As more and more hospitals transition from paper medical records to digital medical records, there is a need for a new role within the cath lab service area to support this transition and the accompanying tasks. One might be tempted to call this person something like “database clerk” or “CV information clerk,” but giving this person a minimal role and title would be a mistake. There are sufficient responsibilities to warrant a major role and title. One possible title might be “CVIS coordinator.” In this article, we will discuss how a CVIS (cardiovascular information systems) coordinator can work alongside the cath lab manager/director, clinical educator and other clinicians to improve the quality of the cardiovascular medical service. CVIS coordinator responsibilities might include the following roles: • Vendor product development liaison • Data standards committee member • Outcomes database coordinator • Process database coordinator • Quality tool educator • Failure modes and effects analysis (FMEA) coordinator • Joint Commission team member • Health Insurance Portability and Accountability Act (HIPAA) team member • Dashboard creator • Care map facilitator • Patient transition care liaison • Hospital IT department liaison • Workflow and transactional analysis coordinator • Special communication analysis • QA/QI data capture and reporting coordinator • Infection control liaison • Data exception reporting coordinator • Physician structured reporting facilitator • Results reporting communication coordinator • Archived data management coordinator Vendor product development liaison As everyone knows, vendors exist as a “mixed resource.” Besides the obvious “lunch support” (albeit dwindling), vendors provide product education at the cost of subtle pressure to use their products. (Please see Dr. Morton Kern’s excellent editorial, “Working With Industry Representatives and Conflicts of Interest in the Cath Lab,” in the November 2009 issue of CLD). However, there is another type of vendor representative (besides sales representative) that should be supported as a vendor representative in your lab — the product development engineer, who is necessary to help improve your clinical products. A CVIS coordinator could work as a vendor product development liaison to make sure product development engineers have appropriate access to clinicians and the clinical environment, and that the engineers present themselves in a professional manner, respectful of the patient and the environment. These engineers often can provide cath labs with some type of workflow analysis document that can be used to help better understand and/or improve processes. Data standards committee member Several external organizations are in the process of defining structured data elements and data transaction protocols. You may be familiar with the HL7 data standard, but you may not know that there are many versions, a seeming paradox that makes the word “standard” a misnomer. However, the road to “standard-hood” is full of impediments. In order for a proposed data standard to become an actual data standard, several things must happen: • A need must exist (in this case, to improve quality reporting, improve prospective and retrospective clinical analysis, reduce redundant data entry, improve data mapping, facilitate multi-vendor solutions, support prescriptive medical processes, improve inter and intra communication, etc.). • A group or organization must provide the idea and present a “straw man” concept. • The “straw man” concept must mature into a workable document via discourse from internal and external stakeholders [this often requires a benefactor – consider the American College of Cardiology’s (ACC) support of the IHE (Integrating the Healthcare Enterprise) standard]. • Early stakeholders must resolve outstanding issues and generally agree upon the “ingredients” of the data standard. • Vendors (or a subset of prominent vendors) must generally support the standard (done in relation to the perceived benefit to the vendor and the perceived demand of the vendor’s customers). • As a side issue, vendors must also provide customers with a solution for legacy products and data, such as providing a dedicated data portal or some type of translation engine. • The customer base must support the standard and ask for products that comply with the standards. [Herein lies the greatest problem — the group that benefits most and that has the greatest leverage to affect this initiative (you, the clinician) comes into the picture last]. A CVIS coordinator can understand, support, help define and push for these valuable standards. Outcomes database coordinator One potential improvement resulting from standardized data would be in the capture of outcomes data. Imagine a patient’s H&P and procedure reports flowing seamlessly to the ACC-National Cardiovascular Data Registry (NCDR) outcomes database. Say, for instance, the patient’s coronary anatomy and historical interventions are documented in the cardiovascular information system and/or cath computer, and this information instantly and automatically flows to the patient’s coronary tree, the outcomes database, the procedure report and the physician’s report. The CVIS coordinator would support the automated capture and documentation of these data elements. S/he would also help improve this data capture process through an iterative analysis of this and future data flows. Such efforts would result in quicker data/report turnarounds, less redundant data entries, and a quicker communication feedback loop eventually resulting in improved clinical quality. (Has anyone ever sent in data to the ACC-NCDR or other clinical outcomes database which was so late that the returning reports were no longer relevant? I know I have.) Process database coordinator People ‘in the trenches’ are the best ones to perform established processes, but over time, they tend to lose the ability to see gaps in or ways to improve these processes. Over time, processes can become obsolete and thus no longer relevant. A CVIS coordinator can formally define existing processes and step back to see the larger picture, while still working with those in the trenches to brainstorm process improvements. Quality tool educator Just as people lose the ability to look outside the box and improve, hospitals as a whole can also lose this ability. Hospitals often look at industry to see what businesses and/or manufacturers use to improve products and services. You may be familiar with W. Edwards Deming and his positive impact upon the Japanese manufacturing processes (deming.org). Indeed, various sectors of industry have provided the medical field with many tools to help jumpstart our improvement efforts. A CVIS coordinator can help introduce these tools and communicate their proper use in various projects intended to improve cath lab services. FMEA coordinator One of the most important quality improvement tools within a hospital is the failure mode and effect analysis (FMEA) tool. Put simply, FMEA is a way of looking at a set of processes and considering what would happen if something went wrong. Consider the widely reported tragic deaths of three infants in a hospital when caregivers confused the adult heparin vial (10,000 units/mL vial) for the pediatric heparin vial (10 units/mL vial). Many of us have made medication delivery errors and/or possibly made errors without even our knowledge. Probably the greatest early benefit achieved from implementing an electronic medical record is the “computerized physician order entry” or “CPOE.” In a very real way, this tool is the result of a FMEA analysis. A CVIS coordinator can facilitate a team of clinicians to periodically review a diverse set of processes to illuminate possible problem areas. Probably the most important (and unfortunately, the most difficult) first step is to change the milieu of your service area to foster a climate where negative issues are uncovered and valued as potential tools used to bring about positive change. This is difficult since it goes against human nature. Our natural tendency is to cover up our mistakes. One of the simplest solutions providing possibly the greatest benefit per cost might be providing waterless hand-washing receptacles in certain high-traffic/high-acuity areas. Solutions need not be monumental — one facility simply provided more trash cans in a patient throughput area to help reduce clutter so people could concentrate better. Indeed, when you put a sharp object safely away from children, you are acting as a FMEA agent. Way to go! The potential harm of a situation is assessed by making a mental (or actual) measurement of the likelihood of harm and the associated severity of this harm. Ideally, this assessment is done independent of any perceived remedial cost and it is important to resist the temptation to “solve the problem” before it is adequately defined. The perceived cost does not have to be monetary. Consider the need to have a consolidated radiation exposure database for each and every patient. Few people would deny that we need such a database, but this requires a great amount of cooperation between hospitals, clinics, hospital departments, vendors, etc. and also requires the use of the patient’s social security number (or some surrogate unique number) to link all of these exposure events together. Joint Commission team member People sometimes tend to think of the Joint Commission representatives as the “quality cops,” serving as the patient’s advocate, often at odds with medical service providers. However, it seems the new tracer methodology approach of the Joint Commission has helped to dispel this impression, and instead places the Joint Commission representatives in their rightful place as both a patient advocate and a medical service provider advocate. The CVIS coordinator is needed to help take a proactive stance to ensure Joint Commission requirements are met (facilitated by clinical computer systems) and use data-driven metrics (captured from clinical computer systems) to measure this improvement. These include the following: • Improve the accuracy of patient identification for procedures, medications, blood transfusions, etc., and make use of information systems to facilitate this identification. • Make sure the “do not use” list of abbreviations is communicated and followed, and make use of information systems to facilitate this. • Make sure the universal protocols are performed and facilitated by various information systems (such as the cath computer). • Improve the communication among procedural caregivers and transitional caregivers. • Etc.2-4 HIPAA team member As we all know, the HIPAA regulations are imposed to protect the patient’s privacy while hopefully providing the least impediment to proper clinical information flow. Of course, there is a healthy balance within the continuum of “too much security/too little access” all the way to “too little security/too much access.” The CVIS coordinator is ideally suited to help navigate this dilemma, since s/he helps facilitate the proper exchange of clinical information via phone, email, fax, mobile phone, laptop PC, tablet PC, PDA, etc. Dashboard creator Every active organization has a few metrics which, at a glance, answer the question, “How are we doing?” These are typically ratios, since this information needs to be indexed to a common reference. Metrics might include infections per 1,000 cases, complications per 1,000 cases, cost per diagnostic case type, cost per interventional case type, overtime hours as percentage of regular hours, etc. These metrics are less effective (as an incentive) if only seen by a manager. Therefore, it is helpful if the CVIS coordinator can create a “dashboard” where these metrics are compared to a plan and displayed along with “red,” “yellow” or “green” indicators, whereby everyone is incentivised to maintain the parameters within the “green” limits.5 Care map facilitator With the emergence of new and improved best practice clinical guidelines, there is a need to create and facilitate “care maps,” which guide caregivers to follow established practices and procedures supported by evidenced-based medicine. A CVIS coordinator can work alongside the physicians and cardiovascular nursing specialists to support care maps through IT solutions such as special prompts (for example, beta blocker suggested, decision trees (if serum potassium 6 Patient transition care liaison Recent studies have determined that many hospital mistakes occur during transitional care. Indeed, this is one of the rationales for the universal bed concept and the Joint Commission requirement to provide improved information along the continuum of care. The CVIS coordinator can serve as a liaison to upstream and downstream departments. S/he can go to the other department meetings in an attempt to gain a deeper understanding of their day-to-day workflows, and to learn about their needs and frustrations. This is not only to develop mutual empathy, but also to help define and create information communication tools (such as transitional care reports) tailored to the needs of these “connected” departments.7 Hospital IT department liaison The hospital IT department typically has two competing goals. That is, they are trying to provide generic IT solutions in an effort to provide adequate utility (to the hospital’s clinical and administrative departments) with the least chance of obsolescence, while at the same time provide service-specific functionality. Typically, within the IT department, the people with the technical expertise do not have the needed clinical expertise, and vice versa. The CVIS coordinator can step in and examine this “big picture, little picture” situation, and serve as an advocate to both the IT director and the clinical department. As if doctors and hospitals didn’t have enough reasons to move from paper to electronic medical records, the current “meaningful use” standards (and accompanying payments) should serve as yet another incentive.8-10 Workflow and transactional analysis coordinator The cath lab as an entity can be broken into many component parts in many different ways (information flow, material flow, physical space, stakeholder analysis, etc.). Indeed, it exists as a very complex set of subsystems (procedure rooms — electrophysiology, cath, peripheral vascular, etc.) linked to other subsystems (billing, clinical lab, pre-procedure area, pharmacy, etc.), which is part of a larger system (hospital). The larger system, the hospital, is in turn linked to still other systems (affiliate hospital, physician group offices, central scheduling). To make sense of these systems in order to help improve suboptimal processes and/or procedures, creating pictorial depictions of these entities can form a framework for discussions and facilitate understanding. The CVIS coordinator can help create these pictures and diagrams, along with “pre” and “post” time-related diagrams, which serve to illuminate improvements that follow remedial efforts. One measurement of a good workflow diagram is whether it is generally “reusable” over time. Special communication analysis Communication analysis is very similar to workflow and transactional analysis, but with special emphasis on communication in atypical circumstances. Normal communication needs are fairly easy to predict and accommodate through the use of simple, laminated phone listings. However, this is not always true for atypical circumstances. It’s often helpful to take a situation to an extreme to help define special communication needs. For instance, say an afternoon elective case is going late. No problem. You stay late or call in the call team. Now, suppose the patient begins having problems. You may need to communicate with pharmacy, clinical lab, respiratory care, central supply, anesthesia, surgery, perfusion, cardiac ultrasound, other call teams, house supervisor, the patient’s family, the performing physician’s partner, etc. This seems tedious, but doable. Now, suppose this happened on the weekend — would this be more difficult? Now suppose you need an intra-aortic balloon pump and all are in use. Say the surgeon on-call is already working on another case. Now imagine the hospital’s information system is down, so you cannot easily order medicines or lab work. There are always special circumstances that are seemingly impossible or at least improbable to predict. A CVIS coordinator can conduct brainstorming exercises and provide tools to help improve such situations, such as providing laminated “cheat sheet” phone lists, special “code white” procedures for when the hospital’s information system is down, scripted and non-scripted walk-through experiments, etc. By the way, these walk-through experiments can be a fun exercise and good team-building practice as well as a good way to alleviate anxiety of your staff. Examples of exercises might be “transition to surgery with ventilator patient,” “care of anaphylactic shock patient,” and “simple and/or complex code patients.” QA/QI data capture and reporting coordinator Most service areas report to the hospital’s quality committee. Typically, they report certain quality metrics to demonstrate the level of quality and also to hopefully demonstrate a positive feedback loop regarding some quality improvement initiative, a loop resulting in improved quality. In order to capture quality-related data, typically a certain number of randomized charts are examined by peers to determine whether certain “good” things were done and documented, possibly done and not documented, or not done. This is often a tedious task, which typically does not provide an adequate sample size or enough objectivity to be representative. A CVIS coordinator can work with the hospital’s IT department and/or IT vendors to create structured data that automatically yields quality metrics. They can query the data to provide not only a sample report, but a report showing individual staff members along with the actual number and percentage number of “good” things documented per opportunity. Table 1 represents quality metrics partially derived from the American College of Cardiology/Society for Cardiac Angiography & Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards document.11 Infection control liaison Typically, the infection control department works with the managers and directors of procedural areas to help measure and reduce infections. However, as we know, often the source of the infection is difficult to determine. A CVIS coordinator could facilitate the investigation by providing several types of information related to outlier situations or events. Perhaps your lab is using a different type of closure device, different prophylactic antibiotic regimen, different antiseptic, different lot number of heparin, a different catheter re-processor, etc. A CVIS coordinator could also facilitate a focused study in a situation where infections seem to be isolated to a certain lab, physician, etc.12 Data exception reporting coordinator The computer industry has a saying, “garbage in/garbage out,” meaning that in order to realize the true benefits provided by information, your source data must be valid. However, at times, the entries that make up the source data are not valid. Performing exception reports on all statistics involving human entry of data is a good idea, since it is the most likely source of error. Your data may look accurate, but “you don’t know what you don’t know.” Let’s look at an example. When a data entry opportunity presents, the operator should provide the data entry and this data entry should be accurate. Say, for instance, one of your physicians is complaining that he/she is never able to start his/her cases on time. You suspect that certain physicians are consistently late. You decide to do a study of physician tardiness compared to physician tardiness opportunities. Your data comes back and you plot your data. Now (in this case), you are surprised to find the information is different from what you might expect. Here, your CVIS coordinator could provide you with an “exception report” showing that “Bill” and “Susan” consistently forget to enter the beginning case time, which defines when a certain physician starts. You can now use this exception report to show Bill, Susan and perhaps others how they might improve and then track their improvement over time. Also, the CVIS coordinator might be able to determine the correct start times, correct the data and produce the corrected report. Physician structured reporting facilitator If your lab is like most labs, your physicians like performing cath procedures, but dislike the processes involved in creating the physician’s report. There are the logistical headaches (and expense) involved with the typical dictation, transcription, signing and routing processes. In addition, hospitals and referring physicians want this report as soon as possible. The CVIS coordinator can work with the IT department and CVIS vendors to both improve the quality of this report and reduce the effort required of the physician to create it. For instance, substantive procedure information could exist as structured data elements that flow seamlessly to the report, complete with annotated angiographic and/or pictorial images. The physician could then be able to select from a set of standard summary report sections where s/he needs only to provide a few edits and then sign and route the report electronically. Results reporting communication coordinator There are many potential issues related to the eventual communication of the physician’s report. These issues can exist whether the report is dictated and transcribed, or automated in some way. However, when the report is automated, issues can often be easily rectified in some way. Consider the following scenario: a physician created and signed off on an electronic report, but then, s/he decides to change some of the measurements within the report. How does this affect the report already signed and delivered? The CVIS coordinator could work with the CVIS vendor to provide system and human processes to mitigate this issue. For instance, when the physician attempts to reopen the study, the reporting system software could first create an audit log and only permit report access if the physician has the proper privileges. After s/he corrects the data, the reporting system software might show the old and corrected entries as an edited value, complete with the physician’s initials, time and date of change, etc. Then, the software may “ask” the physician whether the change is significant enough to warrant the re-distribution of a corrected report, complete with some type of alert. Archived data management coordinator With the advent of high-resolution digital imaging displays and a greater number of complementary imaging modalities, there is a greater need for image archive media and management of the studies within this media. In preparing for a procedure, most clinicians want access to recent same-type studies and complementary studies (images and/or reports). The CVIS coordinator works with the various imaging modality vendors to provide a framework whereby studies transition from “ready to view,” to short-term storage, to long-term storage in a “first in/first out” (FIFO) method. Also, the CVIS coordinator could provide a CVIS system whereby the software “recognizes” any previous patients and automatically pre-fetches these patient’s studies should they be needed. Also, over time, the CVIS coordinator may work with the cath lab medical director, manager and possibly various vendors to designate certain large amounts of data (images, waveforms, etc.) from old studies that might be purged to allow room for additional new studies. In addition, the CVIS coordinator might flag a set of representative and/or interesting cases to “lock” them against purging so they can be used for clinical education. There are now both “push” and “pull” forces leading us toward greater use of informatics in the healthcare environment. We in the cath lab can certainly step into this realm using clumsy trial and error methods. Yet we will be far better served by using a proactive approach and adding a new professional role, that of CVIS coordinator, to the cath lab team, and giving this position adequate power and support. About the author. Jim Wade was previously the cath lab director for The Indiana Heart Hospital and now works as a clinical systems engineer at Siemens Healthcare. Jim also has worked as a clinical consultant for Prucka Engineering, Inc., where he helped define requirements for the Prucka EP and hemodynamic system. Jim can be reached at email@example.com References 1. Wikimedia Commons. File:FMEA.png. http://commons.wikimedia.org/wiki/File:FMEA.png. Accessed Feb. 9, 2010. 2. The Joint Commission. Improving America’s Hospitals: The Joint Commission's Annual Report on Quality and Safety. http:// www.jointcommissionreport.org/introduction/introduction.aspx. Accessed Feb. 9, 2010. 3. The Joint Commission. 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