Industry Talks IT: Innovation, What Cardiologists Want & What’s Next

Cardiovascular Business asked practicing cardiologists about the top information technology issues on their minds. Then we invited representatives from five cardiovascular information technology (CVIT) companies to join us for a roundtable discussion. Participants include:

• Don Woodlock, Vice President and General Manager of Cardiology IT at GE Healthcare
• Ohad Arazi, General Manager of Cardiology at McKesson
• Bob Schallhorn, Senior Vice President of Solutions Management at Merge Healthcare
• Ivan Salgo, MD, MBA, Associate Chief Medical Officer for Patient Care and Monitoring Solutions at Philips
• Robert Taylor, PhD, Vice President of Global Business Development and Technology Innovation, Digital Health Services, at Siemens Healthcare

How are your cardiology customers pushing the envelope with cardiovascular information technology (CVIT) to improve healthcare and reduce costs?

Don Woodlock: The most innovative customers are unifying their cardiology departments into one enterprise CVIT infrastructure, and they are moving to structured documentation. That’s difficult, but it adds a lot of value in terms of analytics to understand which procedures, devices and approaches are better for their patients, more streamlined for the organization and a better value for their care system.

Ohad Arazi: Our customers who are pushing the envelope are using CVIT as a single point of connectivity to the EMR because they’re able to integrate the massive medical record with their CVIT to get a comprehensive view of the patient and drive point-of-care decisions. A second theme is mobility: access to information on the go. The more innovative customers are now able to drive [decision making] from a mobile device.

Bob Schallhorn: The clients who are really pushing the envelope are those leveraging the technology to be able to do extended collaboration. So many of the procedures now are shared, in a sense. They may need to involve a radiologist or other clinicians or be able to review this with their colleagues. Being able to provide technology that allows for collaboration, image sharing, data sharing, and so on. In addition, being able to integrate with all of the business systems—billing and inventory, for example—is critical from a controlling costs perspective.

Ivan Salgo, MD, MBA: We’re seeing some of our more forward-looking customers addressing the eventual shift from volume to value in the context, for example, of [the Centers for Medicare & Medicaid Services] moving forward with value-based care. [They] are actually looking at deeper aspects of the data and comparing that with society guidelines … seeing how they can integrate all of the disparate information so that they can provide a unifying message to the clinicians in the context of guidelines.

Robert Taylor, PhD: There’s a strong compliance need for appropriate use criteria (AUC) that is becoming a very important factor. The most progressive institutions are typically large distributed health systems, and they may have a main campus where they are actively using AUC or documenting the decisions that drive their selection of care paths. They try to propagate this through the rest of the health system. Getting this kind of compliance system-wide is very challenging, and it puts a strong requirement and opportunity in front of CVIS vendors.

Cardiologists told us they need systems that will make it easier for them to share information with their referring providers who may or may not be within their own health systems as well as with patients. Do you view shared decision-making as a priority for CVIS?

Arazi: Interoperability has to evolve around the tools that are already in place. The physicians, the referring physicians, live inside the EMR, and interoperability between cardiovascular information systems and the EMR is going to be a key. Avoiding double-charting or avoiding errors that could stem from information being replicated twice or being out of sync. I think access to tools and joining those two worlds—a confluence of minds—is going to help with cardiology being more integrated into the continuum that occurs outside of the department or outside of their cardiovascular practice.

Cardiologists touch patients all the time and yet how we share information with them is still something the industry hasn’t fully addressed. One thing that we’re looking at from a technology standpoint is how to better integrate into the patient environment outside of the four walls of the hospital. … It’s going to be one of the keys to integrate the patient community into the care, where they want to receive that care, not just when they’re coming into an acute setting. 

Schallhorn: For sharing information with colleagues—referring physicians or others—what we want to leverage where we can is standards … for communication and connecting the clinical care team to be able to put together a cohesive care plan and making that easy for physicians to collaborate.

When we look at technologies and things like remote connectivity and making it easy for patients to engage, we have to be mindful of things like privacy and standards. We all understand that, as you move to value-based care, the engagement of the patient is inevitable. The ability for the CVIS or CVIT solutions to engage the patient in areas such as education will be key. Being able to leverage the technology to document discussions that clinicians are having with patients will be a critical part of the care process, and having the technology for facilitating those discussions in the medical record will be key as the patient becomes more engaged in the process.

Salgo: Physicians are seeing care becoming more complex, not simply with the amount of data but also the patients. The patients are elderly, they’re sicker, they have more complex, multi-organ system disease, they have more medications. A great example of shared decision making can be in the realm of heart failure and chemotherapy. There are many new centers which have partnerships between oncologists and cardiologists in timing and administering chemotherapy appropriately, but certain chemotherapy drugs can cause heart failure and it’s incumbent on the oncologist, basically, to gauge that chemotherapy correctly and come up with an overall care plan. Having imaging technologies and having access to that deeper information, … to have a comprehensive discussion with the oncologist is an evolution to bringing the data together and for shared decision making.

Woodlock: Cardiology to us is not just a department, it’s basically everywhere—in the emergency department, certainly in the cath lab and echo lab, but it’s in the physician office, pacemaker clinic, at home. You really need to have the information that’s sitting in a CVIT plugged into the EMR and available for the entire care team to see. We focused on web-based and zero-footprint technologies and EMR integration so it’s available where the physicians and the other caregivers spend their day.

Regarding patients, we’ve seen many of our customers just simply sit down with patients after cath intervention, let’s say, and show them the images before and after … . It’s really been motivating and they feel that the patients have a better understanding and appreciation of what just occurred and more motivation to take care of themselves going forward. It’s a powerful tool to share cardiology images with patients .... We certainly see more tools getting into  the hands of the patient. It’s a powerful piece of the puzzle.

Taylor: The point of any kind of imaging procedure or cardiovascular workup is to try to advance the care plan. So there’s always a downstream physician who needs to be engaged. When you talk about value and, of course, volume, this is the interface where the imaging physicians are driving the value proposition to their customers, which is the next physician downstream. … We are rapidly moving to a world where the EMR is owning the context of the patient and, therefore, the way we address this is EMR-integrated tools, especially for viewing images.

Having images accessible from an EMR so that other physicians can easily access it is very important, but we also see increasingly multidisciplinary team meetings where, for example, they will have a meeting at one of our sites where they’re evaluating 15 patients in one hour, so four minutes per patient. In order to assess whether the patient should be monitored, should be sent for a standard device or introduced into a trial, all of the cardiovascular record needs to be available: reports, images, echo, cath, perhaps nuclear, CT, MRI. The ability of the software to schedule this meeting, run this meeting, quickly bring these images to the right place at the right time is increasingly important to drive this interaction with referring physicians and downstream caregivers.

What is the most significant technical challenge associated with handling and presenting all of the various file types in cardiovascular imaging in a single platform?

Salgo: From a patient point of view, I think it is understanding that there is a hierarchy of needs of information, from something that is a single data point to something that happened on a particular day to something that is an event on an admission, finally up into population health. From a technical point of view, one of the challenges is that having diverse vendors in the market not necessarily agree on the best way to share data. … So, having customers and vendors harmonize in partnerships probably is the challenge at hand.

Woodlock: One is medical device integration. So many manufacturers, so many different ways that measurements are put out, thousands of measurements on some of these devices, so many different kinds of devices. It is really difficult to offer a great vendor-neutral solution with a plethora of all kinds of devices and lack of standards. But we all do it, it’s the business that we’re in. The lack of standards in this area does make it complex.

The other issue is tailoring of the system vs. standardized content. When you have so many different devices and areas of cardiology run on a single system, the system has to be highly configurable and tailorable, which has its benefits. We can really meet the needs of each of our customers. But on the other hand, it can elongate and complicate implementation and the service life cycle of a customer. So, balancing tailorability vs. standardization is the other technical challenge I’d highlight.

Arazi: From an imaging standpoint, as a modality vendor-neutral solution, we believe interoperability must be based on industry standards. We base our system on that and we’re definitely involved and engaged in developing new standards. We’ve seen the adoption of DICOM [Digital Imaging and Communications in Medicine] web services that allow us to deal much more seamlessly with different file types and different modalities. We see new profiles emerging, like IOCM [Imaging Object Change Management], that allow clients and archives to remain in sync and to bring multimodality together to get to that complete cardiovascular record. It doesn’t end with imaging. The waveforms, the devices, the implantables and mobility are all creating more data, and that information also has to be synced. I see them as new modalities, and analytics is another modality that is also creating data in and of itself that has to be consolidated. … From a technical standpoint, [the challenge is finding] balance between following standards where they’re available, of being aggressive in developing new ones and passionate about it, and then also continuing to integrate new solutions and new data types as they come up.

Schallhorn: From a technical challenges perspective, we really look at it in two major areas. One is the ability to store that data as well as be able to visualize it. So from a storage perspective and aggregator perspective, standards is the key. … One challenge is around storage, another is around viewing and being able to create a universal viewing platform that can be flexible from a file format perspective. Being able to display the different file formats, whether those be images, documents or photos that make up the complete picture of that patient and that care and be able to provide that in a seamless way to the clinician or even the patients themselves. That is the challenge to all of us:  to be able to have that flexibility and a universal viewer to provide a single view of the complete patient record.

Taylor: The world is changing in terms of what’s expected. It’s no longer just a departmental topic. Now we need to make sure that there is access to the software outside the department, integrated into an EMR and also across multiple sites. Most customers these days are either in or becoming part of a larger health system so there’s a great consolidation going on in the country in terms of providers. The ability to access these tools for interpretation, documentation and review now extends beyond the given physical building to multiple locations. In this environment where you have potentially a variety of different available network speeds or compute platforms and so on, you don’t really get the opportunity to expect or demand that you have a certain processing capability from the computer the software is running on.

At the same time, we have higher resolution studies coming and we have more and more demand to get better quality of review accessible across the full enterprise. The challenge is really around making sure that the technology can keep up, the software can keep up with the distribution demand, our unknown network bandwidth, and still perform well, be robust in that environment and also staying current, just staying current with the general commodity technology that’s used in terms of the browser technology, the OS, the database and so on. All of this creates a pretty complex technical environment where you have to move fast and you have to be able to keep up with the requirements of the ever-evolving demands of enterprise users.

How do you advise cardiologists who are struggling with achieving meaningful EMR documentation and maintaining the face-to-face interactions that they and their patients expect?

Taylor: This is a huge challenge because EMR software is designed and actually put in place by administration to bring structure to collect documentation, to have the appropriate records for billing and so on. This collides head on with the clinical desire as a physician to be a physician and engage with the patient. … I would say that, as a CVIS vendor, we are far more focused on the clinical operation of the department than an EMR vendor whose decisions are driven by the C-suite. You’ll generally find CVIS feedback is much, much better at tying in the clinical tasks efficiently in order to maximize time for the patient than an EMR system, which is a generic enterprise-wide system somewhat focused on billing and revenue cycle.

Woodlock: CVIT systems, vs. EMRs, are much more focused on the physicians but, still, physicians should demand that the software work for them and not them for the software. Get the IT department and everybody involved in the software implementation focused on serving the physician, interacting with the patient and not any other orientation. The other piece of advice I would offer is to look at the whole work flow because good integration across devices and IT can really make a much more streamlined environment, instead of just burdening one role, let’s say the physician, with an inappropriate amount of data work. If you design it well, you can get a really nice flow and balance and not have to have information entered multiple times.

Arazi: We have to eliminate administrative tasks for the clinicians by focusing on three main principles. One is to make reporting much more visual. Physicians live in a 3D environment and dumbing down the work that they do into a 2D PDF report takes away from the clinical advantage that our IT can provide. Two is to avoid duplication that comes with systems that require double-charting and data silos. We have to narrow the focus of the clinician to caring for the patient and making sure that any data that can be acquired electronically or by another user in the work flow, we do that for them so that we minimize duplication. The third principle is flexibility. Having a rules-driven approach to documentation and to reporting, not hard-coding it, allowing us as the vendor community to have a very rapid turnaround of new report types and raw customization that really reflect, not the way the machine works, but the way that they work in their 3D environment with patients.

Schallhorn: It’s so easy to get caught up in a new technology, so from a physician perspective, my advice is never, ever lose that human contact. Leverage technology in your favor. If you’re having that discussion with a patient, leverage a universal image viewer where you would be able to provide a nice, succinct picture to that patient and explain to them what’s going on. You also can leverage voice-recognition technology such that you’re able to complete that note in the EMR or other form of technology in a way that’s not mutually exclusive to the patient interaction. As a cardiologist, absolutely never lose and maximize that human interaction—that time you spend with the patient.

Salgo: Cardiologists have at least three main responsibilities: conducting a procedure or doing procedures; collecting and interpreting images; and finally, patient visits, whether it be a wellness check or in the ICU. The physician shouldn’t forget that he or she is really there to serve the patient, and deriving insight is what it’s all about so that the patient’s care plan can be developed. Things that can draw down from the human experience, interacting with the technology, are important. Developing smart, context-specific GUIs [graphical user interfaces] that understand the nature of procedures, imaging and the patient visits are key, as is augmenting the keyboard with more novel types of input devices, again which are smart and which roll with the context of the visit, the event, the procedure. These are going to be critical as information systems evolve.

Looking to the next decade, what do you think is most exciting for the future of cardiovascular information systems?

Woodlock: Two things: analytics and image-based documentation. With analytics, you can get a tremendous amount of value from the information that gets collected. We see it evolving from descriptive information today, to predictive, and then proscriptive, helping determine how the best care might be practiced based on the data we have. The other area that is exciting to us is image-based documentation. We see taking the diagrams and images that we have and revolutionizing the documentation model into something that better integrates the images into the story that you’re trying to tell as a physician.

Arazi: I’m passionate about things that occur outside of the department. … moving out into the community, into other care settings, and the patients themselves are much more engaged in that care and are wearing devices that generate data, that create information that allows us to interact with them in a very different way. Instead of dealing with the pathology, I really like to deal with ongoing care, such as chronic heart failure, and how we integrate into that. That notion of moving outside of the walls where we are today is really what excites us most from a technology standpoint.

Schallhorn: When we look at the future of CVIT, we’re very excited about leveraging truly game-changing technologies in areas such as cognitive computing, such as the Watson Health Platform. When you’ve got a system that’s able to aggregate and learn about, literally, tens of thousands of clinical trials, clinical studies and published papers, it’s impossible for any single clinician to be current on—and for that cognitive computing system to be able to provide the guidance to the clinician regardless of where that clinician is, … anywhere in the world and provide that clinician access to that aggregate body of knowledge. That’s what’s exciting.

Salgo: We’re excited about integration of the care continuum. I think we can get lost sometimes in the technology and then the data, and we have to remember that care focuses around the patient. So that as there’s more and more chronic disease to be taken care of, patients want to be taken care of less in the hospital, more in the home. They actually want to have a partner with them to understand what it takes to integrate information and motivation for wellness and prevention, try to screen for chronic disease earlier because that’s when you have better outcomes, have more precise diagnoses, more targeted therapies and actually faster recovery back to the home. Again, integration to improve patient experience, to improve outcomes and to improve value.

Taylor: We believe things will be about data-driven optimization of outcomes coupled with workflow optimization to support the transformation of healthcare that is underway. That means including the quality of the data we collect and then using targeted analytics to derive the maximum value for that information.