Streamlining Processes and Improving Healthcare Services in the Cardiology Section of MetroHealth Medical Center with Medcon`s

Over the past several years, MetroHealth Heart & Vascular Center has undertaken numerous steps to streamline its operations. Today, the facility prides itself on being a leader in adopting new technologies. The following article describes the Center’s journey during the update to Cardiovascular Services. Old Workflow - the Before In the past, non-invasive and vascular images were captured on videotape. At the end of the study, these tapes were placed in a physician’s basket. The physician would review them and jot down comments on paper checklists. The notes were then typed by secretarial staff into our legacy Computerized Fiscal Planning database. The physician would type an additional preliminary report into our Epic hospital information system (HIS) (Epic Systems, Madison, WI). Upon completion, the reports were returned to the physician for final signature and the hard copies manually distributed to patient charts and referring physicians. In the invasive area, physicians also wrote their preliminary comments by hand during image review. Final reports were dictated. Secretarial staff transcribed the first draft of the reports and the physicians then made corrections. Several days would pass before all the revisions were made and the administrative employees had the final hard copy report ready. The dictated reports were eventually loaded into the electronic medical record. The data from all the modalities was stored separately. Drawing up the Plan Having realized the need to streamline our operations, we decided to evaluate the competitive offerings available on the market. We wanted to acquire a network solution that could:

Integrate multiple modalities within cardiology, enabling a common database for cath, echo and other studies; Eliminate the need for multiple data entry points; Automate the reporting process as much as possible; Interface with our Epic system for data transmission to our virtual patient records; Allow template customization as per the specific requirements of our physicians and the reporting software to which we were already accustomed; Connect to and work with our billing systems.

Evaluating Vendors Heart and Vascular Center physicians, medical staff and administrative staff, as well as the Information Services Clinical Application Team, were involved in the selection process. Contending vendors demonstrated their solutions at our facility and site visits were conducted with the finalists. Our selection and purchasing process was split between the invasive and non-invasive sections due to budgetary constraints. MetroHealth was unable to purchase the total solution all at one time, so it took several years to attain the complete complement of all modules we desired. Reaching a Decision We selected TCS Symphony from Medcon Telemedicine Technology, Inc. (Whippany, NJ). We wanted to have an integrated system within the Heart and Vascular area, so that the physicians could see all the patients’ studies in one record and from any workstation. In addition, we found Medcon’s template customizations and interface capabilities appealing and promising. The TCS Symphony system was easy to learn, and the image quality very good. The images available on the review station were virtually identical to the images in the procedure room. A Gradual Acquisition We acquired the system gradually over the past few years. First, in 1999, we purchased a CPACS (Cardiology Picture Archiving and Communication System) package from Medcon to handle the viewing, managing, and archiving of cardiac images and information in the cath lab. Then, in 2002, we acquired a system from Medcon for our echo and vascular labs. Included was a reporting module for echo and stress, and an interface to our Epic system, which allowed the exporting of reports into the HIS. Our systems analyst, Olga Rodriguez, notes that compared to the TCS Symphony, no other system had the stress echo features and ability to build and expand the vascular module. At the same time, we also attained a professional and technical billing interface for automation of the billing process. Finally, Medcon’s MDQuery enabled us to datamine our records. In 2003, we added Medcon’s cath and vascular reporting packages. These included the interface to the Epic system in order to export results, HemoLink for autopopulation of hemodynamic data into the reports, and the billing interface for cath and vascular procedures. Present Workflow - the After Due to these acquisitions, our workflow and information management has changed tremendously. Today in the non-invasive area, the sonographer/nurse performs the test and enters information into the TCS Symphony. This information does not need to be reentered ever again. The physician both views images and creates and finalizes the reports directly in the TCS Symphony program. The finished report is exported to Epic within two minutes of its completion. The results and billing information are passed to professional and technical billing systems automatically. Again, the need for multiple data entry points has been eradicated. Similarly, in the vascular area, the vascular technologist performs the test and enters information into the TCS Symphony. The physician views images and creates the report right in the system. The finalized report goes to Epic (results interface) and relevant information is passed to the billing systems. During cath lab procedures, images are taken via our GE Innova system and hemodynamic data is entered into the GE MacLab 7000 (GE Medical Systems, Waukesha, WI). At the end of each case, both the images and hemodynamic information are automatically exported into the TCS Symphony. The HemoLink product maps the data from the GE MacLab to fields within TCS Symphony, so that the information becomes a part of a single report. Before the new system was implemented, the report was dictated for the electronic medical record and a hard copy of the hemodynamic information was kept separately. Since they have all the data onscreen, physicians can complete the reports right in the TCS Symphony, most of the time before the patient leaves the table. Results are automatically sent to MetroHealth’s electronic medical record. Professional and technical billing information, including CPT and ICD-9 codes, is sent off to the billing systems. What has been particularly noteworthy are the dramatic efficiencies we have realized in our workflow. Patient information is automatically imported into the TCS Symphony from the HIS and the hemodynamic systems. The reports are finalized right in the system immediately after the procedure and automatically distributed to Epic and the billing systems. Also, the new system automatically sends a copy of the report to the relevant referring physician via e-mail or e-fax. We have over 14,000 referring physicians in our database. The implementation of an archiving solution has helped us realize efficiencies as well. We purchased a server and a jukebox for long-term storage, and the retrieval time takes seconds. We have one year of studies currently in easily accessible storage. System Customizations - Partnering with the Vendor’s R&D Team Medcon’s engineers worked with us to customize report templates per the physicians’ prerequisites, along with echo and stress databases as dictated by the area workflow. They also helped customize the mapping of data elements to specific fields based on our database. Billing interfaces were developed to fit the specific design of our billing systems. In particular, we needed two separate interfaces for billing: one for our professional and one for our technical system. All codes and supply information are now transferred automatically. The integration of TCS Symphony with the Epic system was particularly impressive, as our HIS could only accept ASCII text files. TCS Symphony output was designed to accommodate this requirement. In the cath lab module, a diagnostic signature button allowing for sequential completion and summarization of the report was created. Now, after the diagnostic physician completes his or her portion of the report, they click one button. Next, the interventional physician does the same after finalizing his or her part of the report. The bottom of the report is automatically tagged that it had been interpreted by a diagnostic physician X, and reviewed, interpreted and signed by an interventional physician Y. This is a very useful feature because we now have one report that holds both procedures, whereas before two separate reports had to be created. Benefits of the System Staff Feedback The Center’s staff has been enthusiastic about the TCS Symphony, particularly regarding the integration of patient information into a singular record, the integration of the system with the HIS, and the automation of the billing process. The integration of information from different modalities to create patient-centric records has helped the workflow significantly. Non-invasive physicians no longer have to track down the invasive or vascular physicians. Instead, to get immediate feedback, they sign onto the TCS Symphony system and see a history of all studies performed on a patient, including the impressions and recommendations. The physicians have instant access to a comprehensive record from anywhere. Ms. Rodriguez, who was intensely involved with the deployment of the system, commented on the interface to Epic: The Epic system is MetroHealth’s electronic medical record. MetroHealth and Medcon created a results interface allowing the final, interpreted report generated in TCS Symphony to be transmitted electronically to the Epic system. This allows the physician same-day access to the study results for their patients, a tremendous improvement from the past. Prior to this interface, it would take several days for the referring physician to have access to the patient’s study results. The streamlining of the billing process has also been remarkable. Prior to the deployment of TCS Symphony, the billing flow was very different and not at all optimal. The information was partially manually entered into one billing system, while the rest of the information was done via paper charge tickets sent to the billing department for manual entry into another system. In the cath lab, the nurses would enter the procedures into Epic to be billed, but the secretary would manually enter the data into the technical billing system (SMS). The TCS Symphony interfaces have automated the process and have added continuity. The finance department is very pleased with the outcome. Billing is processed quicker; thus, bill-out-the-door turnaround has improved. When asked about most advantageous characteristics of the system, Dr. John McB. Hodgson, the Director of Invasive Cardiology, MetroHealth Medical Center and President of SCA&I, said, Most helpful is the ability to input the data once and get the report immediately. The report can be done, finalized, and printed out by the time the patient leaves the lab. Rather than waiting for the dictation to come back, correcting it, having it revised and getting it again, we (the physicians) now have the ability to complete the reports ourselves and get them done right away. It used to be a week to 10 days before the report would get on the chart. Now it is done by the time the patient leaves the lab. The information is already exported to the hospital network system, so anybody on the entire network can access it. It is a huge advantage. I also find the ability to query the database very helpful, Dr. Hodgson continued. Adding to the improvements in the reporting workflow and the single database for the multiple modalities, corresponding images and information is the automation of the billing and inventory processes. The technologists and administrative staff have definitely had time freed up. The system is very complete, and is working extremely well for us. We have never been this efficient.

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About MetroHealth Medical Center MetroHealth Medical Center is a 728-bed hospital providing a full range of general and tertiary services, including a level one trauma center, a regional burn center, and Metro Life Flight, the second busiest emergency air medical transport system in the country. MetroHealth Medical Center provides care to over 25,000 inpatients with more than 600,000 visits recorded each year in its 100 outpatient clinics and satellite locations. Emergency room visits exceed 70,000. As a principal teaching affiliate of Case Western University School of Medicine, MetroHealth maintains a fine tradition of academics and research. All active staff physicians are full-time faculty of the school. The hospital also has affiliation with Cleveland Clinic for their pediatric cardiology and cardiovascular surgery specialties. MetroHealth Heart and Vascular Center MetroHealth Medical Center houses a Heart and Vascular Center with ten clinic rooms, physician offices, and a cardiac and pulmonary rehabilitation area. Cardiac services are continually increasing. Annual inpatient stays are counted at 8,034 and outpatient visits at 7,462. The Center prides itself in the work of Dr. Rosenbaum, Director of MetroHealth’s Heart and Vascular Research Center, who has closely studied T-wave Alternans. His work resulted in the Microvolt Alternans Test. The invasive area performs approximately 2,200 catheterizations annually, including diagnostic, interventional and IVUS procedures. There are six physicians, eight nurses, and two radiology technologists on staff. Two labs are equipped with a GE (Innova and DLX) systems (Waukesha, WI) and one EP lab has a Siemens Digitron (Danvers, MA). The hemodynamics system utilizes a GE Mac Lab 7000. The non-invasive section of the Center performs approximately 12,000 adult studies per year, including echocardiograms, TEE, TTE, Stress, exercise, ECG, pharmacological, and nuclear medicine studies. The vascular area performs 8,000 studies per annum, including vein mappings, as well as carotid, arterial, and abdominal studies.

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