Authors: Val Kapitula and Jen Ireland

e l e v a t i n g t h e o u t c o m e ®

CardiovascularInformation Systems (CVIS):Optimizing Cardiovascular Operations and Services

Table of Contents

Executive Summary..................................................................

Why Read this White Paper?..................................................

What is CPACS vs. CVIS (Compare and Contrast)?.......

Comprehensive CVIS Benefits and Impact.......................

a. Technical Benefits........................................

b. Clinical Benefits............................................

c. Business Benefits..........................................

CVIS Risks and Costs...............................................................

a. Risks.....................................................................

b. Costs...................................................................

Transition Methodology .......................................................

a. Steering Committee.......................................

b. Current State Assessment........................

c. RFP and Procurement..................................

d. Implementation................................................

CVIS Market................................................................................

CVIS and the Value of a VNA.................................................

Conclusion.................................................................................

About the Authors..................................................................

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Executive Summary

Today’s healthcare is changing in many ways. There are multiple biomedical and technical advances that are proving to optimize patient care. With declining budgets, healthcare providers are under increasing pressure to develop effective ways of improving efficiency and reducing costs, while maintaining high levels of patient care. While the new technology is increasingly influencing the strategic plans, the legislature, with the new regulations and policies, is not helping to solidify a final plan for healthcare providers. More than ever, healthcare organizations are looking to outside expertise for guidance and insight of the current market in order to, most effectively, take advantage of the available products and services against the available budgets.

This white paper is shaped to serve a single purpose, and that is, to educate the healthcare providers of the available Cardiology Picture Archiving and Communication Systems (CPACS) and Cardiovascular Information Systems (CVIS) and their ability to streamline the delivery of today’s extremely complex Cardiology operations and services.

Why Read this White Paper?

Similar to the Radiology PACS market about 10 years ago, CPACS/CVIS market has reached its potential for maturity and is offering product(s) that can and will improve the clinical, technical and business side of Cardiology services. Today, healthcare organizations have a great opportunity to capitalize on the advances of such technology in Cardiology departments. This whitepaper is drafted with intent to provide just enough information to begin considering CPACS/CVIS as a potential replacement system within your department or enterprise, based on the available resources. Furthermore, this paper will provide common benefits, risks and opportunities linked with implementation of a CPACS/CVIS.

What is CPACS vs. CVIS (Compare and Contrast)?

Cardio PACS (CPACS), similar to Radiology PACS, mainly focused on storage and retrieval of Cardiology-centric images. However, one of key differentiators with CPACS, is its ability to support DICOM Structure Reporting (Dicom SR) for Echocardiography (Echo) measurements; not available through the conventional Radiology PACS. In terms of dataflow, CPACS will receive an in-bound HL7 order with patient demographics from upstream information management systems and once the images are acquired from the imaging modalities via DICOM Modality Work List (DMWL), they are profiled against the order and stored in CPACS for further distribution, viewing, and long-term archive.

Contrary to CPACS, CVIS is more data driven; meaning that patient informatics coming from integrated Hemodynamics system, Echo machines, EKG/ECG carts and third-party integrated monitoring systems are all stored with the remaining measurements and

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nurse charting captured in the course of the procedure. All this patient information is stored within the single CVIS database for patient record and reporting. In addition, the business side of operations, such as billing, inventory and business analytics, which are conventionally managed by separate systems, are now available for storage within the enterprise CVIS. The real power and differentiator of CVIS comes from its ability to provide dynamic reporting (images, informatics, measurements, etc.) that are structured in a template-type format for efficiency and consistent delivery of patient reports. Cardiologists and supporting staff have seen significant reduction in report delivery time with the implementation of CPACS and CVIS combinations. CVIS has also become a big contributor in improving the workflow and process for obtaining department accreditations (i.e. ICAVL, ICAEL, ICANL) and providing procedural data to the common registries (e.g. ACC, STS).

Comprehensive CPACS/CVIS Benefits and Impact

A. Technical Benefits

One of the keystone benefits of a CPACS/CVIS is its ability to create a single platform and storage and move away from multiple storage devices, not just within the hospital, but within a single department, that have been found obsolete and are no longer supported. Ultimately, having a single platform with single storage solutions, an organization can capitalize on fewer interfaces for integration to other enterprise systems and establish a single point of entry and access for cardiologists, referring physicians, staff and administrators. All images, procedure reports and business information are now retained within the same system and are readily available for access regardless of user’s location (within hospital setting or remote). Today, there is an observed pattern among the CPACS/CVIS established healthcare organizations, and that is simply to create a standard within the architecture, hardware, dataflow and related support. Historically, architectural system silos have been proven to create gaps in system performance and interoperability, and ultimately lead to increased costs around hardware, support,

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integrations and learning curves. Single platform CPACS/CVIS allows organizations to establish such standards and strategically prepare for information exchange initiatives.

Some of the additional technical advantages come from the ability to manage the hardware architecture and not be tied to the vendor proprietary products. Virtualizing the back-end of the systems has become a common offering for significant reduction in hardware procurement. The older ways of having proprietary hardware to work with proprietary applications have been slowly dissolving. The market offers a number of vendors that will work with their clients and design system architecture that will meet the application requirements and allow for fiscal flexibility in client preferred hardware vendors.

B. Clinical Benefits

The most commonly recognized and appreciated clinical benefit that CPACS/CVIS provides is the ability for cardiologists and supporting staff to conduct their daily duties from one system. Single platform systems with web-based or thin-client solutions provide the freedom of mobility for cardiologists and referring physicians, regardless of their physical location – ultimately providing an improved patient care, contrary to the desperate systems with thick-client delivery designs. Thick-client desperate systems have always limited physicians to the onsite requirements and, most of all, mandated that the patient information access points come from multiple sources and/or charts. In the past, a cardiologist who is reviewing diagnostic tests and prescribing a treatment plan, may end-up in numerous different departments and access several information sources and charts in order to obtain health information or images. With a single platform CPACS/CVIS, a cardiologist assessing a critically ill patient has a view of their entire clinical history along with all the images from various modalities; most of all, the doctor does not have to leave the critical patient’s bedside.

In the current market of tablets and smart phones, several products in the industry allow access to patient’s images and information via mobile devices. This technology has opened new opportunities and allows for more flexibility in the workflow. Today, a cardiologist is able to review triage tests and prescribe additional tests and imaging procedures prior to arriving for an onsite procedure. Such efficiency allows for immediate care to the patient and limits the liability for unfortunate events in emergency situations.

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C. Business Benefits

Having access to reliable information at a click of a mouse, in a manageable delivery method, is priceless to any administrator. Reliable information is the key for assessing and strategizing business performance. A well selected CVIS allows administration to manage supply inventory, billing, statistical reporting and department performance in a live environment. In addition, by utilizing standard physician reporting templates terms and definitions are consistent, allowing more accurate data mining. Such privileges become extremely valuable for an administrator that may be assigned to cover several physically separated sites within the enterprise.

CPACS/CVIS Risks and Costs

A. Risks

Like any other system that is introduced as a replacement or completely new, there is a risk of adoption and successful implementation. Any change to the current environment will create unease among the work force and administration. Careful analysis needs to be considered of current state and organizational needs to determine the most feasible product that will have the least impact, yet, deliver the intended results. There are multiple products available and, unless selected to meet the organization needs (i.e. clinical, technical and business), the system will not serve its purpose and magnify the risk of change. In addition to procuring the effective solution, the implementation and the actual transition to a new CPACS/CVIS will have a significant impact on the staff and the organization as a whole. Careful implementation planning needs to occur to determine the least disruptive methodology and have early buy-in from the leadership for the entire project lifecycle.

B. Costs

In order to successfully prepare the capital for the CPACS/CVIS procurement, the organization should be aware of their immediate and strategic needs. A CPACS/CVIS is comprised of many components that may be purchased upfront and some left for later phases, as the capital becomes available. Depending on the capital budget, an organization may initially choose to implement the CPACS and then slowly implement CVIS reporting modules as applicable to the priority levels.

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Some vendors offer the entire solution in one platform, including natively integrated hemodynamics, ECG/EKG modules, and other cardiology components. If an organization recently procured an enterprise hemodynamics or ECG/EKG system, it may not be feasible to procure the entire package. All offered products need to be reviewed and only procured if there is truly a clinical benefit and the ROI is justified. Majority of CVIS vendors are tightly integrated with third party systems, so the customer may choose not to procure the complete package upfront and have the new CVIS integrated with their existing devices and systems.

Transitional Methodology

A. Steering Committee

Just like any other project, a CPACS/CVIS will require a governing steering committee for strategy development and roll-out. The steering committee needs to include senior leadership from physician community, directors/administrators and IT. A series of clinical, technical and fiscal decisions will occur throughout this initiative, and a diversified and well informed steering committee is essential to the success of the project. This is not simply another IT or clinical project; collaboration is critical throughout the procurement and implementation to ensure that that limited conflict arises from cross-function groups and, if issues do

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rise, they can be quickly escalated and addressed. Early leadership and physician buy-in is tremendously essential in empowering the appointed project management to drive healthy momentum and product adoption.

B. Current State Assessment

Prior to any procurement of enterprise systems, an organization needs to completely understand their organizational needs in the clinical and technical areas. Knowing the current state of needs and having a clear understanding of where the enterprise needs to go, the procurement and the contract process will eliminate unnecessary loss of capital.

C. RFP and Procurement

Request for Proposal (RFP) allows an organization to compare several systems and vendors that closely meet the organizational needs. Trying to negotiate with a single vendor has never been healthy in the fiscal and product sense. There are variety of systems in the market and, placing them next to each other, will allow the steering committee to clearly differentiate each one in the functional disparities, as well as cost. Competition has always been a great factor in giving the customer an opportunity to leverage good price negotiations.

D. Implementation

A successful implementation is typically a result of comprehensive and well documented planning. The planning committee needs to be composed of vendor and customer teams. Most likely, the vendor of choice has implemented their product in a similar organizations and replicating the project plan with the estimated timeline is never a crime. The beauty of contracting with a well-established vendor and system is the fact that you are not their first customer – in most cases. Every completed project will always have a list of lessons learned and should always be referenced prior to project plan completion. Consider reviewing such documents and discoveries to avoid similar mistakes within your enterprise.

Implementation of any new system will cause a natural change in the organization. A good change is healthy for growing healthcare, but is difficult to manage. A master project plan needs to include a list of possible change risks with mitigation options and contingencies should they occur. Early buy-in from the leadership and physician champions

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will also help in decreasing the possibility of staff rebellion due to the change. Leadership needs to be eager for the project before expecting the remaining support staff to believe and adopt.

CPACS/CVIS Market

CVIS market is reaching its maturity level and this is a great time for organizations to begin their strategy developments and procurements. There is large selection of vendors in the market now that provide a good mix of competition. Today, we see a number of reliable companies offering similar products tightly integrated for a seamless system performance. These vendors are eager to negotiate and are willing to work with the customer.

Furthermore, the cardiology community is becoming more involved in the imaging market and the vendors are beginning to respond to the customer’s needs. This is a good time in the market to begin researching available systems to see how each one may fit your organization in the near future. It is important to view the core components of the product to see where the vendor is heading. Are they integrating with third party vendors (never a native integration) or are they designing their own product code? Such questions are a good starting point and raise a discussion around the company’s ability to grow within the ever-changing industry.

CPACS/CVIS and the Value of Coupled VNA

Similar to Radiology, many more departments (“ologies”) are becoming players in the imaging arena, driving more demand for an enterprise archive solution through the use of Vendor Neutral Archive (VNA). In the past, most of the departments have survived on their own playing field with their proprietary information systems and archive media (i.e. tapes, CD/DVDs, hard drives, etc.). However, with the Meaningful Use (MU) requirements and more demand for the planning of Healthcare Information Exchange (HIE), healthcare providers are now looking into the future and are beginning to consider the consolidation of all of their images and related data into a single archive solution. Not only is there a need for long-term storage with possible Disaster Recovery (DR), but IT administrations are now puzzled with the demand for: intelligent enterprise imaging workflow; single viewer integration to Electronic Health Records (EHR); reduction in storage costs for petabyte-size data storage requirements; purging needs with the use of Image Lifecycle Management (ILM) rules; and ultimately prepare for new near future needs around Accountable Care Organizations (ACO) models and HIE. The concept of having all the departments function on their own islands is no longer fiscally intelligent and creates a liability gap in the patient care continuum.

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There are a number of strategic advantages for coupling a VNA solution with a CPACS/CVIS implementation. One of the key benefits is having the entire cardiology image data migrated early from the legacy systems to avoid operational disruptions after go live. Migration of legacy data can begin much sooner to the CPACS database build phase and the historic images will be available for comparison during go live, depending on the CPACS implementation timeline. Conducting migration during the implementation of CPACS/CVIS will limit operational disruption and avoid increased cost of migrating larger data sets in the future. The more one has to migrate, the higher the price will be and inherent complexity.

Conclusion

Healthcare providers that have implemented a CPACS/CVIS solution have realized a significant reduction in operational costs and improved the delivery of patient care. Cardiologists, who have been strapped to the requirements of onsite presence just to view patient’s Echo images and EKGs, are no longer obligated to spend their valuable time traveling from one site to the other, but in-turn, dedicate their time to the care of the patient. While onsite, a cardiologist who had to leave an ill patient at their bed to reference an image in a department located across the hospital, no longer needs to leave the patient’s bedside and can simply reference their mobile tablet or any workstation on the hospital network to consult the patient and provide a treatment plan. Administrators that had to access multiple systems and documents to manage their supply inventory and billing, now can simply work from the same application that is linked and updated with procedures and patient’s information on a live basis. These are just a few benefits obtained from the available technology of CPACS and CVIS. Healthcare providers are constantly looking into standardizing their enterprise systems, while leveraging improvements in healthcare delivery. Today’s CPACS/CVIS market allows such scenarios and eases the process of achieving advanced healthcare objectives.

If CPACS/CVIS is something that your organization is considering, a good amount of due diligence is recommended to avoid procurement disasters and implemented systems that do not meet the organizational needs. Even if a good system is selected, planning is the key to successful implementation in order to prepare for the natural resistantance of cultural change and workflow disruption. Administration and steering committees need to be ready for pushback and proper steps need to be taken to mitigate such risk. A well implemented CPACS/CVIS has significant positive impact on the organization and extra planning and research is worth the cost.

In order to successfully strategize an enterprise archive solution, which will not only include Cardiology and Radiology, a VNA should be considered with the implementation of CPACS/CVIS. Addressing the questions of archive early will avoid unnecessary spending of additionally purchased hardware and resource hours spent to implement. In addition, future migrations will cost more dollars and definitely create clinical

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disruptions. The eminent concerns of HIE requirements and ACO planning will somewhat be addressed with the enterprise archive, where the existing archive solutions may not be adequate for such demands and may set your organization for near future failures.

About the Authors

Val Kapitula, RT(R), CRT, PMP, is a Senior Consultant at Ascendian Healthcare Consulting. Jen Ireland is a Senior Consultant at Ascendian Healthcare Consulting. Both are frequent contributors to publications and forums focused on HIT innovation. You can contact them directly at vkapitula@ascendian.com and jireland@ascendian.com or visit the Ascendian website for more information at www.ascendian.com