Applied Radiology

Dr. Pearlman 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 study review.

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. *