Despite the industry’s movement toward vendor neutral solutions, gaps remain in connectivity between PACS, cardiovascular information systems (CVIS), cardiac devices, monitors, other departments, and with hospital information systems. To fill the gaps where interoperability is an issue, some hospitals have found the best solution is writing their own programming.
An ideal connectivity solution might be to use computer software and medical devices from the same large vendor. However, most hospitals use a variety of devices and software from different manufacturers and want them to communicate. DICOM and HL7 standards have helped achieve a greater level of interoperability, but hospitals say many glitches still remain with most technology integrations.
Creating a CVIS from Scratch
In the mid-1990s, New Orleans’ Ochsner Clinic Heart and Vascular Institute was a typical hospital using a primarily paper-based record system. However, Richard Milani, M.D., vice chairman, systems and business development had a problem with patients’ waiting three weeks to get their cardiovascular echo stress test results. He found the log jam in the workflow was centered on the use of dictation and transcription. Dr. Milani set out to find a solution.
“It started off to solve a unique problem,” Dr. Milani said. “When we started with this there was no vendor who could help us.”
He worked with Andres Rubiano, director of cardiology informatics at Ochsner and a computer programmer, to create a solution to speed echo reports. This first software module eliminated dictation and changed the process into a point-and-click system of menus so the doctors themselves could quickly create a structured report. There was also an area at the end of the report for physicians to enter additional information.
“The people who read the reports like the structured reports because they want to be able to go in and find something quickly,” Dr. Milani said. “The users love it.”
This was the first of many software modules created by the heart hospital, which evolved today into Ochsner’s own, personalized CVIS. The system now has point-and-click structured reporting modules for all aspects of cardiac reporting.
Today there are numerous CVIS (also referred to as cardiovascular image and information systems – CIIMS) vendors offering similar technology, but Dr. Milani feels Ochsner’s system is ahead of most of these. He said the system was created with direct collaboration with the end users at the facility. Rubiano also has his office in the cardiology department, so he is easily accessible if issues arise or the modules need to be tweaked for a better workflow.
Today, Ochsner’s CVIS has helped make the facility virtually paperless. It is interfaced with the institute’s HeartLab PACS from Agfa, all its imaging devices, electronic scheduling system, patient billing system, bar-code inventory control system, and cath lab hemodynamic monitoring equipment.
Rubiano created a module so doctors can take a PACS image, annotate it with markings on the image and a written report, and send it out as a PDF document. He also created a module for coding for reimbursements.
“Doing coding for the cath lab is a difficult and Byzantine process, it’s like doing your taxes,” Dr. Milani said. The new module will automate most of this process.
The interface with the scheduling system allows real-time tracking of patients. “Every step of the process is entered into the system,” Dr. Milani said. The system also records times, so the CVIS can mine the data to find inefficiencies. Reports can also be generated to see how much time certain procedures take, turn over times, or to evaluate the efficiency of a particular doctor.
In the cath lab, a tech with a laptop computer and bar code scanner records all the items used. The system uses drag and drop menus of anatomical images and the various cath lab devices on hand. The tech can place the device images on the particular places in the anatomy where they were used to help create a pre-populated procedural report. The CVIS also auto populates information for hemodynamics, contrast dye amounts used and the length of time for the procedure. Following the procedure the physician can quickly fill in the rest of the report.
“The report is done within minutes after a procedures,” Dr. Milani said.
The system is also programmed to report data automatically for trials and regulatory agencies or registries.
Programming for Better Interoperability
“Some of the biggest challenges we had were integration of the various systems,” Rubiano said.
Ochsner uses scheduling, hemodynamics, PACS, billing and numerous other systems from different vendors. The facility prides itself on choosing “best-of-breed” systems, but the challenge has been to make them interoperable. It overcame connectivity issues by doing its own programming. Rubiano said it is not as difficult as some may think, since most of these systems work on common industry standards such as DICOM or HL7.
“It’s not rocket science, its just data,” Rubiano said. “The devices have gotten very sophisticated, but software writing has also gotten very sophisticated.” Part of this sophistication is the use of PowerBuilder programming software PowerDesigner enterprise modeling software by Sybase. He said the biggest advantage is the technology significantly reduces the amount of code that needs to be written.
The CVIS has helped Ochsner significantly increase its work volume and eliminate transcription costs, which has saved about $50,000 annually. The facility also reports savings of several hundred thousand dollars a year due to more accurate billing.
Integrating an EMR From the Start
Due to their size, smaller hospitals may find it easier to migrate to electronic medical records (EMRs) than larger hospitals, but the process still takes time. South County Hospital Healthcare System is a 100-bed community hospital in Wakefield, R>I. It began migrating to an EMR in 2002 and is about 70 percent complete today, with Web-based connections to its EMR so physician offices can access data and images and transfer data. The hospital opened its first diagnostic cath lab in January 2009 and planned for it to be 100 percent integrated with the EMR upon opening. The facility is overseen by Rhode Island Hospital in Providence 30 miles away, which has a full-service cath lab where patients requiring angioplasty, stenting or other interventional procedures are referred.
“We wanted to build it right,” said Gary Croteau, the hospital’s assistant vice president and chief information officer. “There are organizations that have had cath labs longer and have a history to contend with (legacy systems), but we started from scratch from the ground up.”
The cath lab adopted the Philips’ FD10 system (formerly known as the Witt Series 4), which integrates the angiography, hemodynamic data and cath lab documentation systems. The system is integrated with Agfa’s HeartLab PACS, which enables images to be called up live or after the procedure at Rhode Island Hospital or other physicians in or outside the hospital using a Web-based interface.
“Documentation is completed in real-time, and post-case the doctors are signing off on those reports right after the procedure,” Croteau said.
The system records tech or nurse documentation during a procedure. Reference images can be attached, and when they are clicked they automatically connect the clinician with the PACS image via the Web. The system also interfaces with the hospital’s Meditech EMR system, which has automated inventory and billing components that pull information from the tech or nurse documentation. Croteau said the system has eliminated duplicate data entry.
Coding for Connectivity
The transition to these information systems was not without bumps in the road. South County Hospital had issues networking its cath lab system with some third-party software. Crouteau said the hospital information system, electronic medical record, PACS, imaging equipment and the CVIS all approach the flow of information a little differently.
“The hospitals want all these things to work together, and they don’t,” he explained. “It was a really a big issue. We had to create our own system.”
The hospital’s IT staff created a succession numbering system. As a patient goes through various departments or procedures, the same patient number is assigned in each software system so the information is easily grouped. The same number can also be used by doctors to call up patient records or imaging studies.
Connectivity is key. From the beginning, Croteau said hospitals need to take the time to build the connection points with HL7 interfaces from lab, admissions, billing, transcription, materials management, nursing and physician documentation, the modality X-ray device, and the PACS archive.
“Assign a project manager that understands all of the technical components and has a clear understanding of the cath lab workflow and corresponding systems data flow, because they all must align,” Croteau said.