Cardiac Images Flow Across the Enterprise

Managing cardiac images offers challenges secondary to the wide array of forms that those images can take. Cardiac catheterization labs produce dynamic images that require storage as cine loops and static screen captures. Ultrasound involves the same configurations, but until recently most of those images were stored as video images and must be converted to digital images from older machines. And 64-slice CT offers amazing cardiac images that pose a serious challenge to manage in terms of volume and quantity.

Cardiac image managment solution approaches vary from institution to institution. Some centers use separate PACS to manage cardiac and radiologic images. Some hospitals have merged images produced in both departments onto a single PACS, and of course, others are in transition.

Across the board, cardiologists appreciate the ability to review images from a variety of imaging modalities on a single workstation. Health Imaging & IT spoke with three facilities about the solutions they have deployed to maximize the benefits and address challenges inherent in managing cardiac images.

Huntsville Hospital, (Huntsville, Ala.)

As one of the largest locally owned not-for-profit hospitals in the nation that includes 881 licensed acute-care beds and serves as a teaching facility for the University of Alabama-Birmingham's School of Medicine, Huntsville Hospital offers a regional referral center with a strong emphasis on the care of patients with cardiac problems. They perform 6,000 cardiac imaging procedures each year.

The answer to their cardiac image management issue was ScImage Picom Enterprise cardiac suite that offers a variety of tools for diagnostic and clinical viewing as well as advanced reporting capabilities that are available through web-based viewing when desired, says Frank Cantrell, administrative manager for cardiology services. Currently, the PACS resides as a separate cardiology component, with another PACS for radiology. They have reading stations installed in the cath, echo, and vascular labs to maximize efficiency.

"In our hospital, the physician who is doing stress tests is also the echocardiogram reader for the day. So he can read echos while he is doing a stress test and doesn't have to go to another department to read," says Cantrell.

With a goal of providing cardiologists with "one-stop shopping" so as they can see everything at one time, this system offers the capability of side-by-side static and dynamic image data set visualization on a single workstation. "So physicians can pull up a nuclear study on one side that may just have a screen capture of the processed images, and on the other side, they can have the echoÖor a catheterization film running," he continues.

The department's previous image management solution included several different systems that they had outgrown, says Huntsville's Manager of the Cath Lab and Electrophysiology Labs Patricia Bailey, RN, BSN. In February, they consolidated image management, going live with the cardiology PACS. They currently have two reading stations in the cardiology area that are not directly inside the cath lab as well as the monitors within the procedure room, says Imaging Engineer Jim Gallardy. This means that cardiologists or surgeons can pull up prior imaging studies or even monitor a case in progress from outside the room.

The cath lab went digital in 1997, and when it came time to install the cardiology image management suite; their modalities produced DICOM3 signals. ScImage was the only company they reviewed that agreed to accept that signal, and that fact saved them between $40,000 and $50,000.

Gallardy and Bailey note that ScImage staff have been extremely responsive to any problems they encounter. "One of the things I truly enjoy about ScImage is that they will help you solve a problem even when it is not necessarily their issue," Gallardy says.

Some of their physicians requested a customized template for reporting, and ScImage staff reengineered the system to permit an individual version that follows that specific cardiologist no matter which reading station is used.

Huntsville continues to build on system capabilities. Bailey relates a work in progress that will enable them to pull in cases from other physician offices, since they function as a major referral center for northern Alabama. They receive few films these days from outlying hospitals, with CDs the media of choice. However, since they are busier than any cath lab in the state of Alabama with five cath labs and one EP lab, they need maximum flexibility in accessing prior studies within their center.

Within the hospital, they are able to move images throughout the institution, including cine studies into the operating room for surgical review.

Finally, Cantrell, who describes himself as quite experienced in the installation of PACS, says the installation process was relatively painless. "We had a few glitches on some of the HL7 interfacing, but it just took a little tweaking."

Memorial Health University Medical Center (Savannah, Ga.)

When Memorial Health University Medical Center was opening their new heart and vascular center in December 2005, leaders of this 530-bed two-state healthcare organization that serves a 35-county area began analyzing several PACS vendors. They reviewed a number of companies before they decided on Medcon, an Israeli-based PACS vendor that was purchased by McKesson in June 2005. Memorial added the new Horizon Cardiology PACS to their other Horizon solutions. "We had a McKesson PACS and wanted integration between the two systems," says Debbie Cook, RRT, PACS administrator, who served as project administrator for imaging. "Plus we loved the way the images looked."

This implementation was not accomplished without a bit of angst. Clinical Systems Lead and Project Manager for Hemo and CVIS solutions Sabrina Hamilton, RN, CPHQ, explains that their move into the new building involved the purchase of new imaging modalities as well as the new Horizon Cardiology PACS, resulting in several layers of "learning curves." Hamilton explains it wasn't like installing a cardiology PACS on an already fine-tuned set of imaging equipment. However, they found McKesson to be an effective and responsive partner in making things work. And Cook explains that the implementation was easier because they already had other McKesson products on site.

Horizon Cardiology is a complete cardiovascular information solution for cath, hemodynamic monitoring, echocardiography, vascular ultrasound, and nuclear cardiology, with web access for remote viewing.

"Installation is more than seeing an image on the screen," says Hamilton. "Because cardiology is so large, you need data flow from the time the patient registers through the report on the images, and you must go through the interface with the EMR [electronic medical record]."

With this system, clinicians can even draw on the images to document and annotate where they placed a stent, or other items of interest. The team at Memorial saw this feature as a differentiator, Cook notes, since they didn't see that capability on other systems during site visits. Another feature that is valuable to this teaching institution is that physicians can create PC files (with patient demographics removed) to use in their educational activities.

While physicians don't have workstations in their offices, there are PCs in each of the nursing stations so that physicians are able to view images throughout the institution. Since the operating rooms offer wireless connectivity, cardiology images are available via the web product.

The next step is to enable physician access in their offices. In its present configuration, cardiologists can use the system to consult with other clinicians within the institution. The next step will be to enable image viewing in physician offices and eventually in their homes.

While they currently have two separate databases for cardiology and radiology, the facility is working towards merging the two. "Our PACS goes to a storage area network [SAN] solution, and cardiology images go to a network-attached storage [NAS] solution. We're in the process of moving our cardio PACS off the NAS with the goal to have mirrored images with one NAS storage solution sites in Atlanta for disaster recovery. When we get to Version 11 of the McKesson PACS in January, we can get it onto our NAS solution."

The end goal is to pull both systems together so that clinicians need only log onto one system to see either cardiac or radiology imaging.

Hamilton and Cook both recommend establishing a multidisciplinary project management team that includes representatives from all of the departments that will be impacted as well as members from the PACS vendor to minimize headaches and maximize functionality of the eventual system selected. They also stress the importance of training for all staff members from technologists to cardiologists to referring physicians.

Thibodaux Regional Medical Center (Thibodaux, La.)

As a 150-bed hospital that accomplishes 75,000 radiology exams every year, Thibodaux installed NovaPACS four years ago to manage all of their medical images. In this institution, radiology has their own network so that the large image files that are produced wouldn't disrupt other hospital network needs. Dedicated radiology workstations are located throughout the facility. MEDITECH provides their RIS, but with an interface, the clinician can review images and the report at the same time.

Nuclear medicine and cardiac cath studies are sent to the NovaPACS, as are cardiac CT angiography images from the GE LightSpeed VCT 64-slice CT scanner, says Camile Richard, RT, imaging director. Echocardiograms remain in the department and are not sent to the PACS because they are videotape images.

The network at Memorial has a 1-gigabit backbone with 100MB drops, says Fernis LeBlanc, RT (CT)(QM) BS, PACS administrator. They use three Dell Quad Processor Dual Core servers and run a RAID5 for storage with the servers piggybacked for redundancy.

"We were one of the first NovaRAD customers to decide we wanted redundant servers so that if one server goes down, we have the redundant server with the exact same information, so we can continue to work," says Richard. And LeBlanc adds, "After the daisy-chain servers, we also send all of our images to be stored in Utah through NovaRAD." This serves as their disaster recovery storage solution.

Richard and LeBlanc agree that NovaRAD has been responsive in ensuring that all interfaces function as needed. The company provides a web product as well so that no matter where clinicians are, they can access the information they need. This scalable PACS solution is designed to be configured to meet each institution's image management requirements. As brokerless products, they are designed to interface with the health information system with no need for additional hardware or service contracts.

Conclusion

When clinical decisions must be made regarding cardiac care, it is often advantageous for clinicians to be able to review images from more than one modality simultaneously. Some facilities separate their cardiac images from those produced by the radiology department, and some utilize a single PACS solution to store all images produced that depends on the workload requirements each healthcare setting designs. Clinical staff must work closely with their PACS vendor to establish a fully functional interface and thus ensure the seamless flow of cardiac images across the enterprise.