Integration Challenges in the Cath Lab Trenches
"Sometimes," mused Jeffrey Westcott, M.D., a private practice physician with Cardiovascular Consultants of Washington in Seattle, "I think that hospital information technologists don't want their machines to talk to anyone outside the hospital."
That's why he's more than a little frustrated when he can't transfer data from his highly integrated office to the cath labs of some of the hospitals where he cares for cardiac patients in the Seattle area.
“If ‘Integrating the Healthcare Environment’ (IHE) gets to work in the cath lab, doctors, hospitals, IT specialist, nurses and even patients will have to make major changes in the way things are done,” he continued.
But it’s a change from which all these players will benefit.
"Essentially, integrating the cath lab is creating a framework or interface in which imaging machines and hemodynamic devices can be put on the same wavelength so that doctors can access either device on their computer device," explained Ben Streff, advance products specialist for ProSolv, Indianapolis.
It sounds simple, but it isn't.
"Most imaging devices now operate under DICOM (Digital Imaging and Communications in Medicine) protocols," Streff said. "The hemodynamic devices that collect various data during procedures can be on any kind of format." A system such as the MacLab can be collecting arterial pressure and electroencephalogram recordings while a PhysioLog Pro may be recording data on heart beat and skin conductance or other information.
ProSolv uses a proprietary software program called "the Analyzer" to figure out what program dialect is being used by the various cath lab devices and convert them into one voice that can be understood by the central computer in the lab, file a report on each patient and enter that information, as well as the various new digital pictures that were taken during a procedure and store it all into a patient's electronic medical score.
Sometimes Streff is faced with scenarios in which a hospital has just purchased a computer console and the hospital wants to integrate 15 different ultrasound devices.
"Ideally, what we would like to see," said Chris Carr, director of Informatics at the Radiological Society of North America, "is for an integrated cath lab to be able to digitally record information on a patient and be able to electronically send that information to the patient's specialty care facility, to his personal physician and to a regional health information registry. The electronic health record is vitally important in case something happens away from home."
Perhaps a patient has had chest pains and is taken to a regional facility where he is admitted to the cath lab — "It would certainly be nice if the physician in that lab knew this man had a history of arrhythmias before they started the catheter procedure," said Elliot Sloane, Ph.D., assistant professor of Decision and Information Technologies, Villanova University, College of Commerce and Finance and a member of the IHE Strategic Development Committee.
"Physicians operate now with so little data it is a wonder they do as well as they do," Sloane said.
However, he said that government interest in IHE is slowly bringing forth standards which may make Streff's work a tad easier. In the end he suggested that "IHE will be good for the payers of healthcare such as government and insurers, good for the doctors and good for the patients."
IHE in the cath lab and elsewhere in the medical workplace will likely be able to prevent patients from suffering the consequences of medical errors.
"These are not errors caused by a slip of a scalpel or a mix-up with drugs, but errors caused by omission of data," Sloane said.
He suggested that errors could occur simply because the blood work report that was sent from the public laboratory when the patient got his test went to the patient's primary care doctor who wasn't able to fax the report to the hospital because the person who was supposed to put ink in the hospital fax machine was on vacation.
Speak to Me
Integrating the cath lab in the hospital may be a relatively straightforward task that Streff at ProSolv can implement in as little as a day but usually requires several weeks to accomplish — including the time for doctors, nurses, hospital staff and hospital informatics technicians to become friends with the new system.
"We can usually figure out a way to integrate the cath lab then with the rest of the hospital, even the echocardiography laboratory, which often deals with the same patients but are on different systems," Streff said. The inclusion of satellite facilities is also feasible — but getting information out of a hospital system can be a chore.
When Dr. Westcott in Seattle consults with a patient, he strikes a few keys on his computer and his cardiology patient's entire medical life streams into view. He selects a particular angiogram and proceeds to explain to the patient how he intends to use catheters and stents to remove the blockage that had been causing angina.
Then he plans the next day’s procedure, dictates into voice recognition software the results of the meeting, and the report is transcribed and placed in the patient's electronic medical record along with the angiogram.
But that data can't be transmitted to the hospital where Westcott will perform the procedure and where important bits of information regarding the patient's medical history may be needed at a critical time in the procedure.
"I think it will easily be three to five years before my office and my hospital labs will be digitally linked," Westcott said.
Sloane at IHE believes that government action will help hospitals integrate and get patients on electronic medical records, which could be life-saving. He expects considerable action in 2007, especially in development of Regional Health Information Organizations (RHIO). The RHIOs will act as demonstration projects as to how IHE and the electronic health record will work.
"The government has been trying to use a bully pulpit to get IHE moving," Carr of RSNA said. "But there are no great financial incentives. Many hospitals look at the electronic health record and integration of services as costing them money to help someone else. There should be altruistic reasons for performing these actions, but it is a real challenge."
Another perceived challenge sits in the road to integration, too.
Streff said that sometimes HIPAA rules that appear top-heavy with privacy rules fly in the face of electronic health records and distribution of medical records to those who need them.
However, Westcott said that is a red herring.
"I can tell whenever anyone looks at a medical record. The computer tells me who did it and when. We can't do that with a paper file." <