What are the areas of change you see for the market?
As a company, Heartlab now has approximately 275 customers, which are principally in North America, although we are rapidly expanding into Asia and Europe. I bring this up because we have been hearing similar needs voiced by many of our customers. They want to take the information collected in the core diagnostic or interventional areas of the hospital, and make it available wherever physicians and technical staff happen to be. The trend now is to require delivery of high-quality documentation and high-quality images outside of the core diagnostic area.

What has been your response?
Anticipating this evolution of customer requirements, well over three years ago, Heartlab began developing thin client architecture for our results management component of Encompass. "Results management" refers to the non-image data related to the procedure. The results could be associated with a cath procedure or a non-invasive procedure such as an echo exam. "Thin client" architecture means we built the system as an entirely web-based application. Our results management module runs on web server technology. The module is accessed throughout the hospital's network on PCs using only a browser application. This allows us to really streamline the workflow, and provides unlimited points of contact with information in places where hospitals cannot fit or cost-effectively install a dedicated workstation. The software we'll be showcasing at the TCT meeting in September demonstrates how the same thin client architecture we brought to results management can be used to deliver high quality images across the enterprise.

Heartlab has developed a new technology which allows us to deliver the same quality of images and user interface functionality that we achieve with the dedicated workstation. The new technology only requires that the PC viewing station be equipped with Internet Explorer. We're able to deliver the same diagnostic image quality and the same performance; performance is very important to cardiologists. The technology offers the same tool set to our users through a web interface.

Web-based technology has been around for awhile. Why do you think the technology you're describing will cause a "sea change" in the market?
Web-based access to images is not new, but the technology has sorely lagged in providing performance and functionality. To date, web technology has offered a secondary method of disseminating information. The sea change for the market is coming from the shift to web-enabled technology as the primary means for accessing cardiology information.

The adoption of portal technology is one of the driving forces that will cause to be rapid and dramatic enough to register as a sea change in the industry. Portal technology is a web-based technology that can be used to organize and deliver all sorts of information and content to the end user. Within Heartlab's installed base, which includes many of the largest cardiology centers in North America, there is a push to implement portal technology to provide consolidated information access for physicians and their user base. The portals being built by our customers today will be the user interface through which our customers will access our information in the future. The whole notion of a diagnostic workstation will cease to be important over the next few years.

What will this mean to a cardiologist or the hospital's clinical staff?
Essentially, you will login to a PC that is running portal software deployed by your center. The portal software will be able to show you all sorts of information about a patient's condition: labs, pharmacy information, nursing notes, etc. It also will be seamlessly integrated with the imaging and results management capabilities of a vendor's web technology for cardiology information. The cardiovascular image study review capabilities and results management aspects of the system are provided by the vendor, but access to the data will be managed through the portal.

Today, only Heartlab is offering this approach to cardiology information management. But as in the past, we think the industry will follow our lead and a sea change will be seen in the market over the next few years.

How will this type of change affect buying decisions in the cath lab?
I think it's important for the readers to know that in the future, their IT groups and their chief information officer will play a more important role than they have ever played before. Hospitals are starting to view access to clinical information as enterprise-wide and strategic. This is a good thing for our clinical customers, because now they're being given access to resources and budgets that previously they did not have. There's going to be a shift from departmental-level solutions to an enterprise-wide solution, which is unlocking a lot of resources for our customers.

We're seeing higher-quality projects, better selection processes, better engineering and ultimately better integration of the enterprise as a result. Projects which in the past would have been small, isolated efforts, are becoming larger, multi-hospital efforts with a strong standardization of technology across the board. That is how things need to be addressed in order to put a solution in place that will give users the same access to information whether they are down in the coronary care unit, up on the floors, in the cath lab, or at home. This vision just can't be achieved with a department-level solution.

Besides making access to information easier for clinicians are there other benefits to integration with a hospital portal?
Heartlab has been able to create interfaces to all of the major healthcare information technology portal products that are available. Siemens, SMS, and Cerner products, for example, have all been quite adaptable to provide a plug-in capability to those portals. We've also plugged in to some home-grown portals, which have been developed entirely by hospital staff and their contractors. We've adopted standardized web technology to do this, and it solves a lot of problems. One center in particular has implemented a single physician sign-on to control access to information through the portal and to provide clinicians with a single, longitudinal view of a patient's care. Information access and authorization is managed by the portal, not by our application. It is a much more efficient model than trying to manage this at the individual department-level.

With the changing environment for information security, IT groups have deployed applications on their portals which are designed to manage information access and security. It's very unwise to have systems operating in parallel to solve the same problem multiple ways. With our new architecture, we're able to piggyback on the portal identification system. If you're Dr. Smith and you're able to see patient Jones, the portal controls that access, not our software.

What challenges does a portal integration project present?
Probably the biggest challenge our customers face is resources. Hospitals in general have to operate on very thin IT budgets. As a result, it's taken a while for the cardiovascular department to become a priority for the IT group. They have been focusing their limited resources on core infrastructure for a long time. First, building an integrated system like this requires being able to focus department and IT resources over a substantial period of time. It takes a year or more to really implement one of these systems correctly. Once that is addressed, the challenge becomes more operational. There are project management and organizational challenges that require a strong working group with a deep knowledge base to solve real-world networking, integration and implementation problems.

The biggest technical challenges in any project are the interfaces. We do projects that have up to a dozen different inbound and outbound messaging interfaces between the different systems. To be done properly, it requires documentation, validation, and on-going support. Interfaces are inherently challenging. Every time something changes with a system in the environment, the interface may be affected. Heartlab is developing tools that our field staff can use to create and configure interfaces, to treat interfaces in a more standardized way. That's really important, because what we've found is that the nature of the information and the format of the information passed between systems changes frequently. Documenting, deploying and maintaining these interfaces, is probably the number-one technical challenge.

What does all this mean to the notion of the Electronic Patient Record?
In this paradigm, the universal patient record can really be seen as a collection of components, which are managed by a single portal or a single environment. The notion of one patient, one record is interesting in the sense that you can develop summary charted information across modalities for a patient's entire experience using some of the electronic medical record systems currently available. However, the detailed clinical information, which is really needed to make interventional or medical decisions, often resides in another system. A complete longitudinal record of a patient's lifetime medical history is not a single file somewhere. The information is really stored in multiple files and it requires a system of systems to access everything.

The goal is to minimize the number of systems required to manage the full set of information and to integrate them for more efficient access. Hospitals might want one system to deal with all of their cardiovascular information, for example, because that's an important business unit. They might have another system that deals with oncology, another with traditional radiology, etc. But they want to reduce the number of systems they have to maintain and interface in order to achieve a coherent patient record. The portal is the one system that brings all the information together.

Can you offer any practical advice to readers who are moving in this direction already?
I would suggest that a clinical customer carefully look at the clinical functionality of the products they are evaluating: the image quality, the tool sets, etc. Team-up with the IT department and let them evaluate the systems' architecture, design, implementation and integration. A strong IT group can be an enormous asset here. It most cases they're able to do things that a clinical department doesn't have a lot of experience with, like planning interfaces and utilizing enterprise hardware, such as storage area networks that they may already own. Projects planned at the clinical level without IT involvement often overlook important elements such as redundancy, data archiving, hot site preparedness, and critical infrastructure needs. The best projects are a collaborative effort between IT and the clinical departments. Believe it or not, some of the very best projects are led by IT, with a strong clinical voice to make sure that the clinical needs are met. The IT group is often in a better position to lead the charge that makes sure the needed resources are there.

There really is a sea change underway here, and we're seeing an enormous shift away from departmental-level purchasing, installation and management of systems to an enterprise-wide focus. It's happening because our customers have realized that cardiovascular disease is an extremely important positive margin activity and they need to give it the attention that it deserves. Budgeting for enterprise projects is opening up because of increased involvement from the IT departments that carry larger enterprise-wide charters. That's a huge change. More importantly, the technology that makes the shift possible is finally available.