Cardiovascular Information Systems

More recently, EMR systems have gained importance for ARRA/meaningful use (MU) compliance. EMRs are positioned to be the focal point for clinical information, and most encompass patient and study management processes. A patient study originates within the EMR with the collection of relevant patient information, and diagnostic exams are ordered through computerized physician order entry (CPOE) applications. Many facilities favor central scheduling for a consistent schedule across service areas. Results are aggregated within the EMR for a patient-centric view.  As such there is overlap with a CVIS in terms of managing the patient and the exam.  But as the aggregator, the EMR usually does not overlap in terms of the level of detailed clinical data captured and the physician review process. Today, the EMR is typically not the primary vehicle for data acquisition and clinical report generation across the cardiovascular service line.

With the EMR’s role expanding, the question arises as to whether there will be less need for departmental systems to manage the order and exam process.

Given the CVIS’s overlap, how then might it be differentiated, and what if any role will it play in the changing IT landscape?

CVIS DIFFERENTIATORS
Both CVIS users and vendors have vested interests in clearly defining the difference between a CVIS and an EMR. One viewpoint is that cardiovascular services tend to be unique among image generating services (radiology, cardiology, pathology, GI, etc.).  In the words of Praveen Lobo, senior vice president of business development at Lumedx Corp., Oakland, Calif., “Cardiology takes a more holistic view and is focused on the morphology of the disease, as represented by multiple modalities, labs, EKGs, etc., before making a diagnosis.” Lobo further states that “EMRs may not be of the proper ‘granulation’ of data, whereas a CVIS represents a specialized view of the data optimized to the cardiovascular physician’s needs.”

Workflow is another major differentiation.  “Cardiologists are more case involved, whereas a radiologist’s focus is on diagnosis,” according to Robert Cecil of The Cleveland Clinic.  Echoing his sentiment is Robert Schallhorn, vice president, clinical solutions at Chicago-based Merge Healthcare, who believes “today’s CVIS emphasis is on workflow and reporting capabilities, data mining, and accreditation support, while image review capabilities are a commodity.” Similarly, Lobo of Lumedx adds that “workflow management during a procedure such as chest pain management or heart failure is important, as it spans the course of treatment, which is not the prime purpose of the EMR.”

Regarding order management and scheduling, cardiovascular exams don’t lend themselves to enterprise order and scheduling processes, according to Tcheng. “In the case of the cardiac catheterization lab and cardiac ultrasound, the concept of an ‘order’ just doesn’t exist.” Tcheng likens a cardiac catheterization study more to a “consultation” than a diagnostic exam, and as such it is difficult to prospectively determine what the “order” is for. Cardiac catheterization procedures can be unpredictable in their length, making it difficult to “schedule” the lab for a fixed time slot. Tcheng adds that a cardiac catheterization study is “the epitome of chaos!”

Another factor in terms of order and scheduling discipline is raised by Robert Cecil, who points out that cardiovascular procedure volumes are considerably less than radiology volumes.  “In the case of radiology, volume is the driver and time limitations favor an order/schedule discipline. Whereas with lower volumes, greater dollar value per case, and greater staff resource availability in cardiovascular services, there is more ability to ‘clean up’ the order post exam.”

Craig Scott, M.D., founder and CEO of Flexible Informatics LLC, Bala Cynwyd, Pa., believes that “physicians interact with EMRs and CVIS in different ways.”  The EMR is accessed during the patient encounter, or as new information is acquired, whereas the CVIS is typically accessed by the staff while performing and interpreting the procedure. Another perspective is Dean Cheatham’s view that the CVIS “is a business intelligence tool instead of a clinical facing system.” Cheatham believes that a CVIS cannot assimilate all of the information an EMR can with respect to the patient, and believes that the future will be a “cardiologist template” within the EMR. Yet, Tcheng believes that EMRs are focused primarily on addressing ARRA/MU needs, and it will be at least 2015 before they can turn their attention to clinical needs, presenting a window of opportunity for the CVIS data integration and management.

From the perspective of a large EMR vendor, the early phases of technology began with a tremendous amount of data stuck in departmental systems that didn’t get to an EMR. But physicians are looking for a way to bring the data together, similar to the way paper represented the “great communicator.” The EMR represents a higher degree of integration than departmental clinical systems, and a means for correlating data that may not be present in individual systems such as the CVIS.