In this article we feature a discussion with Cardiovascular Information System (CVIS) Coordinator Cyndi Ciocco, RHIT, Robert F. Malacoff, MD, Hari Joshi, MD, and Project Manager Carolyn Suess, RN, about their implementation of GE Healthcare’s Centricity CVIS system in Lehigh Valley Health Network’s EP labs.
Tell us about the size of your EP program and staff. In addition, discuss the range of EP services you provide.
Malacoff: It’s a large program. Last year at Lehigh Valley Health Network, we performed in excess of 1,400 procedures. At our Cedar Crest campus, we have 2 fully equipped, state-of-the-art dedicated rooms for advanced EP procedures. We also have a third room that is used for device cases. Staff in the lab is composed of an outstanding and talented group of registered cardiovascular invasive specialists, nurses, and physicians. The types of procedures that we perform range throughout the spectrum of electrophysiologic techniques and procedures, including device implantation, device extraction, and ablations of all varieties, including atrial fibrillation (AF), atrial tachycardia, supraventricular tachycardia (SVT), ventricular tachycardia (VT), and epicardial ablation.
Joshi: Lehigh Valley Health Network’s cardiac electrophysiology program includes EP labs at both the Cedar Crest and Muhlenberg campuses. I primarily perform procedures at the Muhlenberg EP lab. Over the past 4 years, we have grown significantly in both volume as well as in complexity of procedures. We now perform all CRM device procedures including implantations and extractions, and also a comprehensive range of ablations including SVT, VT, and AF. I have the privilege of working with my team of 5 EP staff that are also cross trained in cardiac cath lab procedures, which is an asset in several EP procedures. At the Muhlenberg campus, we perform about 250 CRM device procedures and about 60–70 ablations a year. Our AF ablation volume has grown significantly over the last year.
How long have you been using GE Healthcare’s Centricity CVIS system in Lehigh Valley Health Network’s EP labs?
Ciocco: The implementation of the physicians’ reporting tool was the final component that made our CVIS system complete. We went live with the cath-structured reporting module in October 2008 and the EP-structured reporting module in June 2009. However, it was Carolyn’s team who laid out the groundwork for this final piece to take place.
Suess: First we had to go in and update our infrastructure. We actually put in a brand-new cardiology PACS system, and of course we had to migrate an awful lot of existing studies in order to make that happen. There was also a lot of “behind the scenes” type work that needed to be done in preparation for these two systems to go live.
Malacoff: We really did, with this particular package, start almost at ground zero, because the cath package was much more sophisticated and farther along in its programming than the EP package. It seemed the EP package had really been adapted by individual hospitals for its own use and was more skeletonized. We wanted a more complete and comprehensive reporting system that would more accurately reflect the procedures that we perform and also be able to demonstrate electrograms as well as radiographs that were taken during the procedure. With the help of IS and Cyndi, we were able to accomplish that over a period of approximately 6 months of hard work, meeting several times a week with programmers and getting things exactly the way that we wanted. There was still some additional work needed after that, but I think we now have a system that accurately reflects the complex work that we are doing in the EP lab, and allows our Quality Assurance Program to be successful.
What were your goals in implementing a CVIS solution? Describe some of the ways that the Centricity CVIS system has helped streamline cardiology workflow and improve quality of care.
Ciocco: Our network’s overall vision is to be, as we’ve already been, a “most wired” facility. Our Heart and Vascular Center wanted to follow that vision and position our network with the technology to accommodate efficiency, standardization, healthcare reform, and operational report capability. The CVIS system was what we needed to move forward.
Malacoff: In addition to appropriate and accurate documentation was the speed with which the reports would be generated — not having to rely on transcriptionists but physicians to do the reports immediately after the procedure, to be distributed to all referring physicians immediately by fax, so they have that in their hands within an hour of the completion of the procedure. Just as importantly, the report is accessible to the physicians who are caring for the patient if for example it is an in-hospital patient, but it is also available to the referring physicians who have trusted their patient to our tertiary institution, specifically for advanced care. So they get immediate feedback, even if it comes before the phone call.
Joshi: The CVIS solution is in line with the Lehigh Valley Health Network’s mission to be at the forefront of healthcare-related technology. A digital system had to provide the capability to have all data related to invasive cardiology (cath and EP) in one system, locally and by remote logon. The solution would also need to eliminate redundancy in data entry related to the case. Finally, having digital and standardized data entry into reports would also allow future access to data for quality measures related to procedures. This was the first CVIS solution we implemented in our lab, and therefore, a lot of groundwork was involved in implementing a system that would address most, if not all of these needs.
Ciocco: It really is a system that calls for point-of-care documentation, and that provides real-time access to patient data in our hospital system and physician offices.
Malacoff: That is really helpful, because sometimes when we’ll see a patient in the office, for example, two weeks after the patient has been discharged from the hospital, and we’ve gone to a complete EMR system in the office, on occasion we may not have all the information from the hospital scanned into the EMR. However, we will have this report, which can summarize what happened during the hospitalization, and it makes evaluating the patient in the office much more efficient than having to sort through a lot of information to find out exactly what transpired during the hospitalization. Therefore, it increases our ability to deliver care in a timely fashion, but also in an educated way. We know what the patient had done, because very often, especially with these complex procedures, the patients will know they had a device implanted or an ablation done but they don’t really know exactly what was accomplished. This helps us a great deal when we see the patient in the office, especially if it’s a physician who did not have interaction with the patient during the hospitalization.
Suess: Along the same lines that Dr. Malacoff had mentioned, the data aspect of this system does contain discreet data elements that we can query. The database is pretty robust, and I think the fact that Cyndi and Dr. Malacoff worked closely together to build the structured reporting system and include all the discreet data points into it, certainly made a tremendous difference — it made it much more valuable. Therefore, you can do all sorts of reporting, whether it’s performance or QA, and you can actually pull it right out of the system. In addition to that, we can track inventory, capture charges, all in addition to the structured reporting piece.
Malacoff: That is the whole other aspect that the physicians don’t really see as much because during the case, the nurses and techs are at consoles inputting all that data into the log so that the charges are appropriate, the codes are appropriate, the materials that were used during the case were all listed, and makes it much more complete and accurate than the old way of taking labels off a piece of paper and saying “we used this type of ablation catheter” — all that information is in the log, it’s all there and reported, immediately upon completion of the case.
Joshi: The system allows immediate post-procedural report creation, along with ensuring that critical components of the procedure report do not get missed (such as pre-operative and post-operative diagnoses). Data entered during the case transfers in real time to the reporting system. Data fields (such as device details, lead details, administered medications, and performed procedures) get populated automatically, cutting out the need to enter the information multiple times, and ensuring consistency in the health record. Electrograms, x-ray images, and 3D mapping images of relevance can also be imported into the final report to make it more informative, and therefore, more useful in the future. The CVIS reporting module was structured in a format that is user friendly, thus allowing the physician to complete his or her reports without delay or error. We have a policy in our lab that mandates report completion within 24 hours. This is much easier to accomplish using the new system. Finally, as soon as the report is created, it is faxed automatically to the performing physician’s and referring physician’s offices. This expeditious communication is greatly appreciated by the referring physicians. I have had referring physicians comment on how they have already received the final report by the time I call them to update them on the outcome of the procedure soon after I have spoken to the patients and their families. In addition, along with the report, letters to referring physicians are automatically created using data entered in the case and into the report.
How has the CVIS system also helped reduce costs?
Ciocco: We no longer have transcription costs for EP procedure reports. A reduction in redundant data entry saves time, which also correlates to cost savings and improves data accuracy and consistency.
Suess: They are also sent electronically, so you don’t have to mail reports out. The other thing is coding; I think that with the structured reports and the way that all that information comes across into the system and populates in the report makes it easier for extracting purposes and attributes to cost savings.
Ciocco: We went through several stages of the customization process to make certain that all documentation requirements were met. First and foremost, we needed to assure quality patient care reporting. Secondly, the report had to meet the needs of many — medical records, coders and abstractors, joint commission, legal and risk management, etc. We were able to customize the system by adding flag notes and placeholders that prompt the physician to complete the necessary documentation, which reduces physician queries and turnaround time.
Malacoff: When we started the process, we did visit other institutions that had the initial software package, and had really not approached reporting with the completeness that our team did, addressing the issues that you just heard about in terms of coding, quality abstracting and so forth, so that we could craft a report that would satisfy all those requirements. I think that is what brought this report to a new standard that I do not believe exists in any other reporting system that I’ve seen come from any other institution. We’re really lucky that we had an intelligent and forward-thinking administrative and physician team looking for and anticipating different kinds of data queries that would be needed going forward as the challenges of healthcare evolve. Plus, in addition to creating a report that is explanatory of the procedure that was done, not just to say a “pacemaker was implanted and here are the parameters,” we have a lot of flexibility in free texting if we want to, so a physician who performs the procedure can make any additional comments about patient anatomy conduct of the procedure. Therefore, if another physician has to go back in at a later date, they can be aware of those nooks and crannies, so to speak, that were difficulties during the case that you might not see reflected in a more bare-bones and skeletonized report — that is one of the beauties of this document, it allows that flexibility.
It sounds like a very innovative system now. Tell us about the challenges faced when implementing the CVIS system.
Ciocco: Well, it was pretty much an out-of-box product, so as Dr. Malacoff mentioned, our successful implementation was due to our team’s dedication and innovation. Without the strong support of management and physicians taking an active role during implementation, we would not have the reporting system that we do today. Physician champions were assigned to the project. We went through many rounds of customizations that depended on intense physician participation. Weekly meetings with the CVIS team not only kept us on track, but also provided an avenue to discuss new issues and resolutions.
Malacoff: Also, we believe that our physicians are experts in their fields and wanted the reports to reflect their level of expertise. Fortunately, our network mission was supported by a number of important individuals who have quality and patient care as their primary goals; this includes Chief of Cardiology Dr. Ronald Freudenberger, Vice President Vincent Tallarico, and our Invasive Cardiology Director at the Cedar Crest campus, Kristine McMurtrie, MSN. Their help, support, and guidance made the CVIS EP package a reality.
Ciocco: In order to mitigate physicians’ concerns, Dr. Malacoff and I met with individual physicians to review complex ablation and device procedures. We fine-tuned the procedure narratives and also provided documentation opportunities within the structured reporting tree.
Malacoff: Each physician who does a particular procedure and requires that flexibility can select their own narrative that they have composed, reflecting the way they perform their procedure. As you know, with ablations in particular and especially atrial fibrillation ablations, there is a great deal of variability in technique. Going forward, we will be able to go back into that report and see how that procedure may differ from Drs. A and C, because Dr. B’s narrative was different and said that his procedure was done in a slightly different way. Those small differences can become important down the line, but you don’t think about it at the time when you’re just trying to produce a report and make sure that all the involved physicians get copies. We want this to be a report not for right now but for the ages, so that we can look back in 2–3 years as we learn more about a particular procedure, especially a new one or one that is in evolution like atrial fibrillation ablation, and learn what procedural differences may have existed between physicians and those at other institutions.
Ciocco: Carolyn, could you also speak to the interface to EHMR, your work with the postscript processor and the implementation of Cardio Web?
Suess: Certainly. As soon as the report is electronically signed or confirmed by the physician who is actually building the report, it goes into our electronic medical record. We do have a postscript processor that was developed within our department to get those reports in there, including the letterhead to make it look exactly as it would if it were to come out of a printer, with the diagrams and images as well. If there are any embedded within the report, those are also there as well. Prior to that, we were not able to include that type of information, and to be honest, some of the other reports that come out of our other systems were pretty generic looking (e.g., one type of font, no additional information, etc.). We also have a web component to this particular application, in which users can go through a browser and view these reports from physician offices, so they don’t necessarily need to have a client installed on their workstation. So it has really improved things tremendously from the end-user standpoint.
Joshi: One of the biggest hurdles in implementing such a system is trying to devise a single system that will serve multiple proceduralists, each with their own preferences and styles. Along with more than a year’s worth of extensive, dedicated legwork by our coordinator, multiple meetings with the vendor as well as the physician leaders were needed. In the end, the system was able to be manipulated that allowed customized “QuickReports” for individual physicians so everyone could be satisfied that the text offered in the reporting module precisely correlated with the clinical procedures performed. Conversely, certain fields in the report (diagnoses, procedures performed) were considered critical, and were made mandatory. Going from a paper-based record (chart notes, dictated reports) to an electronic system is not easy, especially for an individual who might be “technologically challenged.” To ensure a smooth transition, the network provided plenty of “Go Live” training as well as post-training user support. As part of the transition, the option to dictate EP procedure reports using the old “phone” method was eliminated only after thorough training was provided and user questions were adequately addressed.
Is there anything else you’d like to add?
Suess: One of the most important parts of our success in this project had to do with our team and the fact that we did follow project management. We have a PM office here in our IS office, and we do follow the Project Management Body of Knowledge, and I think that was certainly helpful in keeping our project on task. I know we initially underestimated — in the beginning we felt we were going to go live with this in April. Then when we looked at the application and found how bare bones it was, we knew we needed something a bit more robust, and as mentioned, Dr. Malacoff worked closely with Cyndi as well as some of the other physicians, and they were able to do a fantastic job tailoring this system.
Malacoff: Well, I think the cath product was much further along and updated than the EP package; I think we were a little surprised at the level that the EP product was available to us, and we realized we had a lot more work to do. It was a real team effort, and Cyndi deserves a lot of credit for listening to all of the physicians’ wants, needs, and requirements to accurately reflect what they do in the lab, which is important not only for transmission of information to referring doctors but also as a medical legal document.
Malacoff: As far as the issue of timeliness in receiving the report — sometimes a patient would be discharged from the hospital and the implant or ablation report would not arrive by mail or fax by the time that patient was seen in the office by the referring physician — nothing irritates a referring physician more than to not know what his patient had done. As I said, even though patients are more informed these days, they still are dealing with very sophisticated technologies where very often they don’t fully understand what was done except for the basics. So it is very important that the report be made available to that doctor as soon as possible, and now that almost always happens within 24–36 hours, usually before the patient leaves the hospital, so the referring doctor has already received vital information before he or she receives a follow-up phone call from the physician. A key feature of this system is the timeliness with which the information transfers, which is so crucial in today’s medical care delivery.
Ciocco: The complete CVIS and Cardio Web provide a “one-stop shop” for physicians to pull up patient data and see over a period of time all of their cath, EP, and EKG reports.