A review of how one facility integrated a system for recording, storing, interpreting, and reporting echocardiographic images and Doppler data in a fully digital manner.
is a Professor of Medicine at the University of Washington School
of Medicine and Director of Echocardiography at the University of
Washington Medical Center, Seattle, WA.
In October 2001, my hospital finally invested in an integrated
system for recording, storing, interpreting, and reporting
echocardiographic images and Doppler data in a fully digital
manner. Nine months later, as I reflect on the changes in our
day-to-day practice, it is clear to me that the most important
benefit of this system has been the improved patient care that we
now are able to provide.
In order to put this in perspective, it is helpful to describe
our previous system. Studies were performed using state-of-the-art
echocardiographic instruments, and recorded on S-VHS videotape.
Recorded images and Doppler data were reviewed on a separate review
station, including a videocassette recorder and a high-quality
monitor. As each patient arrived for a study, a computer file was
created using a template developed many years ago by our hospital's
transcription service. Staff entered demographic information, such
as patient name, age, referring physician, indications for the
study, etc. The sonographer performing the study then entered
clinical information such as the procedure(s) performed, the
imaging system used, and preliminary measurements, which were
usually done online on the ultrasonographic instrument. After
reviewing the recorded images and Doppler information, verifying
measures of chamber structure and cardiac hemodynamics, and
remeasuring when necessary, the interpreting physician then
dictated his/her findings and conclusions, which were transcribed
by our hospital's off-site transcription services and entered into
the report template. The transcribed report was then available for
the interpreting physician to review and edit in the echo
laboratory. The dictated findings and conclusions were usually
available for review in the laboratory within 24 hours of the
actual study, but longer delays in transcription sometimes occured.
The process of report editing was cumbersome and could only be
performed in the laboratory. Hence, if the interpreting physician
had a clinic, inpatient care duties, or out-of-town commitments on
the day following an interpretation session, report completion was
delayed significantly. Edited reports were printed and signed by
the responsible interpreting faculty physician, and distributed to
the patient's chart by laboratory administrative personnel.
Our new digital system (KinetDx, Acuson, Mountain View, CA) has
overcome many of the shortcomings of our old system. Studies are
recorded in a fully digital manner, which preserves the quality of
the original images and maintains the full dynamic range and
temporal resolution of the ultrasound images. No longer do we
suffer the loss of image quality and temporal resolution that is
inherent in videotape. The digitally recorded images are readily
accessible for review. Hence, a sonographer who is about to perform
a study will not have to retrieve the relevant videotape, find the
previous study, and review it in order to be more familiar with the
prior findings. The interpreting physician can also access
different portions of the recorded study simply by paging rapidly
to the relevant images; it is no longer necessary to shuttle
forward and back in the videotape. Reviewing images in slow motion
is facilitated, and flicker-free still-frame images can be selected
easily. When necessary, the interpreting physician can easily
remeasure structures of interest in the selected still-frame
images. When a requesting physician comes to the lab to review a
study on his/her patient, the interpreting physician can retrieve
those digital images rapidly, review them with the requesting
physician efficiently, and quickly return to the study that he/she
had been reviewing prior to the interruption.
The report generating system is also efficient. In our
laboratory, the report has been configured to facilitate completion
by the interpreting physician. Identifying data are entered into
the report directly from the hospital information system, so data
such as patient name, birth date, and hospital record number do not
have to be entered manually. The structure dimensions and Doppler
velocities that were measured during the course of the examination
are transferred automatically to the report template and do not
have to be re-entered manually. The sonographer performing the
study uses a customized "pick list" to choose preliminary
descriptive phrases summarizing the major study findings. These
preliminary diagnostic comments are then edited and expanded, as
appropriate, by the interpreting physician after reviewing the
entire study. A customized "conclusions" section is created by the
interpreting physician to summarize the pertinent diagnostic
findings and to address the specific clinical issues that prompted
the request for the echocardiogram.
One of the advantages of echocardiography is its ability to be
used to evaluate changes in cardiac function as a result of disease
progression, or to assess the results of therapy. Since most of the
patients having an echocardiogram in our laboratory have already
had a previous study, the ability to review the prior study and
compare it directly with the current study vastly facilitates
assessment of serial changes in chamber size, valve function, and
cardiac hemodynamics. No longer is it necessary to find, cue, and
re-review an old videotape to find the relevant sections for
comparison. Now, the prior digital study is retrieved rapidly and
displayed on one of the two monitor screens at the review station.
Current and prior images can be selected and literally reviewed
"side-by-side." This greatly facilitates comparison, makes it
easier to note technical differences that may lead to measurement
differences, and improves our ability to evaluate for serial
changes. The difficulty in obtaining and reviewing prior studies
has led some laboratories to compare the findings of a current
study to the report of a prior examination. Using our digital
system, we find it quite easy to review the actual prior images and
Doppler recordings, and to make more meaningful comparisons.
Once the interpreting physician certifies that the study report
has been completed, the final report is transferred automatically,
and nearly immediately, through our Cardiology Division's
electronic database and onto the electronic hospital record.
Completed reports are available online to the requesting physician
and to others who may be caring for the patient. Study results do
not have to be hand carried to the patient's hospital chart or sent
to the medical records department, and results are available from
any computer in the hospital with access to the electronic record.
It is no longer necessary to "find the chart" in order to take care
of the patient!
In addition, a Web-based method for retrieving study images is
in development. While this will not preserve the full diagnostic
abilities of the review stations in the echo laboratory, it will
allow interested physicians and other healthcare providers to view
images from an echo study without having to come to the laboratory.
Many physicians find that this helps them get a better "mental
picture" of their patient's cardiac function.
In summary, the installation of the digital echocardiography
system has been a major improvement in the function of our
laboratory. It provides superior images for review, facilitates
review and direct comparison to prior studies, and routinely allows
us to provide final reports of study findings to the requesting
physician on a "same day" basis and nearly immediately following
This fully digital system has changed the workflow of the
laboratory, and it offers additional features and benefits that I
find useful. However, in my view, the most important benefit is
that using this system gives us a better end product: a more
meaningful report of the findings of the study, which helps guide
patient care; and it does so more rapidly than our earlier system.