The Next Frontier in Cath Lab Archiving

New, integrated digital archives, multimodality workstations and online reporting tools are bringing radiology and cardiology departments together (really!) to share the benefits and costs of archiving cath lab and other cardiac images.
Many cardiac cath labs are digital archiving pioneers. Most have bypassed the cine film sneaker-net archive scheme and implemented digital archives. The benefits are undisputed and universal. The lost film plague is a mere memory, and images are readily accessible to a variety of specialists. But archiving technology is a rapidly evolving arena, and cath labs are poised to take advantage of the next-generation archiving solutions.

"The next big step in archiving solutions is the shared radiology-cardiology archive. The next-generation archiving solution will be the central digital archive that stores cine films, x-ray images, ECGs and medical records. In theory, the physician could sit at one workstation to view the patient's last ECG, chest x-ray, cine angiogram and history," explains Tim Fischell, MD, cardiologist with Borgess Medical Center in Kalamazoo, Mich.

The technology to realize Fischell's theory is hitting the market. A number of facilities are deploying solutions to implement an integrated archive and enable a single workstation view of the entire digital cardiac patient record. Some sites tap into the integrated archive as an initial step to the larger goal of the digital cardiac record. Regardless of the ultimate goal, for many sites, the cath lab archive is a work-in-progress that hinges on multiple products and interfaces.

The benefits of the integrated approach include anytime/anywhere access to both cath lab and radiology images and patient data, which leads to improved patient care. Hospitals report other gains as costs are reduced because the expense of an enterprise archive and disaster recovery plan are often less than departmental approaches.

Advice from sites on the cutting edge of the cardiac cath lab archiving solutions falls into a few specific areas:

• Develop a vision for the archive and use that to steer the entire process.
   
• Reporting tools can yield additional gains and may be considered as part of a new archiving solution.
   
• Anticipate and research integration and interface issues prior to implementation.
   
• Ensure that the system can be scaled properly to accommodate both radiology and cardiology images.
   
• Plan with the future in mind. This may mean adding other 'ologies' to the same system.

Goal-driven archiving

The cardiac cath lab typically enters the digital archiving arena to extinguish cine film and the associated film-handling problems. Take for example Borgess Medical Center, which deployed OptiMed's archive in its cath lab four years ago. The cath lab archive runs parallel to the radiology archive; the initial cath lab archive eliminated cine film handling and enabled cardiologists to access cath images at OptiMed workstations located throughout the multi-site facility. A one-gigabyte (GB) network facilitates image transmission from the hospital to off-campus buildings. Fischell anticipates additional gains with a combined radiology-cardiology archive that would provide access for modalities such as cardiac ultrasound and MRI and an integrated computer-based medical record accessible from the cath lab workstation.

Other facilities are moving in a similar direction. Edward Heart Hospital and Edward Cardiovascular Institute began implementing Camtronics Medical Systems Vericis for Cardiology archive in September 2003. Mark Goodwin, MD, director of the cardiac cath lab, says the process is shaped by three goals: to enable physicians to access information anywhere in the building; to facilitate efficient digital reading of echocardiograms; and to streamline data collection with structured reporting.

The hospital has met its initial goals. Camtronics' CardioWorks medical record provides access to cath and echo studies, and an interface with the hospital's Meditech EMR enables similar access in the hospital. Digital echo reading has dropped reading time by 50 to 70 percent, and structured reporting allows the site to query data elements such as patients or procedures. Goodwin's sole piece of advice for a smoother implementation centers on structured reporting. He says sites should implement it concurrently with other changes in workflow processes. Because structured reporting doesn't save physicians much time, they can be resistant to learning a new process after realizing the workflow gains associated with digital reading. The next step for Edward Cardiovascular Institute is the digital cardiac record that houses inpatient and outpatient data such as echocardiograms, cath lab images, nuclear medicines studies and CT angiograms.

The need to share images and information among inpatient and outpatient sites is universal among multi-site healthcare organizations. Take for example Aurora Healthcare, a 13 hospital, 100+ clinic organization in Milwaukee, Wis. Its cath lab and enterprise archiving strategy is driven by the goal of placing patient images in the EMR. The healthcare system relies on multiple Siemens Medical Solutions archives to meet its needs. Acom.net serves as the cath lab PACS, KinetDx is the echocardiography PACS, and Sienet Magic PACS provides image archiving for radiology. All data are stored on a common StorageTek tape library. Acom.net allows clinic-based physicians to view cath and echo images as well as radiology studies. "It's the same archive to them," explains project lead Tim Heniadis. Clinicians access cath lab reports via Cerner's Powerchart. Currently, users toggle between the computerized patient record and cath lab PACS as they view reports and images; however, the ultimate goal is to place images in the EMR with current archiving, reporting and viewing systems serving as interim steps to reach that goal.


Cath lab archive plus

For some facilities, the goal is not an integrated radiology-cardiology archive. St. Mary's Hospital in Evansville, Ind., is one. When the hospital decided to deploy a digital archive in the cath lab, it wanted more than an archive, says Nikki Broady, director of the cardiac cath lab. The hospital realized that online reporting offered significant advantages, so it searched for a system that included both archiving and online reporting tools and eventually purchased Medcon's TCS Symphony with Cath Reporting in October 2003.

TCS Symphony imports and integrates hemodynamic data from Witt Biomedical's hemodynamic system. After a cardiologist completes a coronary angiogram, the system displays the patient's images and data with a dropdown menu for reporting. The report is electronically signed and available for viewing over the intranet or internet or automatically faxed to the referring physician. Billing turnaround time has dropped from one week to one to two days.

St. Mary's anticipates additional gains as it implements the next phases of the cath lab archiving plan. The cath lab is interfacing TCS Symphony to its American College of Cardiology (ACC) database. This will streamline workflow for ACC coordinators by automatically populating forms with patients' coronary data. Farther down the road, the hospital intends to integrate TCS Symphony with an EMR to enable enterprise viewing of cath lab images. Broady predicts that the HL7 interface in the Medcon product will facilitate a smooth transition.

Although the shared radiology-cardiology archive is a trend, St. Mary's opted for separate archives. "The radiology department did not want cath lab images in their archive because our files are so large," explains Broady. The island approach has not negatively impacted the cath lab; Broady says cardiologists can view radiology images on Medcon workstations by clicking an icon and input-ting a patient number.  

Other sites also assert that reporting tools can be a powerful workflow booster. Christiana Care Health System in Wilmington, Del., tapped into Philips Medical Systems Xcelera cath lab management solution to meet its image archive and data management needs. The suite handles cardiac cath and interventional radiology images and will eventually include electrophysiology data. "The primary advantage of this approach is the integration of images and reporting. After data are entered, the physician can use them in the report and then import images. We plan for physicians to electronically diagram cases by importing and annotating images and creating an electronic report, which can be sent to the central patient record," explains Pat Wessel, manager for heart and vascular intervention services. An interface to the cath lab data repository eliminates redundant data entry; once data are entered in the Philips system, it is sent to the data repository - a significant improvement over the past process that required multiple common entries.

Final report time has dropped with the Philips solution, and the hospital plans to use Xcelera as the foundation for its new cath lab reporting model to further cut reporting time. The new model trains physicians to sit down at a workstation immediately after the case (or by the end of the day), review the images and complete and sign the report.  Completed current and past reports are available to referring physicians through Cerner's Powerchart EHR, but images such as coronary tree drawings or picture files must be printed and sent to physicians. Christiana Care is exploring several options for electronic viewing of the report and associated images. Upcoming versions of Powerchart may be able to accept documents containing embedded images, or Powerchart may be linked from other applications to view images. Another option under consideration is to use the web viewer capability that Philips is developing for Xcelera to enable image viewing from other locations.


IT challenges

"There are challenges to the digital cardiac record," admits Goodwin of Edward Hospital. Patient identification issues across 15 outpatient offices, 56 cardiologists and nine hospitals are complicated. Although the sites are connected by T1 lines, pushing bulky echo studies through the lines in near real-time is untested and may overtax the network. Finally, interfacing data from multiple sources is not as simple as it sounds, says Goodwin. Archiving and patient record solutions can facilitate interfaces by supporting HL7 and IHE standards.

Other IT challenges associated with the move to the enterprise archive include network and storage issues. For example, HCA Healthcare, a multi-site hospital system in the Richmond, Va. area, uses its newly opened Levinson Heart Hospital as the system model for state-of-the-art cath lab archiving. The rationale behind the new archiving system is the creation of an easily accessible enterprise patient record that leverages the existing radiology PACS. The solutions include GE Healthcare's Centricity Cardiology and Muse cardiovascular information system, which serves as a single source for patient EKG data. "The biggest benefits are decreased reporting time to one to two hours and instant access to patient information," says Kim Harrison, PACS administrator. All hospitals in the system can access cath lab images and patient records via Centricity PACS workstations throughout the multi-site system. Images are available on other workstations via a web-server application.

Prior to implementing the cath lab archive, HCA evaluated its existing network and storage capacity. Network infrastructure was enhanced from 10 to 100 megabytes (MB) to one gigabyte (GB), and storage capacity was increased to accommodate cardiac images, which are significantly larger than radiology images. This year, the system added 22 terabytes (TB) to its archive, designating 12 for radiology image storage for seven hospitals and 8 TB for cardiology images for the one hospital currently in the archive. Other sites prep upfront for projected storage needs, too. For example, St. Mary's Hospital added NAS (network attached storage) to its hefty 1 GB network at the same time as TCS Symphony in anticipation of storage demands posed by cath lab images.

HCA Healthcare, like others diving into the enterprise model, found that each cardiology system, hemodynamic monitoring, angiography x-ray and EKG system, assigns different patient identifications numbers, which the PACS could read as separate patients. Synchronizing numbers across modalities is a challenge because cardiology lacks a RIS-like system to feed a modality worklist.

Mainline Health, a Philadelphia-based radiology and cardiology site that relies on McKesson's Horizon Cardiology as its cath lab solution, overcame patient ID issues by training cardiology techs to enter consistent patient identifiers. HCA Healthcare employs a combination approach that includes tech training and importing information from modality to modality so identification numbers are the same. Manual merges are completed on an as-needed basis in the archive. Harrison anticipates a new solution with the next release of Centricity DMS, which includes software to generate accession numbers and enable synchronized numbers across modalities.

While some facilities overcome immediate IT issues, others are considering larger challenges of enterprise-wide access to patient information including cath lab images and data. Patient privacy is a concern, says Fischell. "We need to determine more advanced ways of protecting patient information [as it becomes accessible at workstations throughout the enterprise]," he continues. Options beyond the traditional password include biometrics such as thumb prints and retina scans.


Advice from the cath lab trenches

There are multiple options and multiple solutions for cath lab archiving. Facilities can gain the most out of a new solution through diligent planning and research.

• Clearly define your expectations, says Wessell. The planning team should be a large, multi-disciplinary group that includes cath lab and information services staff, clinical engineers, administrators and physicians. "Communicating a clear scope and goals to the vendor simplifies project management," adds Aurora Healthcare's Heniadis.
   
• The site visit is key. Find a hospital of comparable size with similar patient volumes, use and workflow. St. Mary's Hospital went beyond the site visit and insisted on live side-by-side demos of systems under consideration. Seeing the functionality of each system in conjunction with its x-ray system facilitated the decision-making process.
   
• Assess storage needs and upgrade paths to ensure that the enterprise is proactively covered.
   
• Consider both the future and enterprise archive needs. Can the system accommodate or integrate with future archives that include other 'ologies'? "If the hospital is not thinking about what it wants to do in five years, it's doing itself a disservice," says Harrison.

Conclusion

Many cath labs are exploring next-generation archiving solutions. Shared radiology-cardiology systems bring a number of benefits and are being implemented at more sites. Interest in a digital cardiac record that includes multi-modality, multi-department images and data also is driving the market and should be considered during the evaluation process. New cath lab archive benefits include improved efficiency with decreased and streamlined reporting time. Patient care is improved with better access to patient images and information. A thoughtful planning process that assesses current and future needs in both the cath lab and across the enterprise helps sites maximize the investment in a new solution.