What happens when you combine digitally captured medical images with clinical data sent over an interactive network to multiple work sites?
If done correctly, you create a computerized patient record capable of improving patient care through increased efficiency at near lightening speed.
But there are challenges to be sure — maintaining a secure network and avoiding leaks of sensitive, confidential patient information, while providing a system that functions smoothly 100 percent of the time.
And while the terms are used almost interchangeably: computerized patient record, computerized data repository or electronic medical record, purists might argue that an electronic medical record (EMR) is different from a computerized patient record (CPR). While an EMR provides access to data stored in a central repository, a CPR allows an interactive process for that data.
The origins
One catalyst to the development of computerized patient records is managed care.
“In a fee-for-service paradigm, there was little incentive for the provider to handle and manage clinical information,” says Kobi Margolin, vice president of marketing for Algotec Systems Ltd. (Duluth, Ga.). “If you came in for a CT, and just had one yesterday, no one cared. They would charge for it anyway. Managed care injected the concept of capitation into the provider world.”
This reality became a driving force for the development of clinical information systems, with a goal of pulling a file that supplied a comprehensive view of all clinical data and that improved the cost effectiveness of providing care. Other influences have spurred on the development of CPRs, not the least of which is optimizing patient care.
“Information and assessment of data is key not only to [patient] survival rate, but to immediacy of care and quality of life depending on outcome,” says Rod Coombs, senior vice president of product development and chief technical officer for ADAC Laboratories Inc.’s (Milpitas, Calif.) Healthcare Information Systems (Houston) division.
Electronic medical records, such as this example from GE Medical Systems, provide access to data stored in a central repository.
CPR technology has developed over time, as the healthcare industry sought to create a centralized data repository that could be accessed by many providers easily. “Now, the technology has moved towards each department maintaining its own records, that are integrated through Web-based technology,” says Vishal Wanchoo, global general manager for integrated information solutions at GE Medical Systems (GEMS of Waukesha, Wis.).
Algotec’s Margolin credits the development of Java technology in 1996 as a pivotal point in CPR development. “To get clinical images outside of radiology, we needed a Web browser to break the wall that surrounded PACS from outside the radiology department. This is the key to the image-enabled CPR.”
Embracing the CPR
Healthcare institutions are at different stages of implementation with their information systems. Even without a fully integrated program, institutions, such as Santa Barbara (Calif.) Cottage Hospital, are able to provide some of the image viewing capabilities through the use of their Web-enabled PACS (picture archiving and communications system).
Using a PACS from DR Systems Inc. (San Diego), every personal computer at the facility has access to patient images and 52 of the hospital’s physicians have access to images in their respective offices.
“We have one neurosurgeon who tells his patients to call him 15 minutes after they have had their MR scan here, and he’ll go look at their images in his office,” says Harlis Maggard, Santa Barbara’s director of radiology. “He says it has saved him an hour a day, because he doesn’t have to handle film.”
As is the case with any budding technology, easy-of-use for clinicains, radiologists or physicians is paramount. Dan T. Soule, Cerner Corp.’s (Kansas City, Mo.) managing director of CDR, advocates that it is important that a clinician sign in only once to identify the patient and see all patient information — from medical images to nursing documentation to the historical record system for that individual — on one screen.
Cerner offers its PowerChart system for a clinician to access a patient’s record. By clicking on an icon, a user can open to a chest X-ray and, at the same time, view blood gas values.
“Using a flowsheet concept, the clinician can access all medical images, read reports, and see all archived information about that particular individual,” adds Soule.
Cerner’s IntelliStrip display provides access to a patient’s lifetime electronic health record. A clinician could use radiology reports over several years to determine subtle changes, for example, in the vasculature of a diabetic patient.
One other feature is the incorporation of a dictation system into the entire integrated patient record. In most patient-care settings, once an image is captured, it may take 24 to 48 hours to have a dictated radiologist’s report written into the record. In PowerChart, a clinician can review the image and click on an icon to hear the verbal dictation of the report. Once the report is written and signed, the oral version is replaced, speeding access to a radiologist’s interpretations of the image study.
Fuji Medical Systems USA Inc. (Stamford, Conn.) features a different approach with its Synapse product. The system is designed to utilize what the company calls Internet protocol technology.
“All data and information within the system is treated as if it were an HTML page,” says George Sledd, Fuji’s national marketing manager for imaging and information networks. “That makes the system straightforward in terms of interfacing with other systems.”
Because the system is designed using Internet and Web-based technology, it is different from so-called appended Web capability. Appended Web allows a user to push information to a dedicated server, and then other users access that server, yielding Web-like functions. If the server were incapable of providing some other functions, the system would not be able to accomplish those requested tasks.
“This technology is helpful in legacy systems,” Sledd continues. “With legacy systems, it does take some work to implement, but once it’s up and running, it becomes a powerful tool. From a single desktop, [the clinician] can access any level of information.”
Fuji offers either a software/hardware or software only option. Michael Albertina, RT, FAHRA, director of radiology at St. Louis (Mo.) Children’s Hospital, says his institution selected the software-only approach because the facility has staff on hand who manage the hardware component.
“A key element is to deliver information electronically to the physician faster than they are traditionally used to, rather than have them wait for a fax or mailed report or to come down to see the film,” adds Albertina. “We want to deliver it to their work place where they can treat the patient in a more expeditious manner.”
The hospital’s system currently works within the institution exclusively. St. Louis is looking to expand outside its confines as their next step.
The CPR’s potential
Over the years, ADAC’s Coombs says one of the problems with medical imaging has been that the radiologist was “disconnected” from the immediate care process in real time, with the possible exception of emergency room settings where some organizations have made a determined effort to have radiologists available in support of emergency medicine.
“We believe this entire process is about the re-engagement of the radiologist into the immediate care paradigm,” Coombs adds. Take the case of Raziel Gershater, M.D., chief of diagnostic imaging at North York General Hospital (Toronto). “When there is an emergency that they want us to look at, I can go to my PC at home,” he says. “If they have an image of a patient who is acutely ill, they can have the opinion in about a minute.”
Gershater explains that with the facility’s Algotec PAC system, either the technologist at the hospital can push the image to his location or Gershater can access images using his Web browser. “This is very important with the new treatments for stroke victims, where minutes make a real difference in outcome,” he adds.
Once a diagnosis has been made, there is only a small window of opportunity for intervention to decrease long-term effects of stroke. Gershater says that some of his colleagues even perform angiograms from home.
“Our requirements are that it must be up 100 percent of the time. [Algotec] has delivered a system that is designed to be up 100 percent,” Gershater continues. “I can accept a 98 percent up time for a single machine, but not the system. We figure six levels of computers must go down at the same time [to disrupt the system.] Short of a complete hospital computer melt down, it’s not a problem.”
Field challenges
Security and Confidentiality. Network capabilities do not automatically involve the Internet or World Wide Web. An intranet provides the means for an institution to transfer information within their walls, while an extranet offers that capability outside an institutional domain.
“A virtual private network [VPN] is where you subscribe to a service through a secure socket,” explains Fuji’s Sledd. If an institution uses a VPN, that service takes the responsibility of providing security, usually through some level of encryption for incoming and ougoing images and files.
“Instead of developing technologies in healthcare, we’ve moved to using technologies developed elsewhere,” notes John G. Faughnan, M.D., clinical applications design and manager of Clinchart.com at Abaton.com Inc. (Bloomington, Minn.), a division of McKesson/HBOC Inc. (San Francisco). “We leverage the work that has been done as a part of the Internet and e-commerce. That has allowed us to do more.”
Faughnan says Clinchart.com uses the same types of encryption modalities employed by central banks for sending information off-site. The security issues faced within an institution also are a concern, making it imperative that healthcare institutions develop procedures to insure privacy and confidentiality of clinical information stored on their internal systems.
Most images sent over an Internet are encrypted. “I think it would be possible for a talented hacker to perhaps get images, but to match the demographic data with the image would be totally impossible,” concludes Gershater. “We’re comfortable with encryption.”
Development of standards. “Traditionally, bringing images and data together has been a vendor specific exercise,” explains Coombs. For example, an institution might have imaging devices and information systems from several different companies. “It’s been up to the institution to pull together to blend that information and images together … an expensive and difficult proposition.”
Coombs explains that ADAC has been a strong advocate for the development of aggressive standards to address those issues. “The onus for this integration falls on us and other vendors, rather than on the individual healthcare institution,” he concludes.
The future, the CPR and radiology
Physician acceptance and demand for CPR systems has been growing exponentially.
“We can provide almost immediate access to radiology data that physicians didn’t have in the past,” says GEMS’ Wanchoo. “If institutions are rolling out computerized patient records on a large scale to tie into physician offices, they may want to invest in a virtual private network as opposed to going through the Internet. [VPNs] have better bandwidth capabilities and better security capabilities.” The bandwidth issue becomes important when transferring large image files quickly. Medical imaging files require a huge amount of space and time to transmit.
Coombs believes that telemedicine will become an increasingly important part of patient care, especially for rural and remote parts of the world. Institutions must develop the capability of distributing various types of image formats to be prepared for these advances.
For example, an orthopedist who looks at an X-ray image also may want to see the patient walk. “If we can put in full motion video and sound, we can absolutely improve the quality of care by allowing for more collaborative care.” Coombs says.
Consultation by experts in the field will be enhanced when audio and video capabilities are added to radiologic imaging studies.Considering the shifts in the way healthcare is managed, flexibility of the system also becomes paramount.
“We can have individuals registered in our system before they become patients and have medical records,” says Michael Bruenn, Cerner’s managing director for radiology. “Most traditional systems require that the person be a patient in the health system before anything happens. It is fairly unique to have a system that is person centered as opposed to patient centered. This becomes important as an individual’s care extends to home.”
For example, a diabetic patient could measure his or her blood glucose level, and then plug that information into the record to be reviewed by the physician. The bottom line of computerized patient records centers around improving the speed and efficiency and cost effectiveness of managing complex data to enhance the provision of healthcare. With the advent of Web technology, these activities are clearly being facilitated. 
