Managing Images & Information Cardiology Style

When cardiology departments headed toward the digital age with images and patient information in the last decade, following the examples of the other image-intensive department - radiology - seemed like a logical step as the benchmark for how to proceed with cardiology information systems (CIS).

Radiology departments progressed to picture archiving and communications systems (PACS) to store and archive digital images and supplemented the control of workflow within the department - scheduling patients and tracking films and reports within the facility - with radiology information systems (RIS).

What cardiology departments unfortunately found in the early development of image storage, archiving and transmission technology was that cardiologists and caregivers were dealing with cine images with file sizes of 500 megabytes, compared with radiology images in the range of 5 megabytes.

"The biggest thing that is different with cardiology is that the heart is a moving organ," says Tom Feigenbaum, president of CIS vendor Problem Solving Concepts Inc. (ProSolv). "You have moving images, where as in radiology, most of the images - if not all - are still-frame images. There may be many still-frame images, but they are not cine loops or moving images. To determine function, you have to see the heart in motion and that leads to larger file sizes for the captured images."

By 2000, technology began to catch up with cardiology's needs. Computers advanced from 200 megahertz PCs to gigahertz PCs and computer memory (RAM) increased from 128 to 512 megabytes. Standard networks grew to 10 megabytes and then to 100 megabytes to offer more image and data transfer capabilities. All of which converged to help handle cardiology images more efficiently.

"Even in the late '90s, people were asking the question: 'Why can't I just store my cardiology images on my PACS with all the rest of my images?'" recalls Harry Chesnut, cardiology segment manager for Agfa Healthcare. "It just wasn't do-able. Now it is both do-able and feasible."


MARKET OVERVIEW

Cardiology is not only more dynamic and represents a distinctly different patient care model than radiology. But it is newer territory for image and information-based technologies.

"Radiology has been doing this for a while, so it has had time to mature in the market," says Shawn Gibbons, product line manager of image management for IDX Systems Corp.'s ImageCast division. "Cardiology has been doing it, but there are more data sources to input - ECG cards, inventory systems, HIS, procedural medicine systems - and traditionally they have not all been aligned together with communication standards."

In its July 2003 report, market research firm Frost & Sullivan noted that the markets for cardiac catheterization lab and echocardiography PACS are "more developed than the markets for cardiology-wide PACS solutions," with the majority of images generated in cardiology coming from cath lab and echocardiography studies. Because cath labs began converting to digital imaging almost 10 years ago, cath labs, the report adds, "represent a more mature market than echocardiography." Eighty to 90 percent of the cath lab installed base now is digital, with some 10 to 15 percent still using film.

Frost & Sullivan estimates revenues for echocardiography and cath lab PACS in the United States at approximately $118 million in 2002, with projected revenues of $430 million in 2009. Cath lab PACS contributed $72.3 million to the 2002 total, while echocardiography PACS accounted for $45.6 million.

Increasing cardiac imaging procedure volumes and proven benefits of digital imaging are the two primary forces expected to drive growth over the next five years. Cardiologists, the report notes, also have come to realize the operational and economic benefits of digital technology and how the "management of physical CD and videotape libraries is a major cost center for most cardiology departments."


WHY A CIS?

Cardiology is amongst the fastest growing (and cost-generating) departments within a healthcare facility, in terms of new technology and equipment and the creation of larger data sets. Thus, greater capabilities and expanded features of CIS are more in demand.

"The complexity of the [cardiology information] systems has grown tremendously over the last couple of years and the vendors are making a push to have broad cardiology systems with image management as a component and not just an end piece," says Thomas E. Kennedy, PhD, vice president of business development at Camtronics Medical Systems Ltd.

As cardiologists and related caregivers require more information - such as hemodynamic data, ambulatory records and text-based information - for the care of a cardiovascular patient, they also are demanding a cardiology information system that can deliver the data to ease today's regulatory and market pressures.

Those challenges include declining reimbursement; demand within the hospital to cut costs and improve efficiency; quality initiatives from the government; and having to prove patient outcomes. The reimbursement issue could become even more critical, Kennedy says, when payments become based on a facility's outcomes and performance.

Needless to say, one of the keys to financial viability in the new medical economy is to improve efficiency.


PROVIDER ISSUES

Healthcare facilities, of course, have a number of issues and concerns when considering the purchase and addition of a CIS.

The questions include:

• How can a CIS improve patient care, make them more efficient and more profitable?
   
• How can the technology help a facility or cardiologist expand service within a geographical region?
   
• And for the large healthcare network, how do you best connect with outreach sites and clinics to extend cardiovascular care to underserved areas.

Ruth Hurley, vice president of marketing at Witt Biomedical Corp., brought a hospital cardiology background with her when she joined the cardiology products company. "I came from the era when we didn't have the technology that we have today. It was all hardware-driven and islands of information. I can't emphasize enough the impact of integration," Hurley says. Providers "want software and hardware that allows them to do all the clinical and administrative things they need at a good price. I think that there are a lot of the overused buzzwords about workflow, efficiency and productivity, but people really need it now."

For a cardiologist, accessibility to complete patient images and data is at the top of the CIS priority list, along with cohesive administrative functions - such as scheduling and billing - to cover the business side of the practice.

Unlike most radiologists who are employed by and work within a traditional healthcare, cardiologists primarily have practices outside of a hospital and are on the move between two, three or four different healthcare facilities and their own main offices. That situation can create two problems: A patient's test and imaging results are scattered throughout a facility among the different cardiac subspecialties, such as nuclear medicine, echocardiography and electrocardiography; and, because the cardiologist is not at the facility full-time, he or she may not have the influence to affect a change in that process.

"I see an increased frustration on the part of cardiologists, cardiology administrators and cardiovascular surgeons in their ability to get the information they need," notes Bill Waters, vice president and managing director of cardiology and radiology enterprises for Cerner Corp. "All the subspecialties have created silos of information which [cardiac care providers] find very problematic to get to. It isn't a new story, but I started hearing it five years ago and it is getting louder."

On the positive side, Waters says that more hospitals are thinking about operational efficiencies within the cardiology department, as facilities begin to appreciate cardiac services as a key revenue generator, despite the hefty costs.

Cardiology departments these days, he adds, also are more willing to work with the rest of the institution. Cardiologists "see the value of IT to help them solve some of their problems and they also see the value of a broader, integrated medical record," Waters adds.


INFORMATION ACCESS

"One thing that is important in cardiology is that speed matters," says Matt Aitkenhead, Heartlab's vice president of technical operations. "Data sets that are produced by cardiac x-ray equipment with today's generation of 1024 cath lab systems frequently approach a gigabyte per exam."

Cardiologists also must store a patient's records for as long as seven years, another requirement that sets cardiology requirements apart from radiology departments. "Take a busy cardiac center that does 10,000 exams per year and has to keep exams around for seven years," Aitkenhead adds. "That becomes quite a data management problem."

Healthcare facilities also will question whether software and upgrades will integrate with their existing hardware.

"One of the major concerns of each site is whether [the technology] can communicate with these other systems," says ProSolv's Feigenbaum.

That's when DICOM capabilities of the hardware become a factor, especially if and when integrating a RIS and a patient's electronic medical record (EMR) come into consideration.

The bottom line is the provider's ability to make the best patient care decision based on the most information available.

Physicians "are making educated decisions that affect patient care based on technology, because that is the only thing they can't carve out of the system," says Mark Scott, Witt's product manager. "The only way they can affect change is with information to make better decisions."


PRACTICAL USE

St. Francis Hospital in Roslyn, N.Y., is a 350-bed facility and New York's only cardiac-designated hospital. St. Francis annually performs some 2,800 open heart surgeries, 13,000 cardiac cath procedures and 9,000 echo procedures. The facility installed Heartlab technology in 2001 and has hastened both the reading and accuracy of images read.

"In addition, we often can compare present studies with previous studies, which is very difficult to do using videotape," adds Alan S. Katz, MD, director of medical information technology at St. Francis and consultant to Heartlab. "Cardiac ultrasound is a study that can be done repeatedly. There are no biohazards and often subtle changes between studies are clinically very important."

St. Francis also can "view images across the enterprise," Katz says, allowing for more than one healthcare provider to simultaneously view images from different locations.

"That means that physicians are not hunting for a videotape that a colleague is reviewing," he notes. "Also, over the telephone, I can consult with referring physicians and surgeons and improve their efficiency by discussing images as we both review them."

Health First has approximately 800 beds between three hospitals in Brevard County, Fla., and currently is building a new $115 million, 375,000 sq. ft. heart and trauma center at its Holmes Regional Medical Center in Melbourne. The new facility - set for completion in 2006 - will add seven cath labs and house all of Holmes' cardiology services.

Health First already has 35 clinics and outpatient facilities throughout the county, eight cath labs throughout its system and 15 echocardiography systems. Health First handles more than 3,000 diagnostic studies per year, more than 2,000 interventional procedures and more than 2,000 peripheral procedures. Health First installed Heartlab CIS technology in late 2002 and has 10 gigabytes available for its storage system to manage images and studies from cardiology.

One prerequisite to ensuring that a CIS functions properly is involving the IT department from selection of the vendor and technology through implementation, says Matthew Litz, manager of Health First's cardiac cath labs. A close working relationship with the biomed department for the different medical imaging modalities that a facility plans to connect to IT system also is a plus.

"We worked closely with the cardiology team and have recruited and hired PACS administrative positions with folks who were formally in biomed and clinical engineering," adds Steve Shim, Health First's director of technical services for IT. "Now they have IT skills and have helped bridge that gap."

Facilities also need to anticipate demand and cardiac service plans for the short and long term when considering CIS technology today.

"Our counsel to customers is, if you're interested in buying image management systems today, buy them with an eye on where you'll evolve your cardiovascular service over the next few years," says Camtronics' Kennedy. "How are you going to expand and react to the quality initiatives that will be mandated by the government? How will the image management system today evolve and address those issues down the line?"

Kennedy opined that bandwidth needs will not become any greater, doubting that expanding multislice CT angiography images will reach the size of a high-resolution cath lab studies.


ROI RESULTS

Nebraska Heart Hospital in Lincoln, Neb., is a 63-bed facility for acute cardiac, vascular and thoracic care. Nebraska opened in May 2003 with Siemens Medical Solutions' Soarian Cardiology as its base for CIS functions within the new heart hospital.

"One of the big advantages was that we could start from the beginning and design the building and the information systems so they followed the patient and clinician workflow," says Nebraska CIO Doug Colburn.

Nebraska uses what Colburn describes as a "patient-centric care model" of care, whereby a patient is admitted directly into a room and is transferred from the room only to go to surgery, the cath lab or for imaging. Other than those applications, other functions are brought to the patient and the modular patient room can be converted to critical care, ICU, OR recovery, step down or discharge.

The technology already has shown benefits in the first seven months of the facility's operation. At the end of 2003, Nebraska had performed 304 open heart surgeries, 358 interventional cath procedures (some of which are performed by Nebraska's affiliate, which has four cath labs), 175 vascular procedures and 20 thoracic procedures.

Colburn says the hospital totaled 1,321 discharges, approximately twice as many as anticipated, based on the experiences of its physicians at other facilities. The doubling of the discharges was due in part to a reduced length of stay to 2.5 days, compared with 4.3 days as calculated by Nebraska's physicians while working at other facilities.

Nebraska also calculated that it may take two years to reach a break-even point financially, but that mark was achieved in seven months.

"There are a lot of factors that go into that," Colburn adds. "It's not just IT. It's also anesthesia, it's how we do our universal care model and the team. A lot of it can be attributed to our length of stay."

At South Carolina Heart Center in Columbia, S.C., Soarian helped the facility on average to add one additional cath lab procedure per day. As a result, SCHC increased revenues by $720,000 in one year. Turnaround time for cath lab reports also used to take 12 to 24 hours to complete.

"Now with the automated capabilities, the report is completed as the physician is walking out of the cath lab and the referring physicians get the report by fax or email within minutes of completion of the study," says Robert Cohen, Siemens' director of clinical departmental solutions.


GROUP PARTICIPATION

Edward Heart Hospital in Naperville, Ill., used a phased approach to convert from a film to digital environment, implementing the PACS piece of Camtronics' Vericis first.

"To go from a film-based to filmless environment, it probably took us six months and it is still ongoing," recalls Joe Valles, the facility's ISS clinical specialist. Plans are to connect Vericis into Edward's HIS in the third quarter and add additional features and upgrades over the course of this year.

Among the biggest challenge, he notes, was the integration of the PACS with the hospital's information system.

"It is imperative that one understands the workflow and you have to get end- users - not just the management - involved," advises Valles. "Get the physicians involved. If you can show them the features and benefits, you can turn them into the biggest advocates of the system."


FUTURE TRENDS

CIS technology is expected to become even more critical in this decade, as millions of baby boomers come to an age when they require cardiac care and healthcare facilities try to handle the increased demand for services.

With the drive to incorporate as much information as possible into the CIS, the natural progression healthcare providers and vendors see is the inclusion of CIS information in the EMR over the next several years. Features, such as report generation - which will save time and allow for more efficient uses of some human resources - will help pave the way toward more facilities gradually adopting EMR technology.

"That time savings has to translate into better patient care," says Witt's Hurley. "Instead of a luxury, the EMR will be the standard of care."

"It is happening in other countries already," adds Agfa's Chesnut, "and it is happening hit-and-miss around the [United States] where customers say they can see the cardiology and radiology images. What [providers] also want is access to the EKG or the stress system or help to synchronize that with what is reported in dictation systems."

St. Francis' Katz sees vendors being able to connect additional modalities, such as nuclear medicine and cardiac MRI, to review workstations. The hospital recently distributed an RFP (request for proposal) for a PACS, which can bring in all the medical imaging modalities and can incorporate Heartlab's Encompass technology.

He also anticipates the development of a multimodality workstation to eliminate dedicated pieces of hardware for each individual medical imaging modality.

ProSolv's Feigenbaum also see the marketing trekking toward multimodality capabilities, replacing the exclusivity of different workstations to view echocardiology, cath lab and nuclear medicine images, and allowing cardiologists and other providers the ability to view different modality images side-by-side.

"Most modalities conform to the DICOM standard and that simplifies the process," Feigenbaum says. "Some, however, do not and there are different challenges between each modality. However, they are fairly straightforward [with] the specifications from each of the modality and hardware vendors."

Siemens' Cohen believes the big advance will come in "bringing a tighter integration between the image and information management, where it is truly one piece."

Whatever the market and technology have in store, the future promises better communication and integration of images with demographic and related health information all for the benefit of patient care.