patients can become partners in care and peer communication is improved.
  • Through better reports and information, improved cardiac disease management becomes possible.
  • A physician has better control over his or her practice as information is immediately available.
Q: What kind of cardiac information is saved in an EMR?
A: A physician has to be careful about the templates and workflow requirements he or she needs that may or may not be included in a general EMR. In the Continuity of Care Records (CCR), the physician has to distinguish between basic health status data and cardiac care data. There is little cardiac information in the health status data set except diagnoses and medications, while the care data include cardiac data. In general, the cardiologist has to assure that the selected EMR system can meet his or her requirements for cardiac information without having to be custom designed, which could reduce its interoperability potential.

Q: How is cardiac imaging integrated into EMRs?
A: An EMR is no good for a cardiologist if imaging is not integrated to the level of point of care. I have seen a heart clinic where physicians are even using PDAs in the exam room and seem to be satisfied with the quality of imaging available on the hand-held devices. Others prefer good quality screens. It comes down to personal preferences, weight versus screen size, and image quality.

Q: What are the challenges of including cardiac imaging in EMRs?
A: The biggest challenge is to find a good EMR system that allows all the functionalities a cardiologist needs. Many companies say that their EMRs are designed for cardiology but, in fact, they are not. The second challenge is to adjust the workflow in order to gain high efficiency.

Q: What is the future of EMRs in cardiac imaging?
A: The future will be an interactive relationship with patients in which the cardiologist will manage the cardiac devices that a patient will have as digital health companions. EMR vendors will learn how to integrate imaging more into their systems.