Cardiology Data & EMRs: Waiting Was an Option

	Screenshot courtesy of Siemens Healthcare

Cardiologists have been at the forefront—some would say bleeding edge—of EMR adoption and data integration. Now, practices that weren't in the early adopter vanguard stand to benefit from their pioneering peers' efforts, but they still need to proceed with caution. There are plenty of systems that suffer from persistent and often paralyzing lack of interoperability.

Cardiology practices are left to try to figure out how to integrate data and images from cath labs, imaging studies and other patient information on a system-by-system basis. "That's the American capitalist engine working: Each vendor develops and sells what will make their shareholders the most profit," says Michael M. Bakerman, MD, cardiologist and CMIO of UMass Memorial Healthcare in Worcester, Mass. "It's not a bad thing, it just means that systems and EHRs are built in isolation and often will not talk with each other."

On the other hand, the benefits of integration almost speak for themselves. "Having the patient in the ER and knowing his or her cath lab report and looking at images and history right there—that is a huge advantage for patient care," says Bakerman. UMass Memorial is currently in the second year of a five-year project to integrate all patient information and images in multiple EMRs among the system's five core hospitals and 1,700 affiliated physicians across Central and Western Massachusetts.

"With the ability to quickly bring up and measure ECGs while reviewing a patient's cardiac history and prior studies, any physician is going to be able to do a better job," concurs Tim Tindle, executive vice president and CIO of Harris County Hospital District. Cardiologists at all 40 of the Houston-area health centers have readily available patient information including ECGs, labs, meds, charts, physician notes and images, Tindle says.  

Many hospitals struggle to compile all of this information in a single location, but Harris County has managed integration while avoiding redundant storage by linking to images and other large files via an EMR interface. All 40 district hospitals and clinics have implemented an EMR (Epic) because of price, integration and the ability to leverage their existing cardiology PACS (Fuji), Tindle explains. Harris County launched the system-wide EMR in 2009.

Interfacing among different modules, information systems and modalities was relatively painless, Tindle says, due to the involvement of district cardiologists, who specified to IT what they wanted out of the system, including such features as seamless access to a patient's complete record and information without having to move between systems and the coordination of modalities, such as echo or CT, with billing.

"You dream of projects where you get physician engagement, that meet or beat the budget and timeline, that are very low overhead to support, and have maximum clinical impact—that's what this project was," Tindle says. "Most physicians don't even realize they're using multiple systems, it's totally seamless."  

Clinical decision support

UMass Memorial decided to replace its paper record systems with an EHR (Siemens), with ambulatory and central facilities switching over progressively between 2003 and 2008, primarily for the system's clinical decision support capabilities, which Bakerman calls "the guts of our EHR."

The inpatient EHR system, which cardiology is currently piloting, will take one to two years to deploy, he says. Still, cardiologists at UMass Memorial's five central hospitals are asked by the system whether patients with congestive heart failure have been prescribed ACE inhibitors and if heart attack patients are on beta blockers, while also being reminded to test for such measures as cholesterol and ejection fraction. Bakerman expects to fully integrate decision support ac nationally reported core measures by 2012, which will also help UMass Memorial achieve meaningful use.

Surveys of PINNACLE Registry participants in December 2009 and October 2010 revealed the prevalent barriers to EMR deployment, but the numbers are dropping. Source: American College of Cardiology

Cardiologists and patients at Midwest Heart Specialists' 25 affiliated practices and hospitals across Northern Illinois also have benefited from IT-based clinical intelligence. "We have our EHR check 120 quality measures, from following up on patients' blood pressure and prescribed meds, to tracking timelines for carotid artery scans and smoking cessation counseling," explains Vincent J. Bufalino, MD, president and CEO of Midwest Heart Specialists.

Cardiologists and IT staff at Midwest Heart Specialists have worked closely at tailoring their EMR (MedInformatix) to track patients' progress and inform clinician decisions. If any of the 120 measures for a patient are out of compliance, the EMR alerts the cardiologist with a blue light in the patient's computer record and an explanation of the missed measure(s). The group has seen a considerable improvement in performance since using the EMR to track these parameters nearly 10 years ago; it's now about 90 to 95 percent compliant with the American Medical Association (AMA) consortium performance measures, "which is quite rare," Bufalino says.

In a study conducted at Midwest Heart Specialists, Bufalino and colleagues found that among the 1,109 patients whose cardiologists used an EMR (compared with a control group of 709 patients whose cardiologists used a paper-based record), the EMR was associated with a threefold increase in the incidence of patients achieving low-density lipoprotein (LDL) goals, as well as significantly lower cholesterol levels and more appropriate utilization of lipid-lowering drugs (American Journal of Cardiology, July 2001;88:163-5). Still, Midwest Heart Specialists has not integrated images into their EMRs, citing storage costs as the primary disincentive.

Quality improvement

"We're using the EHR for QI, to develop new clinical registries, follow patient care and set off healthcare reminders, all of which represent only a part of what the EHR makes possible. And as we redesign care and look toward accountable care organizations, the EHR stands front and center," Bakerman explains. With comprehensive, highly integrated EHRs, cardiology gains the capacity to monitor quality across all physicians for almost all patient information, making for more accountable and higher quality care.

Along with cost (see chart), interoperability is the greatest challenge to implementation for many practices, Bufalino says.

Integrating in-hospital images and information from out-of-network facilities is more challenging, with proprietary fixes commonly requiring hospitals to purchase additional systems to interface PACS, CVIS and outpatient labs, for example, with their installed EMRs, Bakerman, Bufalino and Tindle note. UMass Memorial is rolling out a service-oriented architecture integration engine (dbMotion) to connect PACS images along with patient labs and information to UMass Memorial inpatient cardiologists' EHR (Siemens) and to ambulatory facilities' EHR (Allscripts).

Although cardiology practices still on the sidelines of EMR adoption may have missed out on a host of benefits, they also may have circumvented some of the interoperability obstacles. The time to adopt might be now, with the ONC moving to tackle interoperability standards and incentives available to defray some of the costs. "The systems are better, the incentives are there and the time is right," Bakerman says.