The ARRA/HITECH Act has made electronic medical records a front burner issue, and many believe that EMRs will make departmental systems redundant. Some cardiologists beg to differ, arguing that cardiovascular information systems are deeply clinical and essential to the cardiovascular workflow. Here’s a look at the evolution of CVIS, EMR, and their roles as the healthcare landscape is being transformed by meaningful use.
Today a lot of attention is focused on addressing electronic medical record (EMR) systems to meet the needs of American Recovery and Reinvestment Act (ARRA) and meaningful use legislation. In the words of some EMR vendors, the EMR will act as the aggregator of necessary clinical and operational information, enabling the physician, in one system, to access all relevant patient information across a number of clinical services.
No doubt this is true. The approach has its supporters and its detractors. Robert Cecil, Ph.D., a staff member with The Cleveland Clinic Foundation in Ohio, believes the EMR is the right environment to manage patients, making departmental systems redundant. He believes that the EMR will evolve to fill this role, as the aggregator of patient information. This will leave departmental systems to focus on what is important, which is acquisition and reporting. Dean Cheatham, enterprise manager of cardiovascular technology at PeaceHealth, Bellevue, Wash., echoes this sentiment. He considers a cardiovascular information system (CVIS) to be “another data silo laid flat across the cardiovascular service line,” and not a “clinical-facing” system.
Not everyone feels that strongly about the EMR. Tom Lonergan, executive operations director, Hoag Heart and Vascular Institute, Newport Beach, Calif., feels that “EMRs are still evolving, and they are not all-encompassing at this time, so there is still a place for a CVIS. An EMR is not disease or department-specific in the way it presents information—both important to a cardiovascular physician.” For James E. Tcheng, M.D., professor of medicine and professor of community and family medicine at Duke University Health System in Durham, N.C., the EMR’s focus is on patient management and not procedure management, and therefore the EMR is not specific enough for the cardiovascular workflow.
PROPOSED DEFINITION FRAMEWORK
Understanding the differences between an EMR and a CVIS can be simplified by means of a framework as proposed in Figure 1. Initially, departments focused on what can be referred to as cardiology picture archive and communications system (CPACS) to address image acquisition. Cardiac catheterization lab images from the fluoroscopic X-ray system and cardiac ultrasound images from the ultrasound cart are captured and stored in a central viewing and archival system.
Cath lab procedures involve case documentation of supplies and medications, as well as a record of the procedure, while study parameters and measurements are captured on a cardiac ultrasound cart. In early CPACS, such documentation was usually printed out and used along with the images from the CPACS to produce a dictated report.
Subsequently, CPACS vendors expanded their offerings to include structured reporting tools that enabled the cardiologist to produce a report directly from the CPACS while viewing images. Interfaces to hemodynamic and ultrasound systems enable directly capturing the documentation and measurement information into the structured report.
Unlike radiology, where reports are usually dictated, a cardiovascular report would require a significant amount of dictation effort to include documentation and measurements—hence the benefit of structured reporting. Capturing information directly from the hemodynamic system or ultrasound cart eliminates the need to manually transfer the information into the report and prevents possible typing errors. Thus CPACS evolved into an image management and reporting solution.
Over time, cardiovascular departments realized that their workflow could be simplified if additional administrative and study management functions could be automated. Directly capturing information for registries from the reporting database could speed reporting to the National Cardiovascular Data Registry (NCDR), patient demographic consistency could be improved by passing order work lists to supported imaging equipment, inventory/billing accuracy could be enhanced through tighter integration with documentation equipment, and department management could be enhanced by management reports.
These functions emerged into CVIS. Note that depending on vendor and development evolution, there is an overlap between CPACS and CVIS in the area of study documentation and reporting. Some vendors encompass both CPACS and CVIS functionality in one product, while others offer distinctly separate products.
More recently, EMR systems have gained importance for ARRA/meaningful use (MU) compliance. EMRs are positioned to be the focal point for clinical information, and most encompass patient and study management processes. A patient study originates within the EMR with the collection of relevant patient information, and diagnostic exams are ordered through computerized physician order entry (CPOE) applications. Many facilities favor central scheduling for a consistent schedule across service areas. Results are aggregated within the EMR for a patient-centric view. As such there is overlap with a CVIS in terms of managing the patient and the exam. But as the aggregator, the EMR usually does not overlap in terms of the level of detailed clinical data captured and the physician review process. Today, the EMR is typically not the primary vehicle for data acquisition and clinical report generation across the cardiovascular service line.
With the EMR’s role expanding, the question arises as to whether there will be less need for departmental systems to manage the order and exam process.
Given the CVIS’s overlap, how then might it be differentiated, and what if any role will it play in the changing IT landscape?
Both CVIS users and vendors have vested interests in clearly defining the difference between a CVIS and an EMR. One viewpoint is that cardiovascular services tend to be unique among image generating services (radiology, cardiology, pathology, GI, etc.). In the words of Praveen Lobo, senior vice president of business development at Lumedx Corp., Oakland, Calif., “Cardiology takes a more holistic view and is focused on the morphology of the disease, as represented by multiple modalities, labs, EKGs, etc., before making a diagnosis.” Lobo further states that “EMRs may not be of the proper ‘granulation’ of data, whereas a CVIS represents a specialized view of the data optimized to the cardiovascular physician’s needs.”
Workflow is another major differentiation. “Cardiologists are more case involved, whereas a radiologist’s focus is on diagnosis,” according to Robert Cecil of The Cleveland Clinic. Echoing his sentiment is Robert Schallhorn, vice president, clinical solutions at Chicago-based Merge Healthcare, who believes “today’s CVIS emphasis is on workflow and reporting capabilities, data mining, and accreditation support, while image review capabilities are a commodity.” Similarly, Lobo of Lumedx adds that “workflow management during a procedure such as chest pain management or heart failure is important, as it spans the course of treatment, which is not the prime purpose of the EMR.”
Regarding order management and scheduling, cardiovascular exams don’t lend themselves to enterprise order and scheduling processes, according to Tcheng. “In the case of the cardiac catheterization lab and cardiac ultrasound, the concept of an ‘order’ just doesn’t exist.” Tcheng likens a cardiac catheterization study more to a “consultation” than a diagnostic exam, and as such it is difficult to prospectively determine what the “order” is for. Cardiac catheterization procedures can be unpredictable in their length, making it difficult to “schedule” the lab for a fixed time slot. Tcheng adds that a cardiac catheterization study is “the epitome of chaos!”
Another factor in terms of order and scheduling discipline is raised by Robert Cecil, who points out that cardiovascular procedure volumes are considerably less than radiology volumes. “In the case of radiology, volume is the driver and time limitations favor an order/schedule discipline. Whereas with lower volumes, greater dollar value per case, and greater staff resource availability in cardiovascular services, there is more ability to ‘clean up’ the order post exam.”
Craig Scott, M.D., founder and CEO of Flexible Informatics LLC, Bala Cynwyd, Pa., believes that “physicians interact with EMRs and CVIS in different ways.” The EMR is accessed during the patient encounter, or as new information is acquired, whereas the CVIS is typically accessed by the staff while performing and interpreting the procedure. Another perspective is Dean Cheatham’s view that the CVIS “is a business intelligence tool instead of a clinical facing system.” Cheatham believes that a CVIS cannot assimilate all of the information an EMR can with respect to the patient, and believes that the future will be a “cardiologist template” within the EMR. Yet, Tcheng believes that EMRs are focused primarily on addressing ARRA/MU needs, and it will be at least 2015 before they can turn their attention to clinical needs, presenting a window of opportunity for the CVIS data integration and management.
From the perspective of a large EMR vendor, the early phases of technology began with a tremendous amount of data stuck in departmental systems that didn’t get to an EMR. But physicians are looking for a way to bring the data together, similar to the way paper represented the “great communicator.” The EMR represents a higher degree of integration than departmental clinical systems, and a means for correlating data that may not be present in individual systems such as the CVIS.
Henri “Rik” Primo, director of strategic relations at Siemens Healthcare, Malvern, Pa., notes that “historically each cardiovascular sub-specialty had its own sub-systems for reporting results. It was the cardiologist’s brain that integrated all this information to make a final diagnosis and treatment plan. The increasing complexity is the justification for a CVIS. Logical rules in the CVIS can now guide the cardiologist thru the diagnostic cycle to make sure that all results are included in a comprehensive diagnostic reporting workflow.”
There are those who are looking beyond the EMR to health information exchanges (HIEs), and to physician office integration, particularly as more physician groups are acquired into providers. Because the cardiovascular physician’s emphasis is on treating the disease process, they frequently need to manage data across multiple provider entities. A patient initially seen in a cardiologist’s office may receive an EKG or cardiac ultrasound procedure. Subsequently, the patient may have additional studies done at a primary care or specialty referral facility. Ideally, the physician would like to “manage populations such as chronic heart disease through the entire cycle, including inpatient, outpatient, and home care,” according to Lobo of Lumedx. Lumedx’ s HealthView application is an example of the ability to aggregate information to better manage chronic cardiac conditions, and bridge multiple provider services.
Hoag Heart and Vascular Institute in Orange County, Calif., encompass two hospitals and nine clinics. The challenge, according to Lonergan, is how to tie them all together for a continuum of care. Hoag is planning a form of internal HIE at a layer above an EMR to connect physicians at all facilities.
In the opinion of one large EMR vendor, interoperability is tantamount to addressing accessibility beyond the EMR. It believes that all the capability exists to support interoperability—the government just needs to decide on one approach. The result may negate the need for the HIE per se, if all locations can interoperate to share data. It states that in the instance of its EMR, 35 million patients across 71 sites involving 79,000 physicians can share data with no “hub,” or HIE. If sufficient standards come to fruition, the ability to “plug and play” may negate the need for data repositories such as HIEs.
Conversely, many of the imaging interoperability standards that exist today have come from organizational, not governmental efforts. Consider Digital Imaging Communications (DICOM) and Integrating the Healthcare Enterprise (IHE) initiatives that have been prospered by organizations such as the American College of Radiology (ACR), National Electrical Manufacturer’s Association (NEMA), and the Radiological Society of North America (RSNA). While these standards provide the format for image sharing, they do not directly address the management of the process for sharing data between two or more locations that need to be addressed as part of an HIE.
In addition to the clinical need, there is also the data analytics need for aggregation. The ability to expand information beyond a single provider with the objective of improving outcomes is a key driver of accountable care organizations (ACOs). Providers participating in an ACO may be able to better manage a patient based on a broader base of study analytics.
Siemens’ Primo summarizes it well. “The technology to share information across the Enterprise in an ACO or regional HIE is readily available, and there are no technical reasons why this isn’t done more often. The real stakeholders are the care providers and policy makers. Their commitment to eradicate the internal information silos will be the decisive element to create a true continuum of care.”
IT IMPLICATIONS AND THE FUTURE
While not totally unique, cardiovascular services are indeed different. Information technology services need to be sensitive to those differences and department needs. According to Harry Comerchero, national director, strategic accounts at Philips Healthcare, Andover, Mass., “CIOs need to manage two relationships: the EMR for hospital systems, and the CVIS as a deep clinical system.” Comerchero believes that the past fragmented nature of cardiovascular services will give way to more integrated CVIS solutions for cardiovascular services to integrate into the EMR. The question is: how many people are ready for that level of CVIS integration? Comerchero believes that cardiovascular services need a “visionary” in the cardiovascular department who has a service line perspective, and who appreciates the value of having a single point of access to a comprehensive patient record that spans the patient’s entire cardiovascular continuum of care.
In the past, “CPACS and CVIS components were at a departmental level with no IT involvement,” according to Schallhorn of Merge, but today IT has a seat at the table. But Cheatham of PeaceHealth questions how many places have a dedicated IT resource for cardiovascular services. A dedicated resource may not be essential, but what is important is IT’s involvement as IT initiatives become more pervasive to imaging systems’ integration with the rest of hospital information systems as ARRA/MU takes hold. Cardiovascular services may not perceive that they have a need for integration. It is up to IT management to demonstrate the value of such integration.
In the view of a large EMR vendor, it is all about where one draws the line. Companies that offer EMR and clinical system functionality will offer a high degree of integration, whereas clinical information system companies that don’t offer an EMR by necessity need to offer greater functionality and integration capabilities as part of the clinical system, and excel in interfacing to the EMR.
So, is there a role for both an EMR and a CVIS? Probably, but each institution needs to assess its own circumstances to make that decision. Factors to consider include:
• The state of EMR implementation, and objectives for CPOE, central scheduling, billing services, automated physician data entry, etc.;
• Other enterprise system initiatives that might impact cardiovascular and EMR system integration;
• Plans for involvement beyond the institution, such as participation in an HIE, the level of system compatibility, and the scope of information sharing expectations;
• The extent of current CVIS implementation, and the level of integration across cardiovascular service lines;
• Current physician reporting practices and compatibility with EMR strategy;
• Extent of existing management reporting tools, and their importance to administrative objectives;
• Institutional plans for physician group integration, including cardiovascular physicians, and the need to absorb their IT infrastructure;
• The state of image sharing across imaging services and the opportunity for enterprise initiatives such as the Vendor Neutral Archive (VNA); and
• Business continuity and disaster recovery plans and their application across diagnostic services.
In the words of author Bill Gray, “A lot of what appears to be progress is just so much technological rococo.” Tremendous progress has been made in terms of cardiovascular information systems. As healthcare continues to evolve, there will likely be systems overlaps. But the forces demanding greater information integration and utilization will determine the ultimate CVIS and EMR functionality and interoperability. Let’s hope it’s not just “technological rococo!”
Joe Marion is founder and principal of Healthcare Integration Strategies LLC, Waukesha, Wis.