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Hearts and Minds

September 25, 2008
by Mark Hagland
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When it comes to automating workflow and image management for cardiology, CIOs are finding radiology was a piece of cake

Cindy Eggert, vice president of information systems and CIO at Good Samaritan Hospital in Los Angeles, knew it would be a challenge to bring state-of-the-art cardiology PACS to the 408-bed academic medical center. However, as the volume of cardiologic studies continued to climb, Eggert knew it was a challenge she had to tackle.

For one thing, says Eggert, who has been CIO for over 10 years at the hospital, it had become clear that both cardiologists and radiologists at Good Samaritan needed IT upgrading at the same time. The hospital's radiology department was still film-based in radiology in early 2007, a fact that Eggert acknowledges was both unusual for an urban, academic hospital, and also spoke to the overall focus on cardiology — for several years cardiologists had been working with a standalone electronic imaging system.

Radiology PACS went live in August 2007, while cardiology, echocardiography, and cardiac ultrasound were up with PACS in February of this year. Additionally, in May, the cardiac catheterization lab also went live with the hospital's new system.

For both cardiology and radiology, Good Samaritan is using Alpharetta, Ga.-based McKesson Corporation. Going with a single vendor is the realistic way to achieve a level of interoperability at this point in vendor development, Eggert says.

Joe Biegel

Joe Biegel

The results have been highly successful already, Eggert says, with cardiologists, as well as radiologists, expressing strong satisfaction with the ability to share images, data, and communications across specialties. What's more, the developments fit into a strategic approach that calls for creating an enterprise-wide image management system. Eggert and her colleagues are also about to launch a physician portal to facilitate access to images and data, and inter-clinician communication.

Nationwide, different approaches

Industry experts say that planning and implementing cardiology PACS is turning out to be more of a challenge than anyone had anticipated.

“I think the biggest issue is that cardiology is much more complex than radiology,” says Joseph Marion, principal at Healthcare Integration Strategies, a Waukesha, Wis.-based consulting firm, and an HCI blogger. “That's the primary issue: there are just a lot more data elements to integrate. As a result, they're playing catch-up to radiology in terms of the standardization necessary to integrate all the elements.”

The reality, he adds, is that hospital organizations are turning to single vendors for cardiology image management, as interoperability remains a problem due to insufficient communications standards.

“Cardiology PACS’ evolution has paralleled the evolution of radiology PACS, but has always been behind,” notes Joe Biegel, vice president, product management, for the Medical Imaging Group at McKesson. One very basic reason for the lag in cardiology is the diverse medical technologies, outputs, and clinical workflows involved in the sphere, which encompasses echocardiography, electrocardiography, cardiac catheterization, and angiography/hemodynamic monitoring.

With different medical technologies creating different kinds of outputs, the technological environment in cardiology is far more complex than radiology, Biegel stresses. Therefore, he says, it's not surprising that patient care organizations have difficulty automating workflow processes, image viewing, and image- and data-sharing.

At the moment, “the workflow in hospitals has been shifting from very analog to partially digital, and towards digital,” Biegel continues. But is it the ongoing surge in cardiology volume that is driving the development of cardiology imaging systems?

Indeed, says Robert Tkachyk, a Cleveland-based staff consultant at CSC Corporation (Falls Church, Va.), it is cardiologists themselves who are aggressively pushing CIOs to implement image management systems, as they try to keep up with an increasing volume of activity. Inevitably, individual cardiologists run into bandwidth problems, particularly if they are trying to access images online. “The images in cardiology can be so large that transmitting them reliably over a network can be a very, very significant challenge,” he says.

Roger Hertz

Roger Hertz

So far, he says, the most advanced hospital organizations “have probably partnered with a vendor and come up with a combination of cardiology PACS and a cardiology information system that they may even have worked with the vendor to develop.” Not surprisingly, he notes, the cardiology information systems, analogous to the radiology information systems (RIS), lag behind the needs of today's cardiologists.

Progress in Omaha and Cleveland

At the six-hospital Nebraska Methodist Health System in Omaha, Senior Vice President and CIO Roger Hertz notes, “We've had a strategy of integration since the onset of our journey into the EMR back into the mid-1990s.” For Hertz and his colleague Shawn Wiese, Nebraska Methodist's applications development manager, moving forward on cardiology PACS has been a natural fit with their overall strategy. Methodist Health went live in mid-January with PowerChart ECG, from the Kansas City, Mo.-based Cerner Corporation, in two hospitals, “pushed by the sunsetting of the legacy system we had had,” Wiese notes. Previously, the hospital system had had a standalone ECG product that “required techs to print everything out — it was really only semi-automated, very inefficient,” he recalls.

Hertz and Wiese feel the same way that Eggert and her colleagues do at Good Samaritan. For them, it was only natural that they should move forward with cardiology PACS development, given the importance of cardiovascular services to the Nebraska Methodist's bottom line. “Cardiology seems to be the natural follow-on to radiology,” Wiese reflects. “And that department is similar to radiology in that you've got a number of different medical devices, and the vendors have positioned themselves to support DICOM compliance. So it makes sense to follow on in that area; and in terms of reimbursement, it makes sense.”

At the Cleveland Clinic Health System in northern Ohio, implementing cardiology PACS while staying focused on overall integration and interoperability has been vital, says Robert Cecil, Ph.D., network director, cardiology and radiology. In fact, says Cecil, “We negotiated for almost two years to get the right terms and conditions from our vendor,” the Malvern, Pa.-based Siemens Medical Solutions (Cleveland Clinic has been collaborating on radiology PACS development with Siemens for some time). Cecil and his colleagues have implemented cardiology PACS — they went live at the system's main facility this spring, while piloting the technology at a subsidiary hospital last summer.

Cecil notes that, in addition to the technological differences, there is a strong political dimension to cardiology PACS implementation that CIOs dare not ignore. “Radiology has always been perceived as a service organization,” he notes. “Radiologists service other physicians. And if you were to go into a third-party hospital and take over radiology, there might be some grumblings, but you wouldn't be perceived as taking over the whole hospital. That's not true of cardiology. So politically, cardio-PACS is much dicier than going enterprise-wide with radiology. There are very few single private-practice radiologists, but there are a lot of private-practice cardiologists, and they don't want to share information.”

Indeed, when asked what the key success factors have been in the implementation at Good Samaritan, CIO Eggert says that three stand out clearly. “First, you must have physician champions in each subspecialty,” she says firmly. “It wouldn't have mattered if I'd had the CEO, CMO, or CNO on my side. But we had excellent physician champions in every area.” Second, she says, implementing cardiology PACS relies on having strong cardiology technologists in every sub-area, who really understand “what each machine is supposed to do, and what images are supposed to look like as you move towards storage.” Finally, she says, “You need really strong project management,” given the extent to which such areas as the cardiac cath lab are constantly handling emergency patients.

In the end, says, Eggert, a combination of volume increases and storage needs, and clinician demands, will compel cardiology PACS to move forward nationwide. “There will be a push to bring it into a more consolidated environment rather than standalones. It will be slow-going,” she adds, “but it will get there. I wouldn't have said 10 years ago that I'd be seeing what I am now,” she concludes.

Healthcare Informatics 2008 October;25(10):38-39

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