Efficient Workflow, Care, and Resource Management Using McKesson Cardiology at St. Patrick Hospital

Cardiac manager Carey Holmquist can be contacted at Carey.Holmquist@providence.org.

CIS analyst Mike Luedtke can be contacted at Michael.Luedtke@providence.org.

Tell us about the cath lab at St. Patrick Hospital.

Carey Holmquist, Cardiac Manager: We have three labs. One is for electrophysiology (EP) procedures, and the other two are for diagnostic, intervention, structural heart, and peripheral procedures. One lab is an OR hybrid suite. To date, we have performed 78 transcatheter aortic valve replacements and 12 laser lead extractions. Annually, we complete approximately 1500 left heart caths, 600 interventions, 400 EP procedures, 250 implants, and 375 endovascular procedures. We are a busy, progressive lab, and are affiliated with the International Heart Institute. Staff encompasses cardiovascular technologists, radiologic technologists, registered nurses, health care and administrative assistants. There are 4 interventionalists and 2 electrophysiologists. We also work closely with cardiac and vascular surgeons, as well as echocardiographers, diagnostic cardiologists, and anesthesiologists.  

St. Patrick’s Hospital has been using McKesson Cardiology for a few years now. What was your situation prior to changing over?

Mike Luedtke, CIS Analyst: We had a huge need to replace our systems, because everything was outdated and separate, including our echo, cath, and registry submission databases. It was very difficult to manage. In order to minimize downtimes, we wanted a virtual server environment. We were actually the first system for McKesson, outside of the beta sites, to go live in a production environment with virtual servers. It has been a huge timesaver for me. Another big thing we wanted was the ability for the physicians to do their reporting via a web client, rather than having a dedicated workstation for reporting. Our physicians can now do their reporting anywhere, as long as they have a good internet connection, and 100% of our reporting for cath and echo is done via the web client. However, the most important thing for us was the ability to consolidate everything into a single database. Everything, including echo, cath, hemodynamics, the observation unit, and registry submission data, is now in one application. I am still busy, but it is much easier to take care of. 

You archived material from your old systems directly into McKesson Cardiology? 

Mike: We did. At the time, we weren’t doing any reporting from our Heartlab app; we were just using it for an image archive. We were able to import all of those studies, including everything from our Philips Xcelera echo system and the reports, into McKesson Cardiology.

How did physician and staff resource use change with the implementation of McKesson Cardiology?

Carey: The goal has been to be more effective and to provide service excellence. It has been positive. In the beginning, of course, there is always reluctance to change, but our focus was structured reporting. We wanted standardization that would tie into appropriate use criteria for cath as well as echo. St. Patrick Hospital has diagnostic cardiologists that perform procedures in the cath lab, as well as echocardiography. For these physicians, the ability to use a single application is fantastic, because they can review and reference the different modalities simultaneously. McKesson Cardiology allows you to document by procedure type. Each procedure type prompts the utilization of its own template, and staff documents the progression of the procedure by clicking on statements, value boxes, etc., thus creating a log. Once the procedure is completed, the physician reviews the report, creates a summary or study conclusion, and finalizes the exam. As the physician finalizes the exam, the structured report is automatically faxed to the referring physician. The auto-fax capability is amazing. The patient’s report is immediately at the fingertips of the referring physician.

Can you share more about how the procedure charting works?

Carey: Each lab has a McKesson workstation in the control room and a nurse charting station in the lab. In the control room, documentation is acquired through the monitoring role. This role can be filled by a technologist or an RN. The circulator role is held by an RN, who will also document throughout the procedure. When the patient arrives to the Observation Unit (OU) for prep prior to the procedure, the OU RN documents the prep pieces: informed consent, risk factors, vitals, H&P, lab values, height and weight, and so on. When the patient arrives to the lab, the monitor role captures the details of the procedure. This person drills down through the template, which is made up of sections. These sections include patient demographic information, procedure type, admission info, lab values, and procedure info such as type, description, data, hemodynamics, coronary anatomy, lesions, and percent of stenosis, as well as device usage. Each step of the procedure, including entry site, fluoroscopy time, amount and type of contrast, and medication, comes together into what is called the hemodynamic procedure report. A coronary tree diagram can also be added to show the exact location of the artery lesion. At the end of the procedure, the monitor role signs off on their final piece and the physician will proceed to finalize the report. 

The data from the hemodynamic procedure log simultaneously creates the bulk of the final diagnostic/interventional structured report. The physician will review, make any changes if necessary, create a summary/conclusion, and electronically sign the report. It is then complete. McKesson Cardiology enables us to capture real-time documentation of events, have a streamlined standardized workflow, and rapidly disseminate information.

How many adjustments did you have to make when setting up the various templates?

Carey: McKesson does have out-of-the-box templates, but we wanted to be extremely specific in order to meet guidelines, so we did customize the graphical user interface (GUI) — the template structure. But that wasn’t difficult. If you know what you want to accomplish, it can be customized to reflect your lab’s workflow and data guidelines. McKesson also provides continued support for any change or adjustment that may need to be applied.

Are you using all aspects of the system?

Carey: Unfortunately, we have not acquired the EP module. For inventory, we have Optiflex (Omnicell), interfaced with Epic, and it works nicely for us at this moment. Of course, everything comes down to dollars. But it’s not something that we haven’t considered. The EP physicians have created templates in Epic, because we didn’t own the EP module before we implemented Epic. It would be a change for them if we did acquire the EP module, although it would be beneficial because we participate in an ICD registry, and the advantages for data management would be tremendous. Any data fed into McKesson Cardiology doesn’t have to be manually extracted for registry reporting, although of course we do it for the ICD registry, because we don’t have the EP module.

Have you created any custom queries within McKesson Cardiology?

Carey: Yes. The reporting module is called Statistical Report Center. Reports have been created for volume statistics per procedure type, per physician, door-to-balloon time, diagnostic and PCI fluoro dose summary by physician, and the list goes on and on.  The queries for echo are associated around ICAEL (Intersocietal Commission for the Accreditation of Echo Laboratories). Our echo lab is accredited through the IAC (Intersocietal Accreditation Commission). We built our templates and reports around those guidelines and standards, so we can data mine for quality assurance. McKesson also has a training course where they will teach you the ins and outs of creating your own reports.

Can you tell us about the implementation of the McKesson Procedure Tracking Viewer?

Mike: We were actually the first hospital to have it hanging on the wall. It has been at least several months now. We upgraded to version 13.1 of McKesson Cardiology at the same time.

Carey: Both pre-procedure and recovery take place in the observation unit. The Procedure Tracking Viewer application (Figures 4-6) allows our OU nurses to view what stage of the procedure the patient is actually in, and when they can expect them to return to the unit. There is a blue bar that moves across the patient field as the patient progresses through the procedure. You can set parameters for patient progress; for example, it could be set for pre, intra procedure, and recovery. A quick glance at the blue bar will tell you or the observation unit the status of a particular patient.

Before, we relied on a page from the nurse intra procedure to alert us that it will be about 15 more minutes, and so on. Now we don’t need to initiate that communication. The nurses can look at the monitor. They can also drill down into that patient if they choose to, and look at the procedure log as the log is being created intra-procedure. They can actually see it in real time. This is effective in assisting with nurse-to-nurse hand off.  

There is a Procedure Tracking Viewer for patient families as well. How is that being used?

Carey: Yes, we have one monitor in the waiting room for patient families. Family members are given a card with a number associated with their loved one (patient tracking number), the primary RN’s name and the lab phone number, in case they have any questions or concerns. It is nice that they can just take a peek at the board to see their loved one’s current status.

What are the benefits you have seen with the upgrade and the Procedure Tracking Viewer?

Carey: The streamlined workflow. When we look at the Procedure Tracking Viewer, it is real-time, accurate information, not based on someone else’s estimation. It is also a procedure log in which you are able to drill down. It gives us not only visual management, but a simpler and faster method to communicate patient status.

Mike: The dual monitor capabilities for the web client that came with the upgrade have also been big. Prior to the upgrade, physicians could only see the images within the reporting GUI on the web client, but now they can see the full-size images on one screen, plus do their measurements or any corrections, and have the report on the other screen. They are very happy with this visual upgrade. Costs were minimal, since half of our physicians had two screens already, so we just added an extra monitor wherever it was required.

Carey: In addition to the physician, the dual monitor capability has been huge for the sonographer/end user as well. Before, with a single screen, they would have to click through thumbnails, bring images up, and refocus, but now they can keep the GUI and report on one monitor, and then thumbnail through accordingly on the other.  Their workflow has been expedited; it is much quicker. 

What have you heard from your physicians and staff who are working with this technology?

Carey: From the very beginning, staff was willing. They had been hoping for the changes we implemented. When we were planning our go-live, staff learned everything in about 2 weeks. As end users, if you are not computer savvy, learning a new system can be intimidating, but they all picked it up beautifully. Our staff is extremely happy with the results and with how the process works. The physicians are glad that they can complete and finalize a structured report in the control room, if they so choose, and have it complete and off their plate. 

So physicians don’t always complete the report right at the end of the procedure?

Carey:  That is the goal of our department in order to provide service excellence, although the physicians are able to finalize their exam via the web client. Each cardiologist has access to McKesson in their office.  

Mike: Previously in the cath lab, as I mentioned, we used Heartlab as an image archive and the physicians were using dictation. They were seeing a big delay in their reports, and in referring physicians getting their reports. After moving to McKesson, the physicians took it upon themselves to do the reporting before they leave the cath lab. Once the report is sent and charges are dropped, billing is done at the same time, so a batch can go through the charge manager.  Usually by the end of the day or at the very least, every couple of days, the billing is done as well, so we are seeing huge advantages all around. Procedure charges are in place as soon as the tech sends them via the charge manager, usually by the end of the day, while our prior systems relied on dictation, transcription, and coders, taking up to a week.

Is there a time savings with dictation versus structured reporting?

Mike: I think it takes the same amount of time for the physician, but now the report is done immediately after the procedure. There is no transcriptionist involved. Plus, the referring doctor gets a fax as soon as the physician signs the report. It is the same with echo.

How would you describe your experience with McKesson?

Mike: I’d say it’s fabulous. From a support level, they are right on. I have never had to leave a message; someone always answers the phone. They put somebody on the problem and track it right down to the finish, to make sure we are satisfied with any issue we have. It is refreshing, because with many vendors, it could be days or weeks before simple issues are resolved.

Carey: The word I was going to use was fantastic, so Mike and I are on the same page. An example of when I was really impressed with McKesson was one particular time when I called customer support. The person I was speaking with, Sylvia, wasn’t the one that could help me with my problem. She tried to transfer me, but that person was on the line already with someone else. It wasn’t a dire situation, so I was patient and said, that’s okay, I’ll call back later. The next day, Sylvia called me, and asked whether support had contacted me. They had. But I thought it was amazing that she didn’t let it go, thinking it wasn’t her problem any longer. She called back and made sure that I had been taken care of. I thought that was fantastic. 

Is there anything else you’d like to share about your experience?

Carey: All of our imaging and structured reporting can be found in McKesson. We also utilize McKesson for vascular ultrasound. Another cool thing we customized was for our cardiac anesthesiologists that perform intra-op transesophageal echocardiogram (TEE). They needed to comment on pre and post bypass, so we incorporated summary boxes into our GUI. If an intra-operative TEE is performed, the cardiac anesthesiologists can now use the same TEE template the cardiologists utilize. If the pre and post bypass summary boxes are not utilized, it doesn’t show as a section on the TEE report. We can utilize one template for two types of procedure reports. Finally, I also want to highlight McKesson’s RT monitor keypad, which is an emergency hemo box that you can utilize in order to record hemodynamics. 

Mike: With that, you are never completely down. It can be plugged in to allow you to still do all of your monitoring. It is a backup to the backup system. If the monitor station is down, you can still get the waveforms up and do the monitoring that you need to do in the control room.

Carey: You use the keypad only in an emergency, when all other options to open or continue working on McKesson Cardiology hemo have failed — for example, if the system is not responding despite troubleshooting actions. We can launch an emergency procedure; however, if by doing so it doesn’t resolve the issue, then you go to the RT monitor keypad, which operates independently.

You have had to use it?

Carey: Yes, amazingly. We had a power outage but we could still capture the hemo piece using the RT monitor keypad.

Mike: It was two days after we installed McKesson. I don’t think we’ve used it since.

Carey: No, it was only that one time, thankfully.

Mike: McKesson has been great both from the technical side and in the support that they offer. Every time I get stumped and call support, it’s like a training session for me. I get on the servers and watch what they are doing, and they explain everything thoroughly so that if, by chance, I have to do anything quickly and not call support, I can do it. Anybody can call. Carey, you have called quite a few times.

Carey: Yes, I keep their number handy. McKesson wants us to call support. They want us not to have to deal with any glitch or issue that we might encounter. There really haven’t been any glitches, it has just been things that we want to change or adjust.