It is clear that cardiologists, like other physicians, are continually being challenged to do more. In particular, institutions expect them to become ever more productive while constantly improving the quality of patient care. Only enhanced efficiency permits cardiologists to meet these expectations; without it, increased case loads and better patient care are mutually exclusive.

Enhanced efficiency in the provision of health care has historically relied on new technologies that recapture wasted resources (with the physician’s time being among the most valuable resources of any organization that provides health care). The digital management of patient images and associated information has demonstrated that the physicians who use medical images can, in fact, become more productive without working additional hours or spending less time per patient. This is accomplished by decreasing the time spent locating needed information, recapturing lost data, and traveling to central image-review locations.

Picture archiving and communications systems (PACS) were initially adopted by radiology departments to help them display, distribute, and store diagnostic images. Agfa, through its IMPAX line, has been a major part of the movement toward PACS in radiology. Now, however, IMPAX for Cardiology is also bringing the opportunity to improve efficiency through PACS implementation to the entire cardiology department. The advantages to be gained thereby are clear, after more than a year of experience, to the cardiologists and executives of Brigham and Women’s Hospital, Boston, a teaching affiliate of Harvard University.


Jeffrey Popma, MD, is director of interventional cardiology. He says, of the three cardiac catheterization laboratories of the Brigham and Women’s Hospital, “A year ago, we had all cine films. We were doing 1,800 interventions a year, in addition to 5,000 diagnostic catheterizations, all on cine film.” This high procedural volume was capable of overburdening the digital review stations used to view the cine films; Popma describes the review stations as not quite optimal. He adds, “Sometimes, in tough cases, we would actually have to develop the cine film, go review it with the patient still on the table, and then come back to the laboratory for the next step of our procedure. Obviously, there were huge time delays associated with that.”

Delays of that type are among the best targets of efficiency-boosting initiatives because they can be eliminated so readily when appropriate information technologies are employed. Brigham and Women’s Hospital COO Matt Van Vranken says, “When our cardiologists came to us to look for an image-management solution, we had to look within the confines of our existing infrastructure. One option was to create an island of information within cardiology that would require us to create transmissions from the cardiology system to our radiology PACS.” That method, however, would not have permitted the institution to make the best possible use of its existing technology base; it might also have called for the cumbersome and expensive use of additional desktop monitors Vranken reports, “Our objective was to find a ubiquitous system that would manage both radiology and cardiology images across the enterprise. The Agfa solution was, I think, the only one that was available to us that would allow us to have people call up both radiology images and cardiology images at their desktops in their offices, in their examining rooms, off-site from the operating room, and, specifically, in the operating room itself.” Van Vranken describes IMPAX for Cardiology as a component of a larger strategy being pursued by the institution. “It is really the building block of a system that we believe is going to make Brigham and Women’s Hospital unique in its ability to manage patients, to deal with difficult interspecialty issues, and to leverage the technology that exists in the marketplace today,” he says.

The same ability to function as a linking mechanism was attractive to Ramin Khorasani, MD, director, information management division, department of radiology. He says, “One of the key pieces of functionality that we were looking for when we were pursuing a cardiac catheterization solution was the ability to respond to two major issues in the enterprise at Brigham and Women’s Hospital. The first of these was integration of the new system into other departments that already had PACS in place. The second was the need to view those images coming from the cardiac catheterization laboratory throughout the enterprise.” He notes that there were other programs available to Brigham and Women’s Hospital that might have functioned adequately within the cardiac catheterization laboratory, if its needs had been considered in isolation from those of the rest of the institution. Fortunately, those concerned were farsighted enough to realize that cardiac catheterization could not be thought of as a stand-alone service. Khorasani continues, “We felt that the IMPAX solution was able to provide us with the most integrated functionality and the most open, standards-based tools for viewing data outside the cardiac catheterization laboratory.”


The system chosen by Brigham and Women’s Hospital has been well received by cardiologists. Lawrence Cohn, MD, chief of cardiac surgery, says, “The Agfa technology is just a quantum leap in improvement in the ability to review films and get the most current information on our patients.” This type of favorable reaction is not limited to the physicians who perform cardiac catheterization, as Peter Libby, MD, chief of cardiovascular medicine, states. He says, “I am a noninvasive cardiologist, so I am a consumer where the angiogram and the digital system are concerned. For me, the access to information, almost in real time, is a real boon.” He describes IMPAX for Cardiology as having revolutionized the way in which noninvasive cardiologists can exchange information with the staff in the catheterization laboratory. “I can just pull the information up on my monitor and look at it. For patient care, as well as in terms of the efficiency of conducting our daily business, this has been a real revolution for us,” he says.

Andrew Selwyn, MD, is director of the cardiac catheterization laboratory. He says, “By changing from recording procedures on to using a digital network, we can distribute that information to many experts. These include cardiac surgeons, our colleagues in the rest of the hospital, and other specialists who can participate in the care of the patient and who can help us make decisions. We can see the information immediately, and we can quantify it better, so I think that moving to a digital network immediately brings in a lot more brain power.” He adds that this additional expertise enhances the ability of physicians to focus on the care of each patient as he or she comes through the cardiology service.

In addition to enhancing patient care, IMPAX for Cardiology is able to improve physician satisfaction and productivity. Popma recalls that waiting for slow elevators to take him to review studies was once “the most frustrating part of the day.” He adds, “Physicians do not really have to do that anymore. All they have to do is walk over to the workstation, pull up the image sets, and review them immediately.” That workstation, of course, can be located nearly anywhere: in an office suite, cardiology department, cardiac catheterization laboratory, or operating room. The convenience that this flexibility affords adds further time savings to the improved efficiency made possible by digital imaging and review.

While the advantages that cardiologists attribute to the system are significant, James Kirshenbaum , MD, co-director of clinical cardiology, emphasizes that patients are the ultimate beneficiaries. He says, “There are three areas in which having an on-site system such IMPAX for Cardiology is particularly useful in the ambulatory setting. First, I often see patients who have previously had a catheterization or an intervention that I have done, or that one of my colleagues has done. In these cases, I can immediately review the films, see exactly what was done, and get a better sense of what I would recommend as the patient’s future course of therapy.” The second ability that Kirschenbaum lists as especially helpful is important because of the increasing use of digital catheterization laboratories; patients now bring him CD copies of angiograms done elsewhere. “The advantages of having a system such as IMPAX for Cardiology? are that I can instantaneously play back that CD, review with the patient exactly what the prior angiogram showed, and, by so doing, provide a better consultation,” he says. “Third,” Kirschenbaum continues, “so often, the quality of the images is the key to the ability to decide exactly how you are going to manage the patient. There are several controls that allow us to adjust the contrast, brightness, and size of the image, and having those capabilities improves my ability to decide exactly how to advise the patient.”


The efficiency improvements attributable to IMPAX for Cardiology naturally lead to cost reductions for the institution. Popma says, “The cost savings are both direct and indirect. The direct savings are related to the fact that it is less expensive to do digital procedures than it is to do filmed procedures. I think what we do not always understand the indirect savings, such as how much of my time (and my colleagues’ time) was spent just waiting on the elevator, coming down to review something. All of those things add up throughout the day, but if my colleagues and I are more efficient in our work, then that is a real cost savings for the system itself, because we can spend our time doing other things.”

Popma states that one of the challenges of having access to a system like IMPAX for Cardiology is that, once the PACS has been implemented, its users will begin to think of its capabilities in a different light. “Now that we have nine workstations, we are expanding that number to 12. We want to hook up our conference room so that we can display, using a liquid crystal display projector, what is going on within the catheterization suite,” he says. Popma continues, “We want to extend access to this system and this network to our remote physicians, who may have their offices a mile or two, or 20 miles, from here. That access to the raw image format is something that we look forward to very much, whether we do it by satellite, by fiber-optic cable, or by phone line. We are now talking about a number of different mechanisms whereby we can transmit the images to our referring physicians.”

Popma describes the cardiac catheterization environment as highly competitive, and lists this fact as one of several reasons that made Agfa’s products particularly interesting to Brigham and Women’s Hospital. Among these factors, he says, “the most noteworthy is that there are tremendous image-processing tools available within the Agfa infrastructure backbone: magnification, pixel shifting, landmarking, and measurement tools (including a quantitative analysis package and a left ventricular analysis package). The Agfa system allows us to use a number of different enhancement tools for image review.” He adds, “The second feature distinguishing Agfa from the others is that we are now allowed to integrate other images that are available from the hospital information system.”

Khorasani comments that this kind of connectivity was of great importance to those who chose the cardiology PACS . “We felt that IMPAX provided the best solution for us, both in terms of integration into the information systems environment of the hospital and in giving us a very robust, multimodality viewing tool in the workstations,” he says.

Popma explains that it is possible to review chest radiographs, CT scans, ultrasound studies, and MRI scans simultaneously with the catheterization laboratory images, all on the same image review station. He says, “The integration of the hospital information system’s image sets with our image set has been easy for us to do.” He reports that the next step in implementation will be to incorporate the intravascular ultrasound image obtained in the catheterization laboratory in the same way that cardiac catheterization images have become part of the system. “We can do that with Agfa,” he says.

Popma says, “The most important points favoring Agfa are the quick response that it has to our problems as clinicians” and the team approach that the company takes. He adds, “We identified our ideal review station, based on the shortcomings of other review stations. In very short order, the Agfa engineers developed the review station tools that we needed. That kind of innovation and? creativity has continued.” He concludes, “We want this system to be fluid, with new versions and enhancements. On the Agfa side, there are very creative programmers, and that gives us the strength of support that we have for Agfa today.”

Kris Kyes is technical editor of Decisions in Axis Imaging News.