Choosing the Right EP-Monitoring Platform for a Multi-Lab Practice


Sanjay Deshpande, MD

At many of these facilities, we are the primary or sole providers of EP services. Together, we conduct more than 5,000 procedures each year, ranging from standard diagnostic studies to complex procedures, involving catheter and intraoperative mapping. We also participate regularly in device and drug clinical trials and operate our own, independent animal-research laboratory in an academic environment.

Like our colleagues around the world, we are pleased to be introducing life-saving and life-altering EP techniques to so many thousands of patients each year, especially in previously un- and under-served communities. However, this level of outreach expansion is not without its difficulties. Electrophysiology is a relatively new discipline, with a rapidly growing knowledge base and rapidly evolving procedural tools. As a result, electrophysiologists who are usually independent of the facilities at which they practice do not always have access to the most efficient tools; this is especially true of the EP-monitoring systems on which we rely.

For these reasons, our group decided several years ago to do all we could to ensure standardization of these systems from facility to facility. In this article, I will describe why this is so important and how we went about choosing both a system and a vendor who could meet our needs today and for the future.

To understand why standardization is so important, picture yourself as a commercial pilot who flies 747s. Whatever airline you are flying for from American to Lufthansa to Qantas you can rest assured that when you step into the cockpit, you will encounter the same controls and gauges, time after time. That s not to say you couldn t fly a jet with a different dashboard. However, because you would spend precious time looking for the right switches and interpreting varying gauges, you would not be quite as efficient.
The same is true in EP, especially for electrophysiologists who, like us, travel from lab to lab conducting such a wide range of procedures. Equipment familiarity improves our efficiency, reduces aggravation of staff during set-up, and improves system troubleshooting all this adds up to better delivery of patient care.
By controlling and standardizing the EP lab environment as much as possible, just as cockpits were standardized in the aviation industry, the patient becomes the only unknown variable. The procedure becomes almost instinctual, and ultimately, I feel this should lead to ever-improving patient outcomes.
For health care systems consisting of multiple hospitals in a particular geographical region that have EP labs, there is also a compelling case for standardization. A consistent interface can improve efficiency across all their facilities. Staff can be trained once, then cross-cover the various labs. Multiple lab equipment purchases can save money. Also, the right choice of equipment can result in space and cost savings as well. This is the case we made to the EP lab managers with whom we work: a consistent interface makes everyone more efficient. Apparently it s compelling; nearly all of these institutions now use a common platform and interface, delivered by the same vendor.
There are two labs that are exceptions, however, and they make clear the disadvantages of the multi-vendor approach. Each time I walk into one of those labs, I have to consciously think about what I am doing with the equipment. I have to re-familiarize myself with the tracing display. I have to struggle to customize and reconfigure the screen or set-up, and find myself relying on technologists who are only occasional users to help me get the job done. This situation is far from ideal. The average case here does, indeed, take longer. To borrow another analogy, this time from sports, I don t have the home-field advantage at those facilities.

The skills of the EP staff are obviously very important to the success of any procedure. Yet itinerant electrophysiologists like those in our group do not always have access to experienced EP technologists and nurses at every facility. Our assistants, especially in low-volume electrophysiology labs, are far more likely to be full-time cath-lab employees who have received cross-training in electrophysiology a discipline with a steep learning curve, even for those skilled in cardiac catheterizations.
Of course, ongoing education and experience are the most critical factors in ensuring their continuous improvement. However, we learned early on not to underestimate the value of a common EP-monitoring interface. Our success in establishing this commonality nearly practice-wide has allowed us to quickly develop an army of personnel that are expert enough to make major contributions to our procedures.
In fact, our experience proves that putting a common platform in the hands of even part-time professionals can give rise to a community of highly-skilled EP technologists and nurses a community that readily shares information and insights. Interestingly, these professionals do not see themselves as competitors, even when they work for competing healthcare systems; instead, they are a community of colleagues committed to helping each other learn, in order to provide the best possible patient care.
Not so incidentally, this community often comes to the rescue of the electrophysiologists in our group as well. If I am at a remote site performing a procedure at 9 p.m. and have a question that I cannot solve about troubleshooting or changing a format, I can call a tech hundreds of miles away and have him or her walk me through the approach. The results? Faster procedures and, I am convinced, better patient outcomes.

For all these reasons, we decided to seek a suitable and credible supplier of EP-monitoring equipment to meet our needs. However, that immediately raised questions. Which particular system would be the best among the alternatives? Which would meet our needs not only today, but also years down the road? In addition, which vendor would best meet the overall needs of each hospital in the EP lab and beyond?
Your answers to these questions might be different from ours, but I can describe the thought process we went through. In our case, flexibility was absolutely crucial. There are some facilities where our caseload is primarily diagnostic; others, where we perform the most complex procedures. We needed equipment capable of accommodating them all: scaling down for sites where we perform only elementary diagnostic studies and scaling up for the most complex. We also wanted to be able to add capabilities as needed. Equally important, we had to have a system capable of accommodating advanced applications: for example, left-atrial mapping, which has become a specialty for both one of my partners, Dr. Jassi Sra, and me. We use a variety of catheters and electrogram displays, and need to switch quickly and easily between these.
There were other criteria as well. Ease of use was a major issue. An electrophysiology case does not always go according to plan. When you have to turn mid-procedure and steer the whole crew in a different direction, you have to be able to adjust the equipment quickly, rather than spending half an hour figuring out how to get that equipment to move with you. Intuitive displays that require a minimum of keystrokes to change system settings or tracings are critical to this enhanced performance.
Stability was another consideration. Granted, there is no EP system that will deliver hour upon hour of trouble-free operation; the demands we place on electronic equipment are simply too great. However, minimizing downtime is always an important goal one that warrants conversations with other electrophysiologists, to explore their experiences with a wide variety of equipment. These, then, were the criteria we applied to our evaluation of available EP monitoring hardware and software.

System performance is certainly not the only issue to consider; in the long run, it isn t even the most important. More critical is the company behind the equipment. One reason technical support is readily apparent: There are times when I simply cannot get in touch with an experienced tech for advice, or when I am exploring completely uncharted territory. Being able to contact a knowledgeable vendor support engineer at any time is absolutely essential in these cases.
Even more important is the question of which vendors seem most likely to continue upgrading their products in the months to come as the field of EP evolves and new needs emerge. You must consider which companies are fully committed to the field and product development, and which companies seem most likely to be around a decade from now to provide continued service.
Most of us have experienced the consequences of ignoring this issue. We have been impressed by some exciting capability or another often, a capability developed by a physician who understands exactly what we need to do. We have been so impressed, in fact, that we have allowed ourselves to believe reassurances of the vendor s staying power and we have paid the price. For instance, one of our larger software vendors has switched hands several times in the last few years. Decent service is now a pipe dream. So, too, are the upgrades that we thought would keep us current. We are faced with starting all over.
This is not a lesson we needed to learn twice. So before committing to an EP-monitoring vendor, we took a close look at each vendor s apparent commitment to electrophysiology, and an even closer look at its credibility and prospects for long-term survival.

Once we had evaluated all our alternatives, a clear winner emerged: GE Medical Systems Windows NT ®-based CardioLab system, formerly known as the Prucka CardioLab ® 7000. In the months since the hospitals started switching to this system, it has become apparent that we made the right choice.
First, this system offers sufficient flexibility to address the needs of everyone in our group, as well as sufficient speed and power. It allows us to quickly adjust individual-user preferences, up front or in the midst of a case. It lets us instantaneously change the display, to switch from conventional recording to split-screen mapping for example, if we are doing ventricular tachycardia mapping and the tachycardia suddenly becomes noninducible. It even allows our left-atrial mapping specialist to instantly switch between catheters and electrogram displays.
We are also surprisingly comfortable with the user-friendliness of the CardioLab. The tasks we need to perform frequently have been incorporated into an interface that makes operation intuitive and painless. We don t waste time figuring out how to set up the screen to our preferences, or how to get pacing from this particular place; instead, we re free to concentrate on our patients. Similarly, our staff has found this system easy to operate, especially in terms of set-up. Once we had personalized our protocols in our Milwaukee-area labs, GE transferred them to the other systems we work with via CD.
We are also quite satisfied with the stability of this system, in spite of its being the first Windows NT-based equipment available. There were some bumps along the road initially, but we expected that. While change is always difficult, the trick is to make it worth the hassle.
GE was also extremely responsive to our complaints and suggestions, issuing an extraordinary five new software releases in a single year. Plus, since most people were already familiar with using Windows in other applications, the staff was very comfortable while learning to use the system.
Furthermore, GE met our most painstaking vendor criteria. Their strengths, such as stability, credibility, and innovation, match the strengths on which the Wisconsin Electrophysiology Group prides itself. There are no guarantees, of course, but if we had to place a bet on which company will still be around to support us a decade from now, we would put our money on GE. Their commitment to electrophysiology is clearly there: this company has been involved in the imaging side of EP since the early 1990s, and its acquisition of Prucka in 1999 has underscored its dedication to our discipline.
While some might view the fact that GE is involved in disciplines outside of EP as a disadvantage, we see it as a clear advantage. As a leader in the development of an extensive line of medical systems, GE has the advantage of broad exposure to many technologies, and can apply lessons learned in other disciplines to meet the needs of electrophysiology. In addition, GE can offer hospitals comprehensive solutions in radiology and cardiology as well as EP which is important when considering a hospital s overall needs. The level of technical support GE offers is second-to-none. Also, as we learned from its engineers responsiveness in debugging the problems related to the new NT platform, the company is committed to upgrading its product to meet our needs.
Now that everything is running smoothly, even staff members who initially resisted the move to the NT platform would have to agree that it represents a significant improvement over DOS versions. This is especially true in terms of speed; our new systems respond almost as quickly as we can think.

None of these factors would matter if these systems did not enhance our ability to deliver the finest patient care. However, I am convinced that they do precisely that, primarily by taking the stress out of the lives of the electrophysiologist, nurse and tech alike. With the CardioLab, we re free to concentrate on our patients, and on our procedures, and that translates very directly into improved patient care.

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