Making the Connection

Cardiology departments, hospitals face challenges in achieving true interoperability.
By: 
Dave Fornell

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May 19, 2009

Connectivity and interoperability are big buzzwords in healthcare IT that everyone agrees is required of any device or software system they adopt. Interoperability is said to help increase efficiency, workflow, improve patient safety and saves money. While the industry is moving toward standardizing formats for how health information is saved, the reality is connectivity is easier said than done given today's level of technology on the market.

The healthcare industry is adopting common formatting protocols for healthcare information, including DICOM for images and HL7 and CCD for data. But, industry experts say there is still a large amount of proprietary coding from various vendors that needs to be overcome.


The future is interoperability

The industry needs to make devices and software systems work together more smoothly based on clearer interoperability standards, said Tim Zoph, vice president, information services, Northwestern Memorial Hospital in Chicago. He said companies with products that can interoperate will survive, and those that cannot will fail.

“The future is interoperability and sharing information,” Zoph said. “As end- users we need to demand better from the industry... Dialog between the vendor and provider needs to go both ways so we have open communication.”

He said providers using the currently available EMR technology will tell you there are issues with attaining the ultimate goal of interoperability. “I think it will be the second generation that will carry us over the finish line,” Zoph said.


Vendor-neutral solutions

Cardiovascular information systems (CVIS) began as proprietary systems, but demand for interoperability has lead to more open architecture in recent years. ProSolv Cardiovascular, now a part of FUJI Medical System USA Inc., offers a vendor-neutral platform that is designed to easily connect with several larger vendors, including GE and Philips. The company did this by using standardized workflows offered by most vendors in combination with structured reporting. ProSolv has also partnered with several companies to allow better integration.

Aaron Waitz, ProSolv’s president/CEO, said providers should look for a single system that can accommodate multiple modalities. He said structured reporting in also important because it can be mined for information and shared with other systems easier than freestyle data entry or dictation. He said this will become more important as providers mine information for certification, quality measures and registries.

Waitz said you need equipment that is based on DICOM and HL7 to ensure connectivity. However, he said the industry still has a ways to go before complete integration is possible based on these protocols alone. There are also issues with legacy systems that are not based on these standards.

“We are still trying to get all the data in one place where we can use it,” Waitz said.

He said there are very few providers coming to him and asking to connect only their cardiology department to a system. Today, he said, nearly all providers are looking for systems to help them connect enterprise-wide.

McKesson designed its Horizon Cardiology Version 12 to connect disparate systems. Bob Baumgartner, BSN, MBA, director of product marketing, medical image group, McKesson, said it is important to have a common, enterprise-wide infrastructure, but workflows are very different and specific to each department, which requires different software applications. He said some information in each system needs to be shared, but not everything. He said McKesson’s system will query each department's database to get specific information. He said the radiology department may need patient information from a CVIS to conduct an imaging study, but they don’t need the patient’s entire cardiac history or archived ECGs.

Cardiologists trained for years to become doctors, not to do data entry, Baumgartner said. Hospitals want their doctors caring for more patients instead of spending time in front of computers. Whatever systems hospitals adopt should include workflows to increase efficiency, such as automatic flow of data into report fields, structured reporting instead of dictation and transcription and easier access to information from various devices or imaging modalities.

“I believe our systems can help save cardiologists an hour a day,” Baumgartner said.

GE’s Centricity Enterprise is marketed as user-friendly with other vendor's systems and offers a Web-portal to allow easy access from anywhere to appointments, billing and health history information.

“Going with one system is easier to solve all your problems, but many hospitals want the best-of-breed products,” said Eunice Lin, GE Healthcare’s director of commercial marketing for imaging solutions. “As much as we want to sell GE Centricity to every customer, we realize it’s not realistic, because they want different devices or have legacy systems.”


Single vendor solutions are most seamless

You can easily interface with HL7, “but it does not get you very much,” said Tom Miller, CEO of the workflow and solutions division, Siemens Healthcare. He said most open architecture software only pulls information from another system, and for interoperability you need to both push and pull information. He said basic interfaces will only allow basic information to be pulled, and vendor-specific system features cannot be opened by the other systems.

“Information should be pulled where each piece of information is populated, at each step of the procedure, so that information can help populate the information needed for the next step of the procedure,” Miller said.

This type of interface works well in single-vendor systems, such as those made by Siemens or GE Healthcare, where all equipment and software is designed to interface. Miller said lab results should be able to help determine what other tests and imaging is needed. Information from the imaging and diagnostic systems should help populate the next step of the clinical records, such as a patient going in for surgery or an interventional procedure. These systems should also feed information into inventory and billing systems. He said that is what a single-vendor system can offer without major interface problems.

Miller said every time a piece of software is updated it can cause connectivity issues in a patchwork of disparate systems. However, in a single-vendor system these problems have already been tested with the rest of the vendor’s software and devices to ensure compatibility.

If you want 100 percent interoperability with any system or device a hospital purchases, it can’t be done, he says, due to variables between manufacturers’ coding, and constant software, hardware and new medical device upgrades.

“We don’t have a solution for disparate systems that are all over the place,” Miller said. “You are not going to get connectivity out of the box unless you chose a system as homogeneous as possible,”

Denver Health began adopting Siemens’ Soarian EMR system in 2007 and has found issues with integrating disparate software and devices. While it only took eight months to go on line with Soarian, the system is not expected to be a fully interoperable, paperless EMR system until 2011. Gregory Veltri, CIO of Denver Health e-health services, said the system cares for about 160,000 patients a year, which is roughly one out of every four in the Denver area. For this reason Veltri said the system wanted to be able to mine patient information quickly from any of its hospitals or clinics.

Today, in a seven-minute call with a patient, a clinician can gather all the information they need from the EMR system. “Our PACS allows us to transfer images to 13 different medical facilities,” Veltri added. However, he said there have been some bumps.

Denver Health uses Siemens’ integration engines to help connect its devices and systems together into one EMR. Most of this is being done by connecting common aspects of these systems using DICOM, HL7 or CCD.

“If you go with a best-of-breed vendor that uses HL7, it’s only a minimal level of integration,” Veltri said. But, he points out you will loose some of the information if you rely only on HL7 interfaces. “You don’t get all the bells and whistles as you do with a vendor-specific system.”


Creating enterprise-wide PACS

Picture archiving and communication system (PACS) are used by multiple departments and need to maintain connectivity with the whole enterprise, not just radiology. However, many PACS evolved as independent, disconnected silos of information. The same lack of connectivity is true of some cardiology PACS, sometimes called cardiology image and information management systems (CIIMS). Many PACS and CIIMS require a vendor-specific workstation.

There are three strategies to connect separated silos of information: use a single vendor's enterprise-wide system; use another layer of software to enable free exchange of information; or use a Web-based system where information can be accessed without vendor-specific software or workstations.

“Putting all your images in a box is not good enough, because they are not accessible outside your PACS system,” said Lenny Reznik, director, enterprise imaging and information solutions, Agfa Healthcare. “You want to take this archive out of the PACS so you can access the information by other systems.”

Agfa recently introduced its IMPAX Data Center, a vendor-neutral, enterprise-wide, DICOM-based archiving system for video, images and waveforms. Reznik said it is especially useful for providers who use a data management EMR like Epic, which does not have a PACS.

A big issue for cardiologists is being forced to use multiple workstation platforms with unconnected silos of information for each modality. “Most physicians don’t want to have to learn 25 different viewer systems, they want to use one viewer to look at all their images,” Reznik said.

Vendor-neutral solutions, such as IMPAX and McKesson’s Horizon Cardiology Version 12, are designed with a single platform to support all imaging modalities. Reznik said enterprise-wide PACS could save money just by eliminating the need to maintain numerous modality-specific storage systems and workstations.

“Customers demand interoperability and the reality is they use disparate vendors,” said Miriam Ladin, Agfa’s director of marketing communications in North America. “They should have the ability to use any tool they want.”


DICOM does not guarantee interoperability

For the past few years PACS and imaging device vendors have standardized on the use of DICOM formatting to saving images, but Reznik said each vendor’s implementation of DICOM is a little different so interoperability sometimes is an issue.

Lin said GE designs its systems to allow greater connectivity. “GE can give you an advantage with better integration faster,” Lin said. She said a common problem is annotating DICOM images and then losing those annotations when the images are shared with a different vendor’s system.

Issues also arise when DICOM images are converted into 3D, using advanced visualization software. Baumgartner said 3D images do not have a DICOM standard, so they are only saved in a proprietary format.

“(With DICOM) you can keep 80 percent of the image, but you may lose the proprietary fields,” Lin said. <

Sidebar

Cardiologists Need EMRs Specifically Designed for Cardiology

Step foot into a cardiologist’s office and you’ll notice equipment designed specifically to treat hearts, arteries and veins. Ask a cardiologist about his or her education and you’ll find that they have three to four years of specialized cardiology training. Talk with a cardiologist who is successfully using electronic medical records (EMRs), and you’ll most likely hear that the EMR was designed specifically for the field of cardiology.

One-size-fits-all EMRs are not the best option for cardiologists because they lack the cardiology-specific applications that allow a practice to fully integrate the system into their daily work. EMR solutions that are tailored for cardiologists function much better because, by design, they match the workflow of a cardiologist’s practice and include features needed for the kinds of patients that cardiologists see.
South Florida Cardiology Associates, a practice comprised of 18 cardiologists and internists, and 160 employees, tried using a generic EMR for 10 years. They found that the lack of specialization, integration and inability to become completely paperless limited the physicians from providing 100 percent patient care.

While the generic EMR performed as expected initially, costs increased and reimbursements decreased over time because the solution did not allow for the documentation that is specifically needed in a cardiology practice. Notes were being documented, but cardiology-specific tests, procedures and billing codes were still conducted using paper forms. This limited the practice’s ability to increase efficiency and limit costs.

To combat the rising costs and decreased savings, South Florida Cardiology Associates developed a team of six, including physicians, nurses and administrative staff, to explore the benefits of a specialty-based EMR. After conducting numerous trials and demonstrations over a six-month search period, the team found a cost-effective, cardiology-specific EMR solution that fully integrated into their practice.

The system they ultimately chose works better for them because it incorporates scheduling, procedures, laboratory tests, e-prescribing and billing that are both specific to cardiology and user-friendly for cardiologists. It is able to integrate all aspects of a cardiology practice, including patient questionnaires with cardiology-related history, symptoms and medications, in a simple point-and-click solution. The specialty system also includes cardiology-specific reports that are unavailable in generic applications, such as: carotid ultrasound, myocardial perfusion, stress tests and transthoracic echocardiography. Templates that are easily modified to match the way the practice works offered another added benefit.
The new EMR allowed the cardiologists to go paperless for the first time in the practice’s history. Procedures that the practice commonly uses, including computed tomography and nuclear stress tests, can now be filed electronically. Using a system designed specifically for cardiology helped the practice avoid the “burden of adoption” that the previous generic system caused. Instead, the cardiology-specific EMR gave them a platform for a more efficient practice.

Clear Benefits of Using Cardiology-Specific EMR
In comparison to generic alternatives, a cardiology-specific EMR offers a turn-key solution that integrates medical visits, procedures and billing into a single system without expensive customization. Because the cardiologist’s office can become paperless sooner, this leads to a higher return on investment. Clear benefits include:

• Reduced overhead costs - Lower filing and transcription costs, reduced storage space, simplified administrative duties

• Increased revenues - Improved billing accuracy through coding automation, enhanced compliance and the ability to shorten the accounts receivable cycle

• Improved patient care - Allows enhanced clinical documentation without compromising productivity so physicians can focus on patient care

Deploying an EMR that’s cardiology specific can produce greater results, including speed and accuracy of patient appointment notes, legibility and confidence in the accuracy of the notes. These benefits allow practices to increase patient visits per day, and ultimately the practice's bottom line.

Many tedious tasks can be eliminated; lost, missing and unorganized documents can be minimized; productivity of the office as a whole can increase; the office will feel and look more contemporary; overhead can be lowered; and revenue potential can increase.

About the author: Joe Rubinsztain, M.D., is the founder and CEO of gMed. He has over 17 years of experience in electronic medical records. Weston, FL.-based gMed develops, engineers and trains clients on specialty-based EMRs for selected medical specialties, including cardiology, gastroenterology and urology. Dr. Rubinsztain can be reached at joer@gmed.com or (888) 577-8801. More information visit www.gMed.com.

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