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Pictures and sounds – all on one workstation

Ralph Wagter
ICT Consultant, 
Groene Hart Ziekenhuis, Gouda, Netherlands

Groene Hart Ziekenhuis (Green Heart Hospital, GHZ) is a community hospital in the Netherlands. Most medical disciplines are practised with the exception of cardiac surgery and neurosurgery of the brain.  

We have 125 specialists, and in alliance with three other hospitals in our neighbourhood, provide care to more than one million people. This gives us the advantages of a large hospital (efficiency, purchasing power) and the benefits of a hospital close to the patient. We are looking for further co-operation with care institutions in our region to optimise care delivery.

In 2008, the cardiology department started a project to digitally acquire, review and archive all cardiac ultrasounds. There were several reasons to digitise ultrasound, previously stored in analog form on VHS and CD:

The long time it took for a cardiologist to review and make a diagnosis from VHS.
Avoiding the time-consuming manual 
handling in archiving and retrieving VHS.
The risk of losing precious patient 
information due to degradation of the 
VHS tape itself – which necessitated 
checking and copying tapes during the archiving life cycle of patient records
Besides cardiac ultrasound, there are several other diagnostic tests performed or reviewed within the cardiology department such as ECG, Holter (>24-hour ECG), diagnostic heart catheterisation and cardiac CT.

Complete diagnostic workstation
As well as the cardiac CT, which is stored within the picture archiving and communication system (PACS) of the radiology department, all other tests had a traditional output on paper or were recorded on CD. The GHZ defines all these tests combined within one view as a CardioPACS – the complete diagnostic workstation for the cardiologist within the imaging and waveform domain, including the facility to report on these tests.

It was quickly realised that the PACS which was already available in the GHZ – primarily in use for radiology and x-ray images – would not support the complete diagnostic cardiology workflow. However, the archive function, one of the technical components of the general PACS within the GHZ, has been put to use as a general imaging archive that can also be used within the cardiology workflow.

Medical imaging archive
The PACS is able to store DICOM files, including 12-lead ECG, cathlab images and so on. Part of GHZ’s strategy is to use this capability and hence create a comprehensive medical imaging archive where clinicians can fully compare and review different kinds of data. A key criterion of the project was that a CardioPACS should be able to store and retrieve the data from this archive.

An integrated webviewer is built on top of the imaging archive and is on all the relevant workstations in the hospital. By storing cardiology studies within the general archive, clinicians outside the cardiology department can review all data in a familiar application.

The webviewer is capable of reviewing images and performing some basic post-processing such as measurements and zoom, but cannot fully analyse the images within the cardiology domain, an added application was needed to provide a highly specialised cardiology workstation, able to post-process different cardiology studies and report on them.

We discussed our needs for a cardiologist workstation with diagnostic, reviewing and dictation capabilities, combined with the archive that was already in place, with several vendors and resulted in our acquisition of Carestream Health’s (CSH) Cardiology PACS. This CardioPacs completely fulfilled our specifications and would fit within the existing IT-infrastructure (windows-based, SQL-database).

It was an added advantage that our general PACS was also acquired from CSH as it was already familiar with the hospital – although this was never a pre-condition of our CardioPacs selection.

First of its kind
The CSH CardioPACS implementation at GHZ was the first of its kind in Europe – so the venture began as a green-field project from a design of a basic digital cardiology workflow.

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When designing a digital workflow, we always wanted to maintain a closed-loop information circle, especially when all components were connected to the GHZ IT-infrastructure. This would mean that patient would be registered just once in the hospital information system (HIS) and all other applications would derive information from that system using HL7 connectivity.

All patient reports are delivered, again using HL7, to the electronic medical record (EMR) application. A URL (website address) is also generated so that the clinician can directly open a web browser from the EMR application and view the contents of the study. All intermediary steps complement but never change the information that is delivered from the workflow system. This means a transparent and high-quality audit trail with formerly misplaced patient records, due to manual re-registration, no longer being an issue. 

In the process of creating this closed-loop information circle, we borrowed some functions from already existing applications such as the “work-list broker” that was part of the radiology information system (RIS). These components were used as technical building blocks not requiring manual handling from users.

Great leap forward
After a test (ECG, ultrasound, etc) is performed, the images are primarily stored for review in the CardioPACS. The technicians flag up the test as performed and the cardiologist can review the image and create a report on any workstation within the clinic where the software is installed. This means that the cardiologist can review ultrasounds and other exams almost any where, any place, any time – a great improvement on using VHS and paper ECGs. The report is no longer dictated but created from the results of the modalities (input and output devices). This means all measurements that are performed on the ultrasound are captured and can be used within the report, including results derived from several calculations.

The report creation is produced from predefined templates and can be clicked together, with the cardiologist further able to complement the report with small snippets of text, when needed. The report is then digitally signed and directly distributed to the HIS and EMR.

Before creating the report, the images are, however, already available for all other clinicians from the moment they are stored within the CardioPACS, and a copy is simultaneously made to the general PACS. The report is, when authorised, merged with the images in the general archive.

The CardioPACS archive contains a fixed, small cache, and the images are purged within about three months on a first in, first out (FIFO) basis. When a re-review is needed, the CardioPACS directly retrieves the images from the archive within the general PACS.

Problems encountered
Some problems arose when trying to connect certain modalities to the CardioPacs. Because the implementation was the first in Europe and the main experience of the local CSH personnel as the well as of the project team in the GHZ was in the radiology/x-ray domain, it was not foreseen that some modalities still used proprietary or monolithic protocols.

During the project, it turned out that the Holter modality that is in use, as well as some of the ECG carts, were not capable of retrieving the work-list. A decision was made to implement these modalities in a second phase, which is now ongoing after software upgrades.

Technical implementation was smooth once the architecture had been designed and the workflow was further tweaked and tuned in the department. This means that the last pieces of paper, the handwritten order, is digitised and attached to the appointment in the HIS.

This last step reduced the old workflow consisting of 28 steps to a seven-step workflow. As a result, storage cabinets are no longer needed, orders are no longer misplaced and general administrative tasks are minimised.

The final result is a harmonised and efficient workflow resulting in less manual handling. For the cardiologists, reviewing and reporting ultrasounds within the CardioPACS saves up to 50% of the time compared with reviewing the ultrasounds on VHS. The project has therefore been seen as a success and further positive results are foreseen when integration of the ECG workflow within the CardioPACS is also completed.