Case Study in EMR

Special section sponsored by Medflow

Ophthalmic diagnostic and imaging equipment continue to evolve as the need to acquire more sophisticated and precise data grows. Diagnostic imaging devices are being developed with new algorithms to better evaluate normal and pathologic disease states. This data has a significant impact on treatment decisions, but the ability to process, store and retrieve this information has become increasingly burdensome. While many companies have made incredible leaps in the ability to obtain diagnostic images and interpret them, the storage and presentation of these vital images are equally important.

Major challenges exist in managing images and associating them with the corresponding patient and visit. Paramount to this process is a need for direct communication from one ophthalmic device to another to compile data from all aspects of a patient visit. It is also important to have an access point where all of the information can flow, and to organize and tailor this information to associate with each individual patient. Without the ability to handle, store, print and transmit data, the information collected is not being utilized to the fullest.

One of the major problems faced by most ophthalmology practices is that clinical images and information are confined in isolated databases associated with each instrument. Compounding the problem is the fact that these databases are usually not backed up in a consistent and fail-safe manner nor are they integrated with the practice's (or hospital's) information system.

Case Report

Lahey Clinic is a 550 physician multispecialty group practice with offices throughout eastern Massachusetts. The Department of Ophthalmology, with 15 ophthalmologists and 7 optometrists, has three offices located in the outlying suburbs of Boston. More than 80,000 outpatient encounters are recorded annually. Similar to other practices, the department has increasingly become dependent upon imaging devices including 4 visual field machines, 4 OCT units, A and B scanners, 6 fundus and slit-lamp cameras, 3 IOL Masters, ORB scanners, topography units and a specular microscope.

The search for an eyecare-specific EMR and picture archiving communication system (PACS) system began in the summer of 2007. Lahey's search identified several vendors; then the search was narrowed to two possible solutions, one of which was Medflow, Incorporated. Medflow championed a standards-based image management system designed for interoperability under the Integrating the Healthcare Enterprise (IHE) and DICOM (Digital Imaging and Communications in Medicine) frameworks. Medflow followed the direction of the American Academy of Ophthalmology, a strong supporter of IHE and DICOM. In late April of 2008, Lahey made the decision to move forward with the implementation of the DICOM image management solution.

Preparation and Implementation

First, the IT Project Manager began by working with Lahey's Ophthalmology Department to compile a complete and accurate inventory list of all of the imaging instruments. The list of equipment was analyzed and a determination was made regarding which devices would be targeted to integrate with Medflow Imaging via DICOM.

It is important to realize that ophthalmic instrument vendors have only begun to develop DICOM integration functionality into their device software over the last year. This integration is an option that requires diagnostic instruments to operate on the most recent software.

In order to bring older instruments up to the required level, software and hardware upgrades may be necessary, as was the case at the Lahey Clinic. Lahey upgraded IOL Masters and OCT machines (Carl Zeiss Meditec), a Winstation system (OIS), and the ImageNet 2000/2000 Lite systems (Topcon Medical Systems, Inc.). While the expense to perform these upgrades is not insignificant, the benefits derived from achieving DICOM connectivity to the Medflow Management system greatly outweigh the cost.

Medflow's customized thumbnail viewer allows healthcare providers to access specific image types, based on specialty and disease-specific protocols.

Some of the benefits of archiving images in standards-based DICOM-3 are summarized below:

• The images are no longer confined to a specific system, and if the originating system is replaced, the images remain available.
• The images store meta-data containing patient demographics, MRN and other key information. If the originating system's database gets corrupted, which occasionally happens, the images are still identifiable.
• The images can be stored in an Enterprise Image Archive, making them accessible to authorized personnel via the hospitals' EMR.
• A Modality Work List (MWL), or list of orders for diagnostic exams, appears on the device directly, eliminating the need for Technician or Photographer to move to a separate Medflow Image Capture Station to select the order associated with the specific patient and exam. This saves time and thereby improves patient throughput.
• The expense and real-estate requirements of installing a separate Medflow Image Capture Station in the exam room, which are usually restricted in terms of space, are eliminated.
• The image quality obtained by direct DICOM storage is superior to that obtained by screen-capture methods used by non-DICOM storage techniques.

Once the DICOM upgrades were in process, Lahey scheduled an on-site visit with Medflow to perform a "go-live" preparation assessment. This visit occurred several weeks prior to the actual go-live target date to allow time for the resolution of any issues. During this visit, the Medflow Installation Engineer assessed each device and determined what the hardware and cabling requirements were in order to connect the non-DICOM devices to the Medflow Image Capture Stations. To ensure the equipment was ready for the go-live date, each device was temporarily connected and images were captured, processed and sent over the network to the Medflow DICOM Test Server. Images from all non-DICOM devices were converted to PDF and wrapped in a DICOM header for archiving in the Medflow DICOM Server. The DICOM devices also were configured during this visit and test images were stored by the Medflow Test DICOM Image Server to validate that DICOM parameters were configured properly.

Going Live

The Imaging go-live visit occurred several weeks after the pre-go-live visit. Medflow arrived with several Installation Engineers, their Lead DICOM Programming Developer and a Clinical Trainer. Lahey dedicated their Project Manager and a highly competent IS professional to the go-live task as well. There were three geographically separated clinics to bring live, and the task was to be accomplished in 4 days. The go-live team began at Lahey's North Shore Clinic in Peabody, and then moved on to the Burlington and Arlington clinics. While the devices were being put into production on the live system, training was completed for photographers, technicians and doctors.

Lessons Learned

Success can be measured in several ways. A project can be a technical success and at the same time a clinical failure. For a project to be a true success, it must be successful clinically, operationally and technically. While it is still early in the process, Jeffrey Marx, MD, chairman of the Department of Ophthalmology at Lahey, is secure in the knowledge that the highest standards of image management and storage are being met with the integration of the Medflow image management solution.