Even before they can think about the integration of radiology and cardiology PACS, simply getting first-generation cardiology PACS implemented is turning out to be a major challenge for CIOs.
Why cardiology PACS development should be difficult is illustrated by the simple fact that there are more devices involved, more diverse types of images and data, and a far more complex and interactive patient care environment in cardiology than in radiology. It's no wonder that cardiology PACS remains a first-generation phenomenon, even in the most “advanced” of hospital organizations.
Indeed, when asked what the leading edge is in cardiology PACS development right now, Scott Grier says, “I don't know that there is yet a leading edge, at the moment.” In fact, says Grier, principal in Sarasota, Fla.-based Preferred Healthcare Consulting, “I think that cardiology today is where radiology was in the mid-1990s, in terms of digitization. We spent years porting certain elements of radiology work from analog to digital. Now, we're at the same level in cardiology.” And while there isn't enough pressure from the American College of Cardiology or other organizations to bring all of the disparate formats into one console, some vendors are exploring that, he says. “In hospitals, we have all these formats, but we can't launch from a single workstation. So it raises the costs to be able to view any particular study,” which is why some organizations are moving ahead despite the challenges.
One example of an organization that is quietly making progress is Caritas Christi Health Care System, a six-hospital organization based in Boston, which serves a swath of eastern Massachusetts. Senior Vice President and CIO Todd Rothenhaus, M.D., says his organization began rolling out cardiology PACS using Alpharetta, Ga.-based McKesson Corporation, in early 2008. “We're about halfway done,” he says. “We already had PACS live in the radiology space, and it was one of those systems that was working extremely well for us, so we decided to extend our digital imaging to the cardiovascular space.”
Rothenhaus says Caritas has digitized data coming out of echocardiology modalities, and digital imaging and reporting live. In addition, he says, some nuclear medicine images are coming over as well. Digitization of hemodynamic monitoring is moving forward, and he says ECG digitization will be next. “We want to get all this done by the end of our next fiscal year, in October 2010.”
A complex environment
A more modest step into the cardiology PACS sphere is being taken by the folks at 118-bed Carroll Hospital Center, a standalone community hospital located in Westminster, a small city in a rural region of central Maryland. Kimberly Moreau, assistant vice president and CIO at Carroll, says she and her colleagues have gone live with digitization of hemodynamic monitoring, including the core monitoring element, continuous gathering of vitals information from the hemodynamic procedure, and recording of data. (Carroll's cardiology PACS partner is also McKesson).
And, though the implementation of this first piece has not proven particularly difficult, Moreau says, “How all the pieces fit together from a technology perspective, so that the patient monitors and the cardiac monitors talk to each other, and so forth, is surprisingly complex.”
In terms of the complexity of cardiology as it compares to radiology, Rothenhaus says that people probably thought radiology was a complex environment, too, but that it's just more mature now. “The issue really,” he says, “is that there's just so much more hands-on care involved in the cardiology environment. And though it's true that interventional radiologists see patients, cardiology has a much more patient-centric environment overall.”
Further, says Rothenhaus, he and his colleagues have been implementing cardiology PACS across their IDN, and are looking to build a truly enterprise-wide imaging management system (encompassing radiology as well, of course). As a result, he says, “The biggest issue that we've really had is that the implementation has been way more complicated than we had initially given credit for.”
None of this surprises Joseph Marion, principal with Healthcare Integration, a consulting firm based in Waukesha, Wis. As Marion points out, “Radiology is a serial review process. I look at an image, I report on what I see in that image, and create a report out of it. In cardiology, the interactions are more complex, and the images tend to be dynamic, as opposed to the static images of radiology.”
What's more, he says, “A lot of cardiology studies, particularly the cardiac cath studies, are stat cases. Compare that with radiology, where I create an order, start the study, stop the study, and so on. In cardiology, there isn't time for that; they just put in the minimal of information and go. So in cardiology, there's often more urgency in terms of the workflow aspect.”
Henri “Rik” Primo, who works out of the Image and Knowledge Management division at the Malvern, Pa.-based Siemens Healthcare, says the cardiology environment is definitely more intense.
“Radiology PACS is all about storing and displaying images, and the radiologist is dictating reports that go into a RIS. In cardiology, though, pieces of a report can actually be completed while a patient is being treated. For example, in the case of hemodynamic measurement systems, part of the task is to measure and record wave forms and ECGs; and these can be automatically populating a cardiology report while the cardiologist and technicians are still with the patient. So it's a very different environment.”
Paul Webster, Jr., lead technologist in the cardiology department at the 250-bed Children's Hospital of Michigan (which is a part of the Detroit Medical Center), says such advantages far outweigh the practical challenges of cardiology PACS implementation.
At Children's Hospital, a cardiologist can view evidence-based reporting on customizable templates alongside embedded images while in the background viewing autopopulated hemodynamics. With another click, the cardiologist can view previous cath procedures from the same patient, and one click later can send a report to referring physicians and the billing department.
Such capabilities have improved reporting accuracy and workflow at Children's. What's key, Webster says, is that, “CIOs should be thinking about the potential for integration of tools and systems, and the ability to import images from any modality or vendor,” as he and his colleagues have at Children's. (Children's is using the Syngo Dynamics solution from Siemens Healthcare.)
The path forward for cardiology PACS remains a bit unclear, most agree. For one thing, says Joe Marion, “Until recently, there hasn't been the urgency within cardiology to tie all the elements together. What's more, often, cardiologic services have themselves been fragmented. I'm seeing that at one large delivery system back East,” he says, “where in some cases, nuclear studies for cardiology are done as cardiology and, in some, done as radiology, in different facilities within that system.”
In terms of both workflow and the type of specialty care involved, cardiology PACS is inherently more complex and challenging than radiology PACS.
Very few organizations have gotten beyond some initial work in automating the collection of data from one or a few different clinical processes.
Even at this early phase of development, it's clear that clinician workflow and efficiency can be dramatically improved by cardiology PACS implementation.
Enterprise-wide image and data storage, retrieval, and sharing capability across cardiology, radiology, and other specialties, is where hospital organizations are headed, though the path is a long and difficult one.
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Healthcare Informatics 2009 September;26(9):34-36