Digital Image Management Primer: Integrating ECHO
 Surgeon’s view of the mitral valve obtained with real-time three dimensional transesophageal echocardiography, in a patient with severe mitral insufficiency, secondary to mitral valve prolapse. Arrow points to prolapsing P2 scallop as predominant mechanism of pathology. Patient underwent successful quadrangular resection of this scallop and repair of the mitral valve, with complete resolution of mitral insufficiency. (Source: Judy Mangion, MD, Brigham and Women’s Hospital)

While cost-savings might not be immediately apparent, benefits of digital echo include increased accuracy and efficiency, ease of accessing information and better patient care.

Echocardiography remains the first line imaging modality for many cardiac indications. The advent of 3D and 4D echo as well as speckle tracking translates into increasing pressure to make efficient and clinically effective use of the data. More sites are turning to digital image management solutions, but wedding echo and digital image management can befuddle even the most IT-savvy practice. The benefits, however, outweigh the difficulties.

Echo image management is fraught with challenges. Fewer than 30 percent of labs have embraced digital echo management, estimates Alan Katz, MD, director of cardiac imaging and informatics at St. Francis Hospital in Roslyn, N.Y. Reluctance to invest originates in several corners. For starters, vendors have not adopted DICOM standards for echo, and each vendor stores echo data in a different format.

Cardiology practices are left with unappealing options: review images on the echo cart or purchase vendor workstations for image review. Usually, sites wind up with workstations from multiple echo vendors, which can be a financial burden and breaks down universal access to images. What’s more, unlike deploying a digital cath lab, integrating echo into the digital image management strategy does not correlate with an immediate cost-savings, says Katz.

The benefits of the digital approach, however, are real and include increased accuracy and efficiency, ease of accessing information and better patient care. There are economic gains as well. “Echo may be over utilized because it’s difficult to review prior studies or access images acquired at other locations,” says Judy Mangion, MD, associate director, non-invasive lab, division of cardiovascular medicine at Brigham and Women’s Hospital. Integrating echo into the digital image management platform can help the bottom line and prevent unnecessary tests.

Plus, as the clinical value of echo grows, it’s important for referring physicians to be able to easily access the data. “Echo provides much more information than in the past. Changes in the technology make it possible to quantify many parameters with echo,” says Smadar Kort, MD, director of cardiovascular imaging and echocardiography at Stony Brook University Medical Center in Stony Brook, N.Y. For example, physicians can use echo to quantify the severity of regurgitation in patients with valvular disease or plan valve replacement procedures.

The digital model

More facilities are bringing echo into the digital era. Take, for example, Brigham and Women’s Hospital, which stores echo studies digitally on a GE Healthcare Centricity PACS; clinicians can use the system to review any cardiovascular images throughout the enterprise or at home. “Having all of the information at our fingertips helps us sort through the various differential diagnoses,” shares Mangion. For example, cardiologists can correlate echo data with other studies to determine if a lesion is flow limiting.

Stony Brook University Medical Center archives all echo data on a server. All echo data are available for review, analysis and comparison, and can be accessed enterprise-wide by referring physicians. Although other cardiac modalities like MRI and CT are stored on a separate PACS, physicians can retrieve all images at any hospital computer. The PACS and dedicated echo server can be accessed through the web for universal enterprise review by referring physicians.

Similarly, St. Francis Hospital stores echo and cardiac images on Agfa HealthCare’s IMPAX CV and on an EMC Corporation Centera storage solution. The PACS holds seven years of cardiac imaging data, and a web viewer makes it possible for physicians to view studies offsite or for several users to view or post-process data concurrently. Because echo produces fairly large datasets, images are compressed at 20:1, a ratio that does not compromise diagnostic quality, says Katz.

The digital archive delivers critical advantages over tape. “It’s unwieldy to view or compare echo studies on tape. With digital storage, cardiologists don’t need to rewind the tape to look at a specific lesion or review wall motion,” shares Katz. The digital platform saves time and improves clinical decision-making and treatment.

EMC’s CLARiiON NAS (network attached storage) serves as the short-term repository for echo data at St. Francis Hospital. Raw data are stored on the NAS; however, cardiologists must use vendor workstations to re-manipulate the raw data.

Other models promise to eliminate the need to trek to vendor workstations to interact with raw data. TomTec Imaging Systems’ Image-Arena Software interacts with most vendors’ non-DICOM data to provide a universal platform for image review and minimize dependence on multi-vendor workstations. The software is available on other platforms such as McKesson Horizon Cardiology. Arizona Heart Institute in Phoenix deployed Horizon Cardiology in 2006 and selected echo as the first modality to place on the PACS platform because it represents a large volume of data. Integrating echo data into PACS delivers financial, productivity and clinical benefits, says COO Rick Roth. Cardiologists no longer chase CDs or DVDs to review prior echoes, and clinical decision-making and treatment are accelerated because physicians can access and view studies immediately after acquisition.

More dimensions, more challenges

3D echo brings additional challenges, says Kort. It requires a separate platform and generates large, non-DICOM datasets, essentially magnifying the issues of integrated echo image management. Currently, 3D datasets require offline quantitative analysis to quantify parameters like ejection fraction; however, evolutions in 3D technology and a close-to-prime-time DICOM standard should deliver improvements.

Many sites rely on unrefined 3D echo image management strategies. At Stony Brook University Medical Center, for example, a committee is charged with developing guidelines. “The goal is to determine the best way to archive the data without archiving the entire dataset,” explains Kort.

At the macro level, the American Society of Echocardiography (ASE) aims to lend a helping hand. The society is working toward streamlined archive guidelines to ensure greater uniformity among institutions. ASE is in the final stages of approving a 3D DICOM standard, which will make it possible to interact with 3D datasets on the PACS workstation, says Mangion. What’s more, “smart” 3D technology will automatically calculate parameters like left ventricular volume and ejection fraction to improve sonographers’ workflow and reduce the time requirements of 3D echo.

Digital days are here

It is time for cardiology to integrate echo into the digital image management strategy. The benefits are clear and cover multiple areas. “Integrating echo into the digital platform brings time benefits to physicians and clinical benefits to patients. Implementation costs have dropped to the point where there is an affordable solution for every budget,” concludes Mangion. So investigate the options, and prepare to enter the digital echo era.