Trend Tracker | IHE in Cardiology Makes Progress

You probably know by now that the Integrating the Healthcare Enterprise initiative is moving into the cardiology realm. But if this is news to you, there are some marketplace changes underway that you may want to understand - quickly!

Every vendor that offers systems used in ECG, echocardiography or the cardiac cath lab needs to be on board with IHE Cardiology within the next few months. While a good number of software and hardware device companies already participate in the Planning or Technical Committees, a significant group of vendors are still missing, including both large and small companies.

For OEMs skilled at reading between the lines, the IHE Cardiology opportunity is spelled UPGRADE. Newly minted IHE-capable products and systems are likely to be purchased sooner than the normal replacement lifecycle for products that are routinely connected to networks in a clinical care setting. The benefits from these systems are primarily workflow and departmental productivity.

While IHE specifications are not yet in use in the cardiology world, the upcoming demonstrations at ACC and HIMSS in early 2005 are expected to enlighten many thought leaders. IHE Cardiology has garnered substantial official sponsorship, including the ACC, European Society of Cardiology, American Society of Echocardiography and Society of Cardiac Angiography and Interventions.

IHE Cardiology upcoming events and milestones include a final release of the Technical Framework and Call for Vendor Participation, a vendor workshop meeting, a participants technical meeting for ACC and HIMSS demonstrations, MESA (Medical Enterprise Simulators and Analyzers) testing tools, a Connect-a-thon testing in a multivendor environment, and HIMSS and ACC demo areas.

The sidebar below is a brief summary of key points contained in the IHE Cardiology Technical Framework that is now available for review and comment. To view the complete documents, go to www.cardiosource.org.

The Cardiac Catheterization Procedure in Perspective

It is important to understand the cardiac catheterization procedure that is being addressed in Year 1 of the Cardiology Technical Framework, and to put that into perspective with regard to a broader picture. The cath procedure itself occurs inside of a clinical context wherein a patient has a clinical presentation, diagnostic and/or interventional procedures are performed, and events of interest are monitored after the procedure itself has concluded.

Clinicians may use the terms such as "case," "encounter," or "admission" to refer to this broader scope. To help avoid confusion with other standards documents and nomenclature, this appendix introduces the term "Episode of Care."

The clinical activities associated with cardiac catheterization are shown schematically above. The evidence-gathering activities may actually start hours, days or weeks ahead of time as the patient is evaluated before the procedure. The cath procedure itself refers to the events that occur in the cath lab suite itself. Evidence will continue to be gathered after the actual procedure has finished, which would typically include the recording of complications (if any), and subsequent patient outcome.

At some point in time, there is an event (that may be site-specific) that indicates that the Episode of Care has concluded. In its simplest form, this might be represented by the patient's discharge from the facility. Any evidence that is gathered relating to events after that point in time is no longer added directly to the Set of Results associated with cardiac cath.

In Year 1 of the IHE for Cardiology Technical Framework, activities have been identified that occur between the patient's arrival in and departure from the cath lab suite. In subsequent years, the Technical Framework will be extended to include the entire Episode of Care.

IHE in Cardiology: The Framework

Key Excerpts from the Technical Framework, Vols I and II

The current IHE Cardiology Year 1 Technical Framework addresses the following primary features:

• The Cath Workflow Integration Profile describes mechanisms to manage and distribute the workflow within the cardiology department catheterization labs across the several types of equipment in a synchronized manner.
• The Echo Workflow Integration Profile describes mechanisms to manage and distribute the workflow within the cardiology department echocardiography function, including stress echo.
• The Retrieve ECG for Display Integration Profile describes interoperable ways for ECG waveforms and analyses to be retrieved and presented by display systems both inside and outside the cardiology department.

CARDIAC CATHETERIZATION WORKFLOW
Cardiac catheterization is complex, especially from a workflow perspective. Evidence-gathering activities may begin before an order is placed; in fact, orders are often not created for a cardiac catheterization procedure due to its frequent emergency nature. There may be a variety of imaging, measurement, and reporting systems that need to coordinate to use the same patient identifier, and to assure that the evidence produced is all associated with the same procedure. Further, the procedure itself may include both diagnostic and interventional or therapeutic aspects, and may extend over a long time period (several hours).

ECHOCARDIOGRAPHY WORKFLOW
The Echocardiography Workflow Integration Profile describes the workflow associated with digital echocardiography, specifically that of transthoracic echo (TTE), transesophageal echo (TEE), and stress echo. As does the Cath Workflow Integration Profile, this profile deals with patient identifiers, orders, scheduling, status reporting, multi-stage exams (especially stress echo), and data storage. It also specifically addresses the issues of acquisition modality devices that are only intermittently connected to the network, such as portable echo machines, and addresses echo-specific data requirements.

The Echo workflow for Year 1 is limited to the workflow around the imaging modalities. Items not included would be nursing notes and drug administration documentation. Measurements are accommodated in the workflow, but are not specifically addressed.

RETRIEVE ECG FOR DISPLAY
The Retrieve ECG for Display Integration Profile specifies a mechanism for broad access throughout the enterprise to electrocardiogram (ECG) documents for review purposes. The ECG documents include "diagnostic quality" waveforms, measurements and interpretations. This Integration Profile allows the display of this information without requiring specialized cardiology software or workstations, but with general-purpose computer applications such as a web browser.

This Integration Profile is intended primarily for retrieving resting 12-lead ECGs, but also may retrieve ECG waveforms gathered during stress, Holter, and other diagnostic tests. It only addresses ECGs already stored in an information system. It does not address the process of ordering, acquiring, storing, or interpreting the ECGs.

ECG documents are often created and managed on ECG management IT systems to which cardiographs are connected. Broad access to the ECG documents throughout the enterprise as well as outside the enterprise is facilitated by this Integration Profile. The primary use case involves a cardiologist interpreting a 12-lead ECG on an ECG management system.