ECG Image Management Brings Increased Productivity and Confidence


 IMPAX HeartStation from Agfa Healthcare is a vendor-neutral data
management solution that automates the processing and storage
of electrocardiograms.

Seamlessly integrating ECG information into electronic medical records is imperative in today’s totally connected medical enterprise. Managing ECG image capture and report generation leads to a more efficient use of resources, as well as better patient outcomes.

One of the challenges of ECG image management is to have the images available across the enterprise for a wide range of clinical purposes and use. Typically, ECG workflow is faster, with a higher volume of records, than other cardiovascular data. Many times, older ECG acquisition equipment does not interface well with new equipment, which presents a problem to many departments and practices as they move toward replacing their older analogue ECG systems.

The latest generation of ECG image management systems can dramatically improve rapid access to ECG exams throughout the enterprise via integration with the hospital electronic medical record (EMR). Productivity can be increased because ECGs can be displayed faster and interpreted more quickly—even remotely from a physician’s laptop.

While many of the EMRs are fairly intuitive and straightforward, there is a learning curve. These systems are expensive in hardware and software, as well as in training time for physicians and staff. One of the first things needed before implementing an EMR is a strong commitment from leadership. “If you don’t have a firm commitment from leadership about the value of an EMR, don’t implement it,” says Dan Caldwell, MBA, executive director of Little Rock Cardiology Clinic in Arkansas. “Many people who manage groups have lost their jobs because the EMR implementation turned out to be more difficult and expensive than anticipated. If the leadership doesn’t back you up in those situations, someone has to fall.”

When implementing an EMR, it’s important also to manage the expectations of your physicians and staff. “You want to let them know it will be disruptive,” Caldwell says. “You want to get your physicians to spend time discussing this issue.” He advises to be straightforward about the process, that it will be frustrating in the beginning.

Disruptive, but worth it

Little Rock Cardiology Clinic slowly began implementing an EMR (NextGen Healthcare Information Systems) into its practice in mid-2007 and has since incorporated a digital ECG image management system. In a busy practice like Little Rock (one of the top in the country in terms of productivity per physician, says Caldwell), they had to be careful the EMR implementation would not be too disruptive.

“Even with an intuitive system like NextGen, implementation is difficult and disruptive. It takes time to train people and many physicians do not want to take the downtime to train,” Caldwell says. Having said that, he emphasizes that within four to six months, no one ever wants to go back to the paper system.

“I think it’s a mistake to stay with analogue ECGs. They are certainly useable, but you are leaving aside great capabilities, such as the ability with the EMR to compare ECGs over various timeframes,” Caldwell says.

One of the more laborious parts of the conversion to digital was scanning all the old paper ECG records. Caldwell’s practice handles about 20,000 ECGs a year. The electrocardiograms need to be scanned at a high resolution so they are useable, particularly for zooming in to look at the tracings. Consequently, they eat up a lot of disk space, he said.

Their new system, the IQmark Digital ECG (Midmark Diagnostics Group), creates a much smaller image than a scanned image. When the ECG is pulled up for review, the software writes the image each time and displays it as a graphic. The image itself is not stored. Caldwell adds that the Midmark system makes it easy to line up ECGs in windowing and compare the old with the new. “It’s a great analysis tool for electrophysiologists,” he says.

Rather than deal with carts that must be rolled into rooms, digital systems like Midmark require a set of cables that plug into the workstation. “My medical assistants and nurses walk around with their ECG cables around their neck, like a stethoscope. It’s very portable. They can take an ECG anywhere you have a NextGen workstation,” Caldwell says,

The medical assistants and physicians like that the ECG is available with other information such as vital stats, history, physical and medication use. In the old days, the ECG had to be printed and sometimes it would be with the chart and sometimes it would not, he says. “Today, the ECG is always there to be viewed by the physician with all other relevant information.”

Caldwell says one of the chief benefits of the EMR is 24/7 access to the ECG—anytime, anywhere. Before the digital ECG system, the on-call physician had to have many more discussions with either the patient, ER doctors or someone else in the hospital regarding the ECG. Now, the on-call physician gets the latest data on the patient through the EMR and can render an interpretation more quickly and confidently, Caldwell says.

He adds that the comparative analysis of digital ECGs is very powerful. A list of all ECGs can be brought up and displayed in chronological order. Cardiologists can choose one, two or more to be displayed together—any combination that will help them make an accurate assessment.

Data in one place

The cardiology department of The Washington Hospital in Washington, Penn., had to make a decision. It could upgrade its proprietary ECG image management system (MUSE, GE Healthcare) or it could adopt the ECG module of the cardiovascular information system already in place (Horizon Cardiology, McKesson). Kelly Neal, RN, director of cardiovascular services, says it made more sense to keep all of the cardiology information in one place.

One of the challenges to managing ECG images is the ECG carts, which can be quite proprietary, Neal says. Her Marquette carts (now GE) would not allow ECGs to be uploaded onto another system. They decided to replace the old carts with new ones from Mortara Instrument, which has a working relationship with McKesson. They could have kept some of the carts, working with a third-party translator, but they chose not to add another technological piece.

One of the benefits Neal has realized with her new ECG image management system is a better accounting for ECGs taken in the emergency room. In the old days, the hectic pace of the ER sometimes did not allow timely transmission of the ECG for interpretation. When the cardiology department finally received a batch of ECGs, it had to spend time cross-matching them with the orders. The new carts wirelessly or via modem transmit the ECG to a central repository. Cardiologists can go into the repository, select the patient from the modality worklist and interpret the ECG. The report is electronically signed and distributed to offsite locations, while a hard copy goes on the patient’s chart.

Neal reports that the cardiologists like being able to read ECGs remotely, as well as being able to simultaneously look at other reports such as from the cath or echo labs.

The cardiologists at The Washington Hospital were already familiar with the look and feel of the McKesson cardiovascular information system, so adapting to the ECG component was not that difficult for them, Neal says. The challenge was educating all other personnel enterprise-wide who read ECGs such as family practice and ER physicians. Neal says the intuitive maneuverability of the system, however, made it less difficult for physicians to adapt.

One thing seems clear: hospitals and practices are moving toward total digital integration of all relevant cardiovascular information. In the case of ECGs, it seems to be a natural fit, one that leads to improved workflow, quicker diagnosis and, despite a learning curve, very satisfied physicians.


Digital ECG: One Part of the IT Solution
When Timothy Attebery was CEO of South Carolina Heart Center in Columbia, he oversaw the implementation of a cardiovascular information system (Soarian Cardiology, Siemens Medical Solutions). Like similar systems, Soarian provides an integrated view of patient data, images, ECG and physiological waveforms that can be accessed anytime, anywhere.

The improvement in workflow offered by the ability to have all relevant patient data available in real-time translated into enhanced revenues, says Attebery, now the CEO of Cardiovascular Associates in Kingsport, Tenn.

For example, Attebery suggests that increased efficiencies leading to one more cath procedure weekly would significantly impact the bottom line.

Earlier this year, Philips Medical Systems released a new version of its Xcelera cardiology information management system, which offers support for nuclear quantification, cardiac CT and MR images and electrophysiology, among others. The system also provides “access to relevant ECGs from market-leading ECG management systems from multiple vendors,” according to the company.

Kirk Spencer, MD, an associate professor of medicine at the University of Chicago says that bringing together the cardiac patient’s clinical information from multiple exams and procedures is “imperative to delivering quality care while controlling costs.”

Vendor Neutrality Offers Facilities Flexibility as Well as Cost Savings
When legacy ECG management systems vendors decide to upgrade their proprietary product, it often forces users to discard, for example, ECG carts that still have some life left in them. Many hospitals today look for vendor-neutral systems that can accommodate the wide range of products that make up one’s information technology system.

Like similar products, Agfa HealthCare’s HeartStation ECG image management system is vendor-neutral when acquiring ECGs from legacy or existing carts at sites. Consequently, hospitals do not have to replace all carts when upgrading, says Neil O’Connell, HeartStation product manager. “Departments can phase out the old carts on their own timeline,” he says.

In June, GE Healthcare announced its alliances with leading EMR vendors such as McKesson to “create bridges and enable compatibility.” The company said it wants to offer solutions that are not tied to any single device.

“What we’re seeing is that customers want more flexibility in how they purchase their products,” says Agfa’s O’Connell. “Tying a purchase to an enterprise-wide upgrade is not a good model,” he says.

From Legacy to Open Standards
Unlike cardiovascular information systems, which are essentially contained in cardiology, ECG management systems are used enterprise-wide by residents, fellows, attendings and ER physicians, to name a few. “Everyone is taught how to read an ECG,” says Robert Baumgartner, director of product marketing for the Medical Imaging Group at McKesson.

One of the biggest challenges, therefore, says Baumgartner, is finding an ECG image management system that works with open standards, such as DICOM, that can be easily integrated with other data management systems. Legacy ECG management systems are generally self-contained, meaning they were built as ECG management systems. Today’s connected cardiology practices want all of their relevant patient data available in the same window from any workstation.

McKesson, like other vendors, offers this type of integration within cardiology and the hospital-wide enterprise. In McKesson’s case, they’ve built the ECG management system on top of the same database that supports their cardiology PACS. Within the same dashboard, one finds all relevant patient data including hemodynamic, cath lab, echocardiography, vital statistics, medications and ECG.