IT Enables Excellence in Cardiovascular Medicine at the Cleveland Clinic

Cleveland Clinic, one of the nation’s leading healthcare facility, has upped the ante once again with the debut late last year of a new cardiac care facility equipped with state-of-the-art imaging with sophisticated diagnostic and treatment technology that is smoothly integrated with enterprise-wide clinical IT systems.

The new 278-bed Sydell and Arnold Miller Family Heart & Vascular Institute at the Cleveland Clinic houses an impressive array of systems and services: two dedicated robotic OR suites; a clustered diagnostic imaging center with echocardiography, MRI and CT systems; state-of-the-art cardiac cath labs and four distinct ICUs with same floor step-down units dedicated to specific patient needs. One conventional staple of 20th century medicine is missing from the high-tech campus: the institute is the first building on Cleveland Clinic campus without a single lightbox. The Institute deployed a cardiology PACS for viewing all clinical images, including dynamic movie clips from the cath lab and echo Doppler.

Planning for the Miller Institute offered a once-in-a-lifetime opportunity to develop and support a different paradigm in image viewing, reporting and distribution, says Robert Cecil, PhD, staff, Cleveland Clinic Foundation. Cecil and his colleagues seized the opportunity, connecting with vendors as partners in support of a vision focused on infusing images and imaging tools throughout the enterprise. The second part of the vision integrates radiology and cardiology at both the IT and clinical levels.
“There are so many opportunities to move from adequacy to excellence in healthcare,” Cecil says. “The technology to truly improve the quality and efficiency of patient care exists today.” Until recently, diagnostic imaging, specifically the flow of images among image-centric specialists, presented a major obstacle to achieving significant improvements in patient care.

Digital image management systems at Miller Institute are designed to erase the image flow obstacle, support state-of-the-art cardiovascular surgery and enable true excellence in cardiovascular medicine. This issue, CMIO tours the Miller Institute to provide a sneak peak at the future of cardiovascular medicine.

The dynamic duo: Patient care and efficiency

Improved patient care and increased efficiency often travel together. Continuity of care, or hand-off communications, represents the point. The Joint Commission promotes a standard approach to patient hand-off among various providers. In the typical cardiovascular surgery case, a cardiac surgeon operates on a patient and immediately moves on to the next case. Multiple clinicians and nurses share responsibility for the patient and visit him over the next few days in the ICU and step-down unit. During each clinical contact, the patient is bombarded with questions. Caregivers often repeat the same series of questions because the information provided to the previous caregiver is not readily accessible.

The answer to better efficiency, says Cecil, is the electronic medical record. “The EMR, spearheaded by Martin Harris, MD, CIO of Cleveland Clinic Foundation, makes it very easy to support continuity of care.” The Miller Institute, along with every Cleveland Clinic facility, uses an EMR to support communication and eliminate time-consuming, repetitious patient queries.

While an EMR helps sites cover the basics of clinical communication, it also supports care excellence. Cecil explains, “We’re seeing an aggregation of facilities.” Take for example complex procedures such as heart transplant surgeries. Hospitals need to maintain a minimum base volume to support the infrastructure and staffing resources required for the surgery. Large, specialized facilities, however, don’t operate in a vacuum. For sites like Cleveland Clinic to maintain excellence, they need to distribute quality care to allied facilities. Providers at every stage of the transplant process need to share information. The hitch, again, is communication among physicians. “The growing complexity of pre- and post-transplant care requires an ever-increasing need for physician-to-physician communication,” says Cecil. The EMR is a critical first step in supporting clinical communication and collaboration. It facilitates communication among physicians and keeps all providers in the clinical loop.

Digital image distribution is an essential part to the EMR. “Imaging is pervasive, and its importance increases as patients become sicker,” shares Cecil. Ninety percent of all Cleveland Clinic patients are referred for a diagnostic x-ray. The volume and variety of images increases for cardiac patients. Cardiac specialties—cardiology, cardiac surgery and endovascular surgery—are incredibly image-oriented, says Fred Heupler, MD, director, diagnostic cardiac laboratory. “Nearly every cardiac patient presents with images acquired from multiple modalities,” notes Heupler. It’s not unusual for a patient to arrive with a host of imaging data including previous cardiac CT, echocardiography, MRI, x-ray and cath images. “[Early in the planning process,] we realized that the ability to distribute images throughout the Heart and Vascular Institute is essential,” he explains. Access to images improves the speed of decision-making and the quality of care, says Cecil.

The ability to support enterprise image distribution became a key factor in the digital image management system decision-making process. A second factor—a roadmap for enterprise advanced visualization—also influenced the decision-making process. Although cardiology is an image-centric specialty, clinicians are not trained to view images as radiologists are. A cardiovascular surgeon may not conceptualize axial slices; he needs 3D tools like MIP and volume rendering to create the appropriate views to guide the surgical plan. And there are differences across specialties. A cardiologist performing an echo study needs to view image data in a manner that best displays an aneurysm. The surgeon, on the other hand, needs to see the path to the aneurysm. Advanced visualization provides the right toolsets to support each specialist’s needs, says Cecil.

The clinical 3D paradigm is very difficult in current practice because the most robust advanced visualization toolsets are limited to dedicated workstations. It’s inefficient for cardiac specialists to travel to dedicated workstations for 3D toolsets; the toolsets need to be delivered to the clinician wherever he or she works. The distributed advanced visualization approach was a vision—not a current product, says Cecil, but the institute aimed to deploy digital image management systems that support the Clinic’s vision of an open and standards-based PACS.

Improving critical care

The new paradigm at Miller Family Heart & Vascular Institute supports the complex needs of critical-care physicians. Under the new model, the clinical information systems adapt to the needs of the patient and procedure. The ICU is a particularly complex environment. Unlike cardiologists and radiologists who immerse themselves in imaging systems 90 percent of the day, critical-care clinicians split their time between the EMR and PACS, says Cecil. “Their job is not image review. Imaging is a tool,” he notes. Sometimes, clinicians need an EMR-based view that enables them to quickly review the charts of 10 patients to check for complications. In one of the 10 patients, however, the physician needs to view the chest x-ray to determine whether or not the patient requires a change in medication. A single click in the EMR launches the appropriate images. In other cases, a pulmonologist may need to immediately access the images of 10 patients and subsequently amend orders in the EMR for one of the 10 patients. Miller Institute planned IT systems to support both models, providing clinicians rapid access to necessary datasets. PACS is integrated with the EMR to provide clinicians with streamlined access to images.

Inside the image-driven OR

The Miller Institute houses a massive, yet patient-centered, high-tech surgical area. The OR area includes 14 rooms dedicated to cardiac, thoracic and vascular surgeries. Included in those are two rooms dedicated to robotic heart surgery. Recently added were two endovascular rooms with advanced imaging capabilities and robotics. By the end of the year, the institute expects to complete 3,700 cardiac surgeries, 1,500 thoracic surgeries and 2,700 vascular surgeries.

At 600 to 750 square feet, the new suites are larger than traditional cardiac ORs. The large footprint makes a difference, says Gina Cronin, co-administrator, cardiovascular surgery. The suites better accommodate high-tech devices required for the performance of lesser invasive surgeries including endoscopic towers used for vein harvesting, minimally invasive coronary bypass grafting and lung resection, alternate energy ablation systems for the treatment of atrial fibrillation, robotic surgical systems for valve repairs and multi-axis x-ray systems for endovascular procedures. All of the new technologies can be used in concert with conventional surgical equipment, such as cardiopulmonary bypass pumps and ultrasonographic imaging systems, in one setting to perform hybrid procedures and allow for the precise delivery of cutting-edge devices such as percutaneous aortic valves. The new rooms are outfitted with multiple high-definition, flat-screen monitors and digital video processing units that allow for flexible viewing access to the expanded intraoperative imaging tools from all points in the rooms. Advances in imaging are the single most important factor to facilitate minimally invasive surgery, says Eric Roselli, MD, staff surgeon, department of thoracic and cardiovascular surgery.

Another critical factor in the state-of-the-art OR configuration is pre-operative image access and viewing. Miller Institute placed a pair of ceiling-mounted, 46-inch display systems in most of its surgical suites. Surgeons and clinical staff need unrestricted access to the surgery table; displays cannot hinder access. Consequently, ORs typically require larger screens that can be viewed from a distance of 10 feet. The institute is experimenting with a quad configuration, using a 56-inch system; however, the larger systems are very expensive, says Cecil. The new endovascular rooms will provide additional flexibility with monitors mounted on tracks that can be pulled to the table for close viewing and pushed out of the surgical field as necessary.

The new suites did pose an image management conundrum. With the new ORs as robust image acquisition units, digital image management and communication is essential. Miller Institute wanted to avoid the mini-PACS arrangement that often hitches an OR to a single vendor and hinders communication. “We wanted a digital standard in the heart center and realized we needed to outfit the ORs with the infrastructure to support future, all-digital components,” explains Cecil. The OR also has a vendor-neutral device that converts all OR video imaging input to MPEG4 digital video data. The system solves one problem, but initiates other challenges. Once image data are available, they become an essential clinical commodity. Surgeons want video streaming in their offices, so they can watch the video of one patient being prepped as they confer with a second patient in their office. MPEG4 traffic requires a minimum of a 100baseT network, estimates Cecil. Miller Institute planned ahead and installed a gigabyte network with a 10 gigabyte backbone to support video flow.

Clinic Cardiology C-PACS Network
The PACS at the Miller Institute is part of the Cleveland Clinic Cardiology Enterprise-wide PACS deployed over a variety of geographically disparate healthcare facilities. All patient studies residing in C-PACS can be accessed by authorized users from any location at any time. All of the data are stored long term in the centralized Cleveland Clinic Foundation Archive that currently holds more than 2 petabytes of data. Here is a list of the connected healthcare facilities, their locations and the number of workstations installed.

Integrating clinical resources

The adjunct to integrated digital image management infrastructures across radiology and cardiology is integrated clinical resources. “The walls between the radiology and cardiology departments have been diminished in Miller Institute,” shares Heupler.

The commitment extends to the physical layout of the institute and revised operational procedures. “The institute re-organized conventional cardiac department specialties into patient-centric teams. The Aorta Center and Heart Failure teams, for example, are comprised of surgeons, cardiologists and other clinical care providers dedicated to those specific conditions,” explains Cronin. Similarly, the multi-specialty ICU team includes radiologists, and an ICU-based CT suite eliminates the need to transport critically-ill patients to the radiology department. At the IT level, the cardiology PACS service and support team collaborates closely with the radiology PACS service and support team. The teams offer cooperative classes, and staffers cross-train on both types of systems and software to stimulate resource sharing.

Technology deployment reconsidered

Cleveland Clinic engineered Miller Institute for patients. “Everything we’ve done is designed to improve our end product: patient care,” Heupler says. That commitment to patient care starts early in the technology decision-making process. In an effort to create the optimum patient experience, Cleveland Clinic clinical and IT leaders employ a purchasing process that begins with the hospital’s needs rather than a survey of currently available technologies.

Decision-makers determine what the hospital needs, which may or may not match current products on the market. If current offerings do not meet the desired specifications, decision-makers analyze vendors’ visions and product development timelines to understand how various vendors plan to realize the vision. In the case of enterprise image management, Heupler and Cecil aimed to provide sophisticated, advanced visualization toolsets on PACS workstations throughout the enterprise. Most cardiology and radiology PACS vendors, however, did not offer such capabilities during the Miller Institute planning process. The goals of the co-development process are fairly ambitious. According to Heupler, the partnership is designed to cooperatively generate new software features and functions, including:

  • User interface improvements including speed of access, image processing and ease of use.
  • Improved image analysis tools and display of results.
  • Improved ability to handle advanced image processing, e.g., 3D rendering, digital subtraction.


The future of cardiovascular medicine is here. It combines top-notch clinical resources with robust, future-oriented IT infrastructure and digital image management technology. Imaging is infused throughout the enterprise. Cardiac image acquisition modalities are available where they are needed: in a clustered imaging center and in the ICUs and ORs. Integrated cardiology and radiology PACS and the EMR ensure that image data are available to all clinicians who need it. The end result is optimal patient care.

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