PACS and RIS have helped radiology departments improve efficiency, integration and workflow. Now, those same efforts are going into cardiology departments—a bigger challenge but with, perhaps, even more to gain.
Cardiology is where radiology was about five years ago, says Joseph Marion, an independent consultant and principal of Healthcare Integration Strategies. While PACS was originally viewed as an image management solution, users eventually realized it was really an integration of images into the rest of the workflow. “The same thing is now starting to happen with cardiology, but because there are so many different players and systems, it’s a bit more of a challenge.”
For one thing, cardiology workflow is much different than radiology workflow, he says. Cardiologists have a much more integrative interpretation process that often includes multiple imaging study results. Reliably getting hemodynamic data and associated images into a common viewing and reporting environment is a process still in the works.
Creating a cockpit
Tri-City Medical Center, a 397-bed district hospital in Oceanside, Calif., is in the preliminary stages of accomplishing that by working with McKesson Provider Technologies, says Donald Dawkins, RN, cardiovascular service line administrator. The goal is to eliminate the cumbersome process of viewing separate applications and put all relevant information into a single ”cockpit” (also called a “dashboard”) so that cardiologists have everything they need in front of them.
“As soon as they complete a procedure, the system creates a final report that is faxed directly to the referring physician and into the electronic medical record,” Dawkins says. “We’re moving into a much more automated process to get all of our processes paperless.”
Tri-City’s cardiovascular services growth has been consistent year over year. The facility has one each 64-slice, 8-slice and single-slice CT scanner, two cath labs, two echo rooms, four nuclear cameras and four ultrasound rooms, several interventional radiology suites, two 1.5T MR machines and a strong PET/CT program. The facility is looking at implementing 3T MR and moving into cardiac MR next year and upgrading to a 256-slice or a dual-source CT scanner. “Part of our advantage is that we are so cutting edge and can move rapidly,” Dawkins says. “Administration recognizes the power that our imaging has for referring physicians. They have a clear understanding that they want to keep funding imaging because it really drives volume.”
Cardiovascular services aren’t necessarily in a traditional orders-driven environment, says Steven Young, director of cardiovascular services for Tri-City. “When you want to automate and tie in images, it’s very challenging because there isn’t the infrastructure in the HIS [hospital information system] or RIS [radiology information system] to really drive cardiovascular services through the order process.” He’s leveraged the facility’s RIS to make cardiovascular procedures part of the ordering system. Now everything is structured by date of service, time and results, along with radiology services, and available in one location. Clinicians can see CT, MR, echo and CV reports in one place. “That’s a huge advantage for us,” Young says.
Tri-City has been able to take advantage of the work and expense already devoted to its radiology department’s information systems to link and synch the two systems. The radiology infrastructure already included networking, servers, domains, user groups and more. “We didn’t have to spend any money for this project. It was already built and in place, including the archival piece,” says Dawkins.
Although there are plenty of differences between radiology and cardiology, weekly cardiovascular conferences has served as a forum to highlight the similarities. “The techniques and skill sets of each specialty are starting to come together,” Dawkins says. “The technology is driving that level of communication.” Implementation of 64-slice CT at Tri-City has led the two groups to talk about how to use the technology most effectively and efficiently and the implications for reimbursement and patient selection. The value of the infrastructure and information systems has been particularly apparent through the conferences. It used to take a full hour just to get through two patient cases. Now it takes half that.
The physicians were accustomed to that kind of time waste. “They don’t see it because it’s their daily practice,” says Young. “But as we eliminate 15 to 20 minutes here and there, they wonder how they worked in the past.”
Integrated records also has helped Tri-City with all aspects of competition. In the San Diego area, “we’re the small ship in an ocean of big aircraft carriers,” says Dawkins. “We need this to compete with them.” Because of its small size, the facility has the benefit of being able to deploy cutting-edge technology faster than the larger competitors. It not only helps them keep up, but it helps them gain market share as well. Dawkins credits his forward-looking administration. “It’s critical that there is a long-term strategy in place to support growth of cardiovascular services, which can make up 50 percent of an organization’s gross revenue.”
Meanwhile, information systems make radiologists more efficient. Tri-City has fewer radiologists reading 30 percent more exams compared to before the implementation, says Young. Before, studies would be left at an outpatient imaging center overnight for interpretation. The next morning, one-third of the studies still needed to be read. Now, almost all studies are turned around the same day. Those advantages are now applicable to cardiology.
Recently, Young met with an invasive cardiologist Tri-City was recruiting. “He specifically asked about our technology, deployment, how to read remotely and how systems are set up and running. Had we not done what we did, I couldn’t have answered positively. I could speak to almost 100 percent of his requests.”
Dawkins notes that patients are starting to expect this level of technology. “Ultimately, I hope to use this as a marketing tool to the patient population. We can tell them that the more in depth their records are, the safer they’re going to be.”
Setting up a one-stop-shop
When the South Shore Hospital’s Cardiovascular Center in Weymouth, Mass., decided to create a one-stop-shop for its cardiovascular services, they wanted a single dashboard set-up, says Bill Burke, MHP, MBA, director of cardiovascular medicine. The facility implemented GE Healthcare’s Centricity system, which has been live since November, 2006.
Coming from a background in a large academic medical center, Burke was accustomed to systems and departments that have evolved over time and resulted in a haphazard, piecemeal patchwork of information systems. To consolidate into one integrated system, his RFP asked vendors for a single information system that would handle physician reporting, operating statistics, volumes, turnover times and more. He also wanted seamless regulatory reporting, web-based scheduling tools and inventory management. Since the equipment used in cardiovascular procedures, such as stents, wires and balloons, are so costly, “we wanted to track them down to the penny and see what we’re using and where we could cut costs.”
Integrating images into the system is huge, he says, because “gone are the days when everyone relied on the cardiologist and took their word on cases.” Nowadays, the various clinicians want to feel empowered to know more about their patient.
Just registering a patient used to take about 10 minutes and introduced multiple opportunities for errors. Now, information is entered one time, at the point of admission, and transmitted to every piece of equipment. Cardiac ultrasound in particular has changed dramatically, Burke says. Previously, an echocardiography study would go on tape so anyone needing to review it would have to watch the entire tape in a linear fashion. The report was a separate process after the review. Now, doctors can review a whole screen of thumbnails from an echo, which takes about one-fifth of the time. Meanwhile, a tech has already put together a preliminary report that requires that the physician input a few values and sign off. Report turn-around time is instantaneous. “We hardly measure in minutes, let alone hours or days.”
Staying on the forefront
The Cincinnati Health Alliance, a consortium of four hospitals in Ohio, implemented VERICIS and HeartSuite from Emageon back in 2000. Because the alliance saw the benefits to staff and patients, “we chose to get into the foreground of this type of technology,” says Mark Weber, manager of clinical services for the health alliance clinical engineering department. Because the alliance incorporates multiple facilities, they knew patients would be transported between those facilities. “We wanted to make the diagnosis and the transportation of that information more seamless. We realized we were going to have to invest in technology.”
A selection committee spent a lot of time choosing a vendor. “We really set a goal on partnering with a company, not just making a purchase.” Although the alliance chose Emageon, Weber says they continually evaluate the company against other competitors to make sure Emageon is on the cutting edge. “That’s the difficult part of buying technology early. If you’re not careful, you can quickly fall behind.”
Having the HeartSuite cardiovascular information system (CVIS) in place has helped avoid unnecessary expense. Since physicians can access images remotely and make consultations or diagnoses over the phone, patients don’t have to be transported by ambulance, or perhaps even helicopter, for a real-time consultation.
VERICIS is the cardiology PACS which manages the alliance’s cath lab images, echo, cardiac echo dictation and noninvasive vascular images. The echo department is using the reporting package rather than the former process of dictation and transcription. “The software lets them compose their own reports,” Weber explains. “Once they are finished, they confirm the report which is then immediately available through the CVIS.”
The alliance is just starting to integrate nuclear medicine, which is done through a competing vendor. “That’s another reason we chose Emageon—even though it’s a cardiac system, it’s not limited to just cardiac images. Their technology supports both radiology and cardiology.” Weber says he has yet to find a system from another vendor that he couldn’t get to communicate with HeartSuite.
He says the workflow advantages are definite. The image management system allows images to be warehoused, so physicians can go to a dedicated workstation or access them through a web browser. He has seen improvements in follow-up decisions because the information is readily available. Since cardiology often involves patients with ongoing disease, the CVIS helps clinicians compare against prior images and studies more efficiently.
For successful results, Weber advises that other facilities really understand their workflow before buying a system. “People are unwilling to adopt their workflow to the product they just bought. They try to bend products.” Facilities need to replace their current processes rather than cling to what they know. “Understand your processes and how they will evolve.”
|Integrated records require suitable storage|
|Integrated cardiac records allow for better patient care and more efficient clinicians but they do require significant review of storage needs.|
Tri-City Medical Center in Oceanside, Calif., has two separate sets of servers to run radiology and cardiology, each with its own independent storage platform. “We could have integrated but we felt that the two would grow at different paces and the archival requirements might be different,” says Steven Young, director of cardiovascular services. Currently, the facility has enough storage for three years. The cardiovascular system has about seven years of GE Gemnet data archived on DVD jukebox. “We went live with two years of depth in the system but we will keep the GE archive alive and just pull studies off as we go.” Since the retrieval percentage of studies more than two years old drops off significantly, there’s no need to keep the data online.
Young notes that everybody is struggling with 64-slice CT data. But, even as storage capacity needs to grow year by year, fortunately the cost has come down. Thirty terabytes cost about $30,000 and facilities can just add to that as their storage needs increase. Young hopes next year to deploy a system that involves a huge block of storage disks that spin down and stop when they’re not in use. “That exponentially extends lifespan. It sits idle unless you need something from far in the past.”