An inside look at cardiovascular information systems (CVIS) and the myriad data elements that go into the successful integration of cardiology images, lab results, patient histories and hemodynamic monitoring and procedure data to facilitate access to key caregivers at the point of care—wherever that may be.

Compared to radiology, cardiology lags in integrating data into the hospital enterprise. To be fair, radiology, for the most part, deals with images. Cardiology, on the other hand, deals with myriad patient data including images, hemodynamic information, ECG waveforms and more. Structured reports were initially built for text, and then images were added. Now, the push is to include all relevant patient data and to follow the patient throughout the continuum of care.

“There is a lot more information to interact and integrate in cardiology than has been the case with radiology and other specialties. And that is the primary reason integrating cardiology data has been considered more complicated,” says Joseph L. Marion, principal of Healthcare Integration Strategies, a consulting company in Waukesha, Wis.

Another factor in imaging’s favor is the DICOM standard, which enables the transfer of images regardless of vendor. There is no such “DICOM-like” standard in the works for cardiology, Marion says. Like PACS and other image-storage devices in the days of old, hemodynamic equipment today is proprietary. “If cardiology were to follow the path of radiology, one might see an effort to develop standardized means of exporting hemodynamic data into a documentation system in such a way that it wouldn’t matter whose documentation system or reporting system was used. But to date, no one has initiated any effort in that regard,” Marion says.

This limitation results in the potential for many key documentation elements to be left out of the final report and it inhibits the ability to have information available for data mining for ad hoc outcomes queries. Cardiology is very sensitive to outcomes analyses, Marion says, for business, marketing and accreditation purposes, among others. The bottom line is that many facilities or practices cannot data mine effectively because of the lack of integration between various information systems. 

One of the only solutions currently available is to go with a single-vendor approach. Most of the bigger vendors have hemodynamic systems and reporting systems that “talk” to each other. For example, Sensis, the hemodynamic monitoring system from Siemens Healthcare, is directly coupled to syngo Dynamics, Siemens’ reporting system. The process is bi-directional. As physicians or personnel enter data into the hemodynamic system during the procedure, the report is automatically updated. If patient data are input pre-procedurally or if certain values in the report are changed post-procedurally, the hemodynamic system automatically updates.

The fully integrated digital imaging environment

Over the last several years, Alegent Health, a nine-hospital system in Omaha, Neb., has embarked on a massive campaign to update its imaging and IT infrastructure and implement digital processes. The fully integrated digital imaging environment delivers a number of benefits, says Senior Vice President and CIO Ken Lawonn. Standardizing equipment, processes and technology helps the organization meet key goals including trimming costs, optimizing quality and increasing efficiency. Another critical benefit, says Lawonn, is the widespread availability of information to caregivers. Caregivers can access information not only at the point of care, but also at their offices and homes and across the hospital system.

For most of its IT solutions, Alegent has adopted a single-vendor approach, the rationale, of which, is simple, says Jeff Broz, operations director, imaging applications. “Alegent Health is a multi-entity enterprise, and many of our healthcare providers travel between our different sites. They need seamless access to images and information to provide optimal patient care.”

Alegent’s image management solutions include Siemens Healthcare’s cardiology and radiology picture archiving and communication system (PACS) platform and syngo Workflow RIS, which handles radiology workflow. Before web-enabled PACS, an image was an island, says Broz. Images weren’t portable, and multiple providers could not view an image. Fast forward to the integrated era. Physicians can view patient images and information—including hemodynamic data—across the enterprise. Image viewing options include PACS workstations located throughout the enterprise or Soarian Clinical Access EMR.

The capacity needed to store cardiology images presents a further challenge for the healthcare enterprise. Alegent is grappling with exponential growth in the amount of patient information needing to be stored. The healthcare system has entered into a strategic alliance with EMC Corporation to help it tap into cutting-edge information infrastructure. The alliance provides a solid foundation for the future as well, says Broz. “Applications, particularly radiology and cardiology PACS, fall under one umbrella. Alegent Health was ready for consolidation on the back-end as the organization has deployed a common radiology and cardiology storage platform.”

The healthcare enterprise invested in a tiered, networked storage strategy with three EMC Clariion systems. It also employs several EMC Centera content addressed storage systems for image archives. As the PACS archive grows, management represents an ongoing challenge as the site must continue to add disks to the Clariion archive to keep up with PACS growth. The site’s Clariion systems relied on a tape-based back-up mechanism. Centera removes tape from the equation. “The difference between managing a tape library and Centera spinning disk archive is night and day,” says Broz.

Moving from C-PACS to CVIS

Beth Israel Deaconess Medical Center in Boston also is in a state of IT transition. The institution has a huge investment in an infrastructure that supports proprietary homegrown information systems. One of the challenges is to interface standardized systems into the proprietary environment, says Marion, who has done consulting work for Beth Israel.

The facility has an excellent structure that supports two physician web portals for inputting or viewing exam results. The cath lab report in the hemodynamic system, however, has to be manually transferred into the hospital information system (HIS) for it to be accessible via the web portals. This type of system worked well when reports were mainly textual. Today’s CVIS, however, offers the capability to include more graphical aspects, such as images and diagrams, into a report. Rather than update the C-PACS at Beth Israel, Marion’s advice was to move from a C-PACS and independent reporting environment to a full CVIS environment.

Even the CVIS of yesterday looks different from the CVIS of tomorrow. The current emphasis is to incorporate patient data from when the patient is in the hospital—cath lab reports, echocardiograms and/or vascular services. The next step, however, is to incorporate information from the patient’s ancillary services, including cardiopulmonary, rehabilitation and implantable cardioverter defibrillator (ICD) follow-ups, among others. “There is continuum in terms of patient care in cardiology and ancillary services need to access—and potentially input—patient data into the CVIS,” Marion says.

The CVIS is more than a technology to capture information; it also can be used as a patient and department management tool. From a patient management perspective, cardiac rehab specialists, for example, may want to review the last ECG or input progress notes. In the context of department management, facilities in competitive markets may want to know how they do in terms of services compared to other service options that referrals might have. Detailed statistical data gleaned from a CVIS can help facilities and practices determine if they are meeting its growth objectives and, thereby, manage the operation more efficiently. The CVIS also can be used to capture data for government incentives regarding quality metrics.

Some of the larger vendors have recognized the value of the “holistic” approach to the continuum of care. Philips Healthcare, for example, last year purchased Tomcat Systems, a developer of CVIS. Tomcat’s software connects with different clinical information systems and with systems from other vendors. It also provides scheduling, staff and resource management, cost capturing, and the generation of reports and statistical information.

Enhanced efficiency and operations

North Shore Hospital-Long Island Jewish Health System (NS-LIJ) is a 21st century mega-enterprise. The integrated delivery network is spread across Long Island, Staten Island and Queens and encompasses 15 hospitals as well as multiple affiliates and centers of excellence. The system employs 1,200 physicians and maintains referral relationships with nearly 10,000 physicians.

North Shore University Hospital, the system’s largest hospital, includes nine cardiac catheterization labs; in 2007, 50 physicians completed more than 3,000 interventions, placing more than 10,000 stents. Cath image volume amounts to nearly 45,000 studies annually.

Two of the IT solutions helping NS-LIJ remain at the forefront of cardiac care are GE Healthcare Cardiology DMS Solution and GE ?Centricity CVPACS Solution. The health system deployed the combined cardiovascular information technology (CVIT) solution to tackle the universal challenges of cardiac image and data management.

CVIT provides efficient access to images and reports throughout the enterprise at workstations in the department, cath labs and physicians’ offices. The reporting embeds flexible structured reporting that grows as cardiologists use the system. It also automatically captures all New York state-required quality reporting elements—approximately 75 field entries—for each coronary intervention.

CVIS offers cardiology departments an IT tool to improve patient care, workflow and other key metrics. Implementing a system, however, is a multi-faceted process that requires hospitals to analyze, and often, update IT infrastructure, particularly storage and networking. Designing the storage system requires close collaboration between cardiac imaging and IT. Sites need to understand cardiac imaging volume, how long they want to retain data and how quickly physicians need to be able to retrieve data and design storage infrastructure to meet those needs in the most efficient way possible, says CIO John Bosco. The network presents a similar challenge. That is, facilities need to establish how quickly images need to move from place to place to determine network bandwidth, switches and redundancy needs.

Cardiology at the crossroads

Cardiology has reached a tipping point. The volume of data, including images, has exploded. Managing and making use of the data without IT represents a nearly insurmountable challenge. Robust CVIS solutions offer a new and improved model. Aspects to consider when evaluating CVIS solutions include:

• Useability—Many physicians at different levels require information from the system.
• Speed and the user interface—Reporting common items such as Plavix (oral antiplatelet) administration should take one click, not three steps.
• Reporting should be immediate, robust and flexible—As procedures change, the system must adapt.
• Involve and satisfy the three key stakeholders—Cardiac administration, cardiology clinicians and IT.