The Process of Implementing a New Cardiovascular Information System: The Solaris Health System Experience
Solaris Health System serves the central New Jersey area with two acute care hospitals, inpatient and outpatient rehabilitation centers, convalescent facilities and specialized treatment programs. The system was created in 1997 through the consolidation of JFK Medical Center (535 beds) and Muhlenberg Regional Medical Center (396 beds).
Could you describe the current cardiovascular program at Solaris?
At Muhlenberg Regional, we offer preventive, diagnostic, therapeutic, invasive and non-invasive services for cardiovascular care. The hospital became the first in New Jersey without a cardiac surgery program to be awarded state approval to perform emergency angioplasty on patients who had experienced a heart attack. We also offer cardiac rehabilitation services.
Why did Solaris decide to purchase a new cardiovascular information system?
The decision was related to a larger enterprise-wide picture archiving and communication systems (PACS) initiative at Solaris. PACS has been one of the biggest projects we’ve undertaken at Solaris, starting in radiology and then moving into cardiology. The cardiology team wanted to support the overall transition to an electronic medical record, and we believe the cardiovascular information system (CVIS) will help us automate redundant processes, such as the collection of information during a procedure. With the new system in place, this data can populate both the physician report and the American College of Cardiology National Cardiovascular Data Registry.
Both cath labs and echo are up and running with this system, which will be a positive change, since it has been a cumbersome, manual process for physicians to produce the echo report and this has affected length of stay for patients. Both invasive and non-invasive cardiology services will benefit from the new system and processes.
How long did it take you to implement the system?
We started on the cath lab project at the beginning of 2006, and had a good work year as we started to plan the implementation. We had ongoing meetings for the project internally and also with GE Healthcare, our partner in this process. Last November we finished work on the Muhlenberg cath lab, and then moved on to focus on the JFK cath lab, which was finished in June of this year. One of the goals of the project was to have an integrated PACS system so we would be able to seamlessly review a patient’s chest x-rays and cardiac cath images. I should say it is seamless for the users, but there is a lot of difference in how the technologies interact.
We have an older system at JFK, and we needed to use the NAI box (North American Imaging) that captures the image from x-ray device and merges with the order.
Can you tell me about the project structure and the roles that the clinical and information technology (IT) experts played in this process?
The overall project to improve cardiovascular services at Solaris encompassed the cath lab and echo at two sites. The team was comprised of IT, and clinical staff had weekly meetings with our vendor’s project manager and consultant. Working together, we developed a detailed project plan to monitor our progress, identify any issues and ensure they were appropriately resolved.
Since much of our focus was on the installation of the hardware and software, we also established two clinical teams (one for cath and another for echo) to concentrate on other departmental and clinical matters involved with putting a new system in place. These teams included representation from both sites, since we wanted to use this initiative as a way to promote standardization and “cross-campus” learning. The GE consultant provided guidance and leadership for the clinical teams. The team’s role encompassed organization-wide communication, revising policies and procedures to support the new workflow, coordination of training for staff and physicians, and a dashboard to monitor progress. In short, everything was done to ensure we would have a successful clinical “go live” process.
We worked with GE Healthcare to come up with a task list and milestones so we could closely track current performance against where we thought we should be. We formulated a process for escalating issues as needed and conducted weekly team meetings. We also involved process engineers from Solaris, who work with us on current and future state workflow analyses.
It was actually very helpful to understand where we are and where we’re going. Building the interfacing capabilities was also really important. From an IT perspective, we had to coordinate order entry in the healthcare information system (HIS) and build onto the DMS side so when they came across they could send the order to PACS. We also created charge interface back through DMS to do the procedure charging out of DMA.
What impact did the CVIS have on workflow and how did you adjust for that?
We radically changed the whole workflow process, and this actually improved our efficiency significantly. Just being able to route the images, for example, saves time over having to pull them individually. There was a study done by a hospital in Boston and they found that productivity increased by 80% by converting to digital echo. We getting close to finalizing the echo process, but it has taken some time due to the difference in hardware. The cath lab at Muhlenberg is new, while the cath lab at JFK is 10 years old. There are slightly different processes that people follow from one site to another. We spent time working with everyone involved to understand and accommodate for the differences.
When you say you worked with everyone involved, who did this include?
In the cath lab, we went down to the staff level. We sent the “super users” for training and started at the staff level to build an understanding of what they need. Then we worked with the cardiologists. The other people involved included a physician relations person Solaris engaged and a team leader who takes care of all the reports. She was involved to make sure we were on track with the reports we have to submit quarterly in the state of New Jersey.
We took steps to ensure that the new workflows would be very clear to everyone. Both echo techs have been involved in helping us determine aspects of the existing workflow we didn’t want to lose, and we’ve made sure to elicit input from the physicians as well.
In radiology, the PACS system was primarily a way to manage images. For cardiology, it was twofold — managing images and also the report narrative. There is a certain amount of complexity involved. We didn’t realize at the outset how much the new system was going to change to things, but it was definitely worth it.
What role did the system administrator play in the implementation?
The system administrator has primary responsibility for all aspects of the cardiology information system, including system maintenance, system integrity, overseeing end-user training, database maintenance and report generation. He works with the information systems team to provide hardware/software support and insure system integrity. He also provides 24/7 first line of response to address system issues.
I understand an oversight committee was involved with this process – what was their role, and what was the involvement of physicians?
Before we begin to structure a project, we typically assign a strategy owner and business unit owner. For this process, we’ve had monthly meetings with administration to discuss any issues that might require escalation. We also presented at cardiology section meetings; conducted numerous 1:1 conversations with physicians and provided regular updates at the hospital’s IT physician advisory committee. Because of our deliberate and structured approach to change, physicians are eager and motivated. The staff prepopulates most information for the physician’s report. Instead of the physician picking up the phone and dictating, they can now create a structured report online. One of our primary metrics was to reduce report turnaround time. The new system creates a greater level of efficiency for the physicians and staff. We believe we’ll have a high level of acceptance from the cardiologists going forward.
We have also successfully changed physician workflow and the way images are handled and stored. Security for imaging is better now as well. We used to have to burn disks and store them on a giant storage server. This new process improves security and reduces the risk of image loss.
What challenges did you face in implementing the system?
One of the greatest challenges was simply working through the learning curve together. Having a dedicated system administrator has been critical to our success. Moving forward, he’ll probably need someone to work with him since it will be quite a job to handle both locations. Other challenges included a variety of technical issues, competing demands for our time and just the sheer complexity of the project. Working as a team, we all felt we had to be very clear about what we’re trying to accomplish and what is needed from the new system. Some people didn’t realize they wouldn’t be able to do reports the same way once the new system was in place. I think we might have placed greater emphasis on not losing certain abilities from the previous process.
All in all, this has been a very positive experience, although there are always lessons learned and things we might do differently.
Can you share more about your future state workflow mapping?
Yes, we worked with GE Healthcare on this and it was helpful to show where we were currently and where we wanted to go. It helped us to create the right process and interfacing for both information flow and workflow.
We developed a common vision between IT and the clinical staff as to how information would flow between the various applications. Addressing questions about the flow of information prior to building the interface helped us to avoid design issues later.
Working with our vendor, we were able to identify placement of workstations based upon workflow, and basically engaged with clinical teams to ensure everything was in place for a successful clinical “go live.” This included organization–wide communication, downtime planning, developing procedures to ensure staff proficiency, overseeing staff and physician training, and identifying and addressing any barriers to end-user adoption.
How successful has the physician transition been from dictation to electronic structured reporting?
Within the cath lab, this transition has been extremely successful. We actually required the physicians who work in the cath and echo areas to use structured reporting after “go live,” so we now have 100% compliance in cath and expect to achieve this in echo as well. More than half of the physicians complete their cath reports immediately after the procedure, and we’d like to see this trend continue. Our vendor’s consultant helped us develop a solid communication plan, so we were able to identify and address any potential resistance prior to going live with the new system.
Another thing that proved to be beneficial was leveraging physician champions at Solaris. We identified such champions early in the project and they were able to help pave the way for the transition. Training was also structured to ensure everyone who needed to learn the system had ample time with either the vendor’s applications specialist or one of our super users. We placed “helpful hints” at each of the terminals and made sure a super user would be available to act as coach for the physicians.
At the Muhlenberg campus, we are in good shape, although we still have a few delays with JFK due to the older system. The physicians love the reporting capability. When it comes to the actual record they’re very happy and they know they’ll get a new imaging system at some point. We are also hoping that compliance and acceptance will be much easier going forward.
How did the CVIS change workflow in the cardiac cath lab and echo departments?
For one thing, I think we were able to increase communication between physicians and the staff. For example, in the cath lab, the more the physicians communicate during the procedure, the more that can be recorded. Thus there is less for the physicians to do to complete a report post procedure. Also, because the information gathered in the procedure rooms populates the ACC registry, we had to find a balance between what was reasonable for the procedure staff to gather without impacting room flow and achieving our goal of reducing chart-abstracting time.
For echo, we developed protocols to support the transition from film to “clips” and this helped to standardize documentation. In echo, it is now a performance expectation that the staff document certain things, such as the patient history and certain measurements.
One of the biggest concerns we had going in and the main reason we brought in consulting help was that we recognized this was going to represent a major shift – especially going from analog to digital echo. We felt we needed outside expertise to guide us in changing our workflow throughout cardiology, and we did get this support. The consultants were essential in creating a lot of the downtime process and working with staff to help go through process changes and flow. We’ve been able to enhance the relationship between technical people and physicians, and encourage better communication across different functions.
What type of data analysis was involved?
We did a lot more of this on the radiology side at Solaris. With every project we have metrics, and in radiology, we just have more measurable metrics. The biggest return on investment in PACS was the reduction of film. This is somewhat relevant in echo (tapes), but not so much in the cath lab. We kept statistics on film production for well over a year, and we hit our 95% reduction metric within months in radiology. Our primary metric in cardiology was report turnaround time. We have a baseline metric for this now and as we move forward, we can do a comparison to gauge improvement.
We’ve found that the actual clinical or procedure report increases satisfaction. Ultimately, one of the things we’re anticipating downstream by getting reports turned around faster is a reduction in length of stay. We’re also looking for a reduction in transcription costs, but this wasn’t focused on positions or tied into the project dashboard.
As you went through this process over a number of months, how did you keep the organization informed of project milestones?
The clinical teams developed a communication plan that included presentations at medical staff meetings, cardiology section meetings, and department staff meetings. In addition, letters were sent to the physician offices and posters placed in the reading rooms. Communications occurred at key milestones in the project, so they would be meaningful.
We publish a chart with major milestones at every weekly meeting, and that same type of graphic goes into our status report that is distributed to senior executives and ultimately makes its way up to the board. We had all the tests and workflow changes posted to make it easier for the staff to follow through. This gave everyone visual reminders and updates, so if someone forgets something they can see it right away.
In the cath lab, we would post things in the physicians’ locker room, and also have the physician relations person handle system-wide computer communications. People would actually pay attention to messages from this person since he works at both hospitals and they were used to hearing from him.
What were the most important lessons you learned through this process?
I would say the most important lesson we learned is that any project is iterative and you learn as you go in some respects. The reality is that we put many modalities into the radiology PACS system and we were able to do it within an eight-month period. The contrast in cardiology is that we’re going from analog to digital with a great deal more complexity involved.
We essentially went from a standalone cath lab to a fully integrated digital cath lab. If you have an older C-arm or DX in lab it will be a challenge to integrate into the enterprise PACS, and this is something we weren’t fully aware of when we started this process. We were also changing how the physicians complete their interpretations, and the collection of registry data.
What advice would you give to another hospital considering implementing a cardiovascular information system?
From an IT perspective, the biggest thing is that if they’re looking to integrate into an enterprise-wide PACS they will need to make sure their network can handle it, and that is has fast enough switching. The cath images are basically streaming video, which is very dynamic and bandwidth-heavy. They will have to ensure they have sufficient storage for the images.
I would also say that any hospital considering this type of project should not skimp on the planning phase. If anyone wants to do this, they could talk with us about our experience. Knowing your current state is a key first step. It’s important to make sure you know what you’re doing now, and then to get a clear understanding of what is going to happen as you transition into a new system with new workflows. Make sure you understand what is working or not working in your current situation, and then be very clear on the details involved with the implementation. Those early meetings where you sit down and look at every detail are critically important and time well spent.
The authors can be contacted at jschneider@solarishs.org
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