Defining Cardiology's Clinical Dashboard

Cardiology image and information systems - also known as cardiovascular information systems -share the ability to provide rich repositories of up-to-the-minute clinical information from physician offices to clinics to inpatient studies and tests, including managing patient images and physiologic data - but vendor to vendor, capabilities differ a bit. Here is a sampling of systems in action at a variety of facilities. And click here for a comprehensive CVIS vendor chart to do some comparing.

A common error comes in comparing cardiology and radiology image and information management systems, but given the different workflow patterns and goals of the two departments, it seems inappropriate to do so. In radiology, the usual end goal involves acquiring images for the radiologist to interpret and use in creating a differential diagnosis, followed by a report to guide the referring physician in designing a treatment plan (with the exception of interventional radiologists).

In cardiology, images as well as a large amount of quantification physiologic data are gathered to assess the overall health and function of the heart. Not only is a differential diagnosis generated, but often the cardiologist serves as the physician managing the next steps in treatment.  Given the dynamic processes dependent on evolving information, cardiology image and information systems must possess innumerable capabilities not necessarily found in a typical PACS or RIS.

A patient, who enters the hospital with chest pain, when the EKG and laboratory studies are positive, proceeds along a diagnostic and treatment path that may take him or her to the cardiac catheterization laboratory for an invasive procedure that could evolve into a treatment intervention. The need for documentation of all parameters of testing requires systems that are extremely powerful and that can correlate data from a wide array of different diagnostic modalities.

Here, presented in alphabetical order by vendor, is a description of the capabilities of cardiology image and information systems manufactured by a variety of industry leaders.

Agfa Heartlab, Agfa's Cardiology Business Unit, offers an enterprise-wide cardiology image and information system that allows physicians and staff to gain access to critical patient information. It is designed to manage physician reports in a single repository while creating a database that integrates relevant patient information into one system. Because staff are able to query and export structured data, Heartlab's system provides physicians with a longitudinal view of clinical patient information to facilitate care and increase operational efficiency.

Alan S. Katz, MD, FACC, director of medical information technology at St. Francis Hospital, The Heart Center in Roslyn, N.Y., is using the Heartlab system in their 270-bed hospital where 80 percent of their caseload involves cardiology. They perform 7,000 cardiac catheterizations, including 4,000 percutaneous coronary interventions (PCIs), each year, as they accomplish fewer procedures in the operating room and more in the cath lab. St. Francis first installed a Heartlab system in their cath lab in 1998, and went live with digital echo two years later. They selected the system because of the speed with which images could be stored and retrieved.  In addition, the system is used to generate reports in the echo labs with both images and reports currently available for review throughout the hospital. At this point, they are working to enable that capability on an extranet in secure access across the internet.

Katz describes great service from Heartlab staff, and says this is a very reliable system as they've experienced few problems. Once when the web access went down, Heartlab replaced the server.

Additionally, he notes, "The ability to interface with multiple different vendors' equipment is important. We have systems from Siemens, Philips and GE. Each has specific capabilities so it is good to be able to have all of them available." The Heartlab system has effectively managed images from each system.

Given the benefits of reading digital images (Katz says he would never want to go back to routine reading of echo studies off of tape), this system has enabled improvements in their ability to manage their complex cardiac patients.

Introduced in 1999, Camtronics Medical Systems' Vericis for Cardiology system serves as an enterprise-wide information management system for multi-modality cardiovascular images and information. These networks provide digital acquisition, review, distribution and archive functions for cardiac patient data from both inpatient and outpatient centers.

Craig E. Fleishman, MD, FACC, director of non-cardiac invasive at the Arnold Palmer Children and Women's Hospital and the Congenital Heart Institute at both Arnold Palmer and Miami Children's Hospital in Florida describes the common database between these institutions from Camtronics. Each campus has a Vericis image server and archiving with a wide data pipe (DS-3) between the two locations.  They can view 30 frames per second in real time, which facilitates collaborative review of images between the two centers.

"There are a couple of reasons I've enjoyed working with this system," Fleishman explains. "On the database side, it is the best out there for pediatrics and congenital heart disease because it was designed from the ground up for these uses. The key is having a normative range of values for measurements which are dependent on age and size."

Describing the system as extremely stable and reliable, he says that it is quite unusual to have unscheduled downtimes. Upgrades and routine maintenance have caused brief disruptions, but they can be scheduled for times when the system is not in heavy use. The system also is interfaced with a variety of different vendors' imaging equipment.

Fleishman describes service from Camtronics as excellent, and says that they are good at troubleshooting specific problems that may arise through remote access evaluation. "It's unusual that if we make a request for service that they don't take care of it immediately." He also notes they are exceptional in working with their hospital Information Systems departments to install the system and that they provide appropriate advice about how a network needs to be configured to accommodate all aspects of deployment.

Centricity Cardiovascular PACS from GE Healthcare offers a scalable digital imaging and information network for both standalone cardiology departments and within an entire healthcare enterprise. When fully deployed, this system provides on-demand access to any image, study, exam, report, data or information from a variety of modalities including echocardiography, cath labs, CT, nuclear medicine and PET and MR sorted into comprehensive electronic patient jackets.

The Centricity Cardiology Data Management System (DMS) streamlines physician reports and provides a cardiology-wide database. Echo measurements automatically populate the report from virtually any DICOM-compatible ultrasound system, and a single stress echo report with both ECG and echo findings could be generated to send to referring physicians.

Lucretia J. Craig, RN, director of the Kansas Cardiovascular Center imaging services at the Olathe Medical Center is using the Centricity DMS to facilitate their patient care in this 264-bed facility located in rural Kansas City. This cardiovascular center was built in 1997 and in a short period of time, they tripled their patient volume.

"We use this database not only to document our patient care, but also to document physician reporting and to provide outcomes assessment that pulls multiple data elements to compare," says Craig.

One feature the system provides is reporting to the American College of Cardiology (ACC) and Society of Thoracic Surgeons (STS) registries to enable comparison of their patient care outcomes with those from other centers across the nation. This experience has allowed them to analyze data that reveal they provide care where they are better than national average in 96 percent of the data elements. Considering that their older patient population is 50 pounds heavier than the national norm with a higher level of smokers reveals that their care is more than meeting the needs of their patient mix.

In the past, they conducted manual retrospective chart reviews at the end of each day. With Centricity, they perform concurrent data acquisition so they can validate the accuracy of their data entry in real time. "At the end of the day, the system checks the integrity of the data, and then sends it to the ACC. When it returns from ACC, if there is a disparity we can review it."

Besides that functionality, the facility is implementing an interface between Centricity and a financial materials management package for tracking supplies and equipment, as well as performing charge captures for billing purposes.

John N. Alex, director of CVIS at Rush University Medical Center in Chicago, is using the Centricity DMS for cardiology which performs file sharing, structured reporting and clinical functions for their cath lab - with a separate PACS for managing images.  They perform eight to 10 cardiac cath procedures and 35 echo exams each day. Currently they share a deep archive with radiology, with local storage within their department provided by DICOM RAIDS.

"With any cardiology information system, it is important to be able to cross-query different modalities," Alex says. This capability, offered by their Centricity system, provides both clinical and administrative benefits.

Xcelera, released in July 2003, is a cardiology information system from Philips Medical Systems that supports echo, cath, vascular and invasive vascular procedures. Their next step anticipates bringing ultrasound online followed by CT and MR.

Xcelera Cath Lab Management employs a Windows platform, which facilitates installation on "off-the-shelf" computer hardware, and features a relational database that follows DICOM and HL7 standards.

Once deployed, cardiology staff members are able to modify lists of medications, and input information about physicians, staff and medical devices. There is a built-in provision for emergency data recovery, and automatic back-up is accomplished without the need for downtime for the either the server or database.

Connie Rezanka, RDCS, RCS, is lead sonographer at St. John Macomb Health Center in Detroit. This 380-bed hospital conducts open heart surgery, as well having as a large angioplasty and stenting practice. They installed the Xcelera system in 2004 when the physicians began producing their own reports.

Besides the echocardiograms read by their cardiologists, they use the system in their cath lab as well. Reading stations are available on all of the cardiac monitored floors plus the operating room, emergency department, cath lab and ICU.

"We are working to have all of the reports flow out to the desktops on the floors," says Rezanka. While Xcelera includes the ability to accomplish those tasks, the hospital IT department is in the process of implementing this capability. "We want this for the convenience of our physicians. The doctor's reports are all password protected."

Soarian Cardiology from Siemens Medical Solutions is a cardiovascular information system and image management system that addresses a full spectrum of needs within the cardiology department. The system's ability to consolidate numerous databases allows customers to manage both images and information. It is capable of reporting data to the ACC and STS as necessary.

Sherry Shults, RN, BSN, chief information officer of the South Carolina Heart Center in Columbia, describes their outpatient physician clinic that performs a variety of imaging studies including cath lab, with peripheral vascular intervention, and both 16- and 64- slice CT scanners. With approximately 65,000 patient visits per year, their 28 cardiologists (including 7 interventionalists) do most procedures, except routine coronary stenting.

"Soarian was implemented in August 2002, and we started with the cath lab diagnostic procedures," says Shults. "We generate our diagnostic reports through the Soarian Cardiology system and have totally eliminated dictation and transcription."

The system also offers materials and media management. As cases are completed, it tracks the supplies that were used for re-ordering purposes, and can send charges to the billing department. If they burn a CD with the images and report to send to a hospital or physician without direct connectivity, the system will track the date and time the CD was sent and to
whom.

The speed of this system has proven valuable in this outpatient setting. "In the hospital, you would have a turnaround time of 30 to 45 minutes, but for us we only have 10 to 15 minutes between cases," explains Shults. For simple studies, they can usually generate the report within five minutes of completion - while a complex patient, such as someone who has had
several open heart surgery or several stents placed, could require 15 to 20 minutes for adequate documentation.

Finally, Shults reports that the Soarian system interfaces well with a variety of other systems and imaging modalities from other manufacturers. While their CT equipment is from Siemens, their nuclear camera's are ADAC and Siemens, and their echo systems are from a number of different companies. Additionally, it interfaces with their IDX Systems patient scheduling system.

Calysto for Cardiology from Witt Biomedical is a cardiovascular image and information system with several components capable of storing any image, waveform or type of test result that would be performed in a cardiology or interventional radiology department. The system interfaces with all vendors' equipment. Calysto serves as the primary documentation tool for invasive procedures in 99 percent of the facilities where they are installed. They have focused attention on providing their customer base with end-user tools that can be used to customize data collection.

The other issue Witt has worked to address is the fact that although most imaging equipment is based on second- or third- generation DICOM standards, there are many legacy systems that use the old forms of the standards with "retired syntax." Witt has worked to support any type of equipment a facility may have regardless of the DICOM standards that are implemented.

Tami Kessler, RN, BSN, clinical manager of interventional cardiology and special procedures for the Banner Estrella Hospital in Phoenix, works with the Calysto system in this new center that began admitting patients in January. Besides this particular facility, Banner comprises a large hospital organization over four states, and they have placed Witt systems in all of the sister facilities. Other than her experience with this system in her current position, Kessler was a traveling nurse who used Witt in other institutions, and says this is one reason she decided to take this job.

Witt menus are very user-friendly and easily modified when necessary, says Kessler, who notes that they submit information to the ACC registry. She finds it easy to document their cases and appropriately and accurately complete the fields necessary to send information to the data collection function of ACC.

"Our hospital is 'paper light' and we rely on our computers," says Kessler. "We have 2.5 pieces of electronics per patient, so we don't have patient charts, we have computers. Of all of the equipment we have, Witt is the only one that has not gone down - it is very reliable."

Another benefit to this system is the capability to develop a wide variety of reports. If a manager needs to generate information about the number of cases they have completed or the equipment they have used, they are able to custom-build a database for queries. Therefore, when these requests are made in the future, that report can be produced easily. "I have as yet to come up with anything that we need to know that we can't find with Witt."
Finally, Kessler notes Calysto interfaces with all other equipment easily. They anticipate installing this system in their endoscopy lab and surgical areas in the near future.

Julie Pope, RRT, RCP, director of cardiac catheterization and cardiopulmonary at Georgetown Memorial hospital in Georgetown, S.C., uses Calysto for Cardiology in their cath lab, nuclear medicine and echocardiography. As a small community hospital of 142 beds, their cardiology department includes two interventional cardiologists and three non-interventional cardiologists. They cannot do routine interventional cases, but can do emergency intervention only.

Although they had the Witt system in 1999, they began using it to full capacity when they built a new cath lab in 2001. At the current level, Pope says it addresses all of the cardiology needs of their physicians, and they can read studies from echo, nuclear medicine and echo from any one of their several reading stations, both at their institution and sister facility.
"Our physicians can look at images and go directly into the transcription module, create a template on a Word document from all of the data entered, press a button to electronically sign the document, and then it is automatically passed into our HIS [hospital information system] for immediate recovery if a referring physician needs the report," she says.

Because they have secure, password-protected internet access, when their patients (who often come to Georgetown as vacationers) return home, their physician at home can gain access to their studies and reports after being certified and granted permission to view this protected information.

While describing the cardiologists in their department as being extremely flexible and helpful in advancing this technology, Pope relates that she knew this system was well-accepted when, "Our least computer-literate physician said 'What did we ever do without Witt?' and said that he loved the system."

Conclusion

The powerful capabilities of cardiology image and information systems have enhanced patient care in this complex and exacting field of medicine. With underlying structures that permit easy clinical report generation activities while supporting storage of data, these systems feature numerous other capacities that underscore their power. They can be used to send aggregate data to national organizations such as the American College of Cardiology that are designed to improve patient care on a global level. In a totally different vein, they can be used to assist in the management of materials and equipment any given individual department may use as staff completes their patient diagnostic and interventional cases. The range of functionality is impressive.