A look at how the Michigan Congenital Heart Center has managed to improve efficiency and patient care through technology.
is a Professor of Pediatrics and the Director of
Echocardiography, Michigan Congenital Heart Center, University of
Michigan, Ann Arbor, MI.
The echocardiographic laboratory at the Michigan Congenital
Heart Center is one of the busiest labs among pediatric cardiology
divisions in the country. The laboratory is under constant pressure
to simultaneously perform multiple studies, as well as to spread
its manpower and equipment to other areas in the hospital,
including the operating room, catheterization laboratories, fetal
center, and the different ICUs. The laboratory performs
approximately 8000 studies per year and serves the Michigan
Congenital Heart Center. With improvements in technology and the
introduction of digital solutions for image manipulation (5 years
ago), it was very clear that the only solution to improve and
smooth regular laboratory tasks was to convert the laboratory to
digital imaging. The conversion was performed in two stages. The
final stage was completed 2.5 years ago. During this time, the
laboratory has performed approximately 20,000 echocardiography
studies and we believe that now is the appropriate time to reflect
on the past, evaluate the system (KinetDx, Siemens, Mountain View,
CA), and plan for future development.
The first part of the installation included five sonographer
stations (with a single monitor in each of the sonographer/imaging
rooms) and two workstations (with a dual monitor in a central
imaging room where the server was located). A year later, after
being acquainted with the system and appreciating the tremendous
value of digital imaging, six additional stations were installed
each with single monitors in six separate locations: clinic area,
patient ward, intensive care unit, library, auditorium, and fetal
center. We also added another dual-monitor workstation in the
central imaging room. We were concerned that the server would not
be able to handle such a major load; but with the appropriate
upgrades and enhancements, we didn't experience any deterioration
in the system's performance.
Transition to Digital Imaging
What have we learned? The first obstacle we encountered was to
convince our sonographers and pediatric cardiology fellows to
convert from the habit of taping the whole study to saving short
clips. We tried to design specific protocols through which specific
clips should be acquired, but after a week we realized that when
working with skilled and experienced pediatric sonographers this
step is not needed. The learning curve of the sonographers was
extremely quick. A detailed study performed at our center of 100
consecutive echocardiographic examinations in neonates and children
with congenital heart disease comparing tapes with digital clips
didn't show any loss of data or misdiagnosis.
In the following paragraphs, we make suggestions based on our
experience of moving to a digital lab, from the perspective of
physicians, sonographers, patients, and the administration.
The digital laboratory offers physicians several review
capabilities that were not feasible using the old tape technology.
The physician can review multiple images in real time and can
monitor several studies at the same time. The quick feedback can be
relayed to the sonographer/pediatric cardiology fellow during the
study. The study can be reviewed on the digital monitor in
different formats (i.e., full screen or up to 32 small loops in 1
screen). All loops are available to run simultaneously.
The system saves a significant amount of time for the physician.
It is easy to review and retrieve any study. The studies can be
retrieved either by patient name and/or registration number and
will appear on the screen within 4 to 5 seconds. If the studies are
not online, but in storage mode, it will require up to 4 minutes to
bring up the study. Using this technology eliminates the need to
identify a tape and to key the tape to the right spot. Digital
technology also eliminates the potential of image degradation.
One of the most used capabilities of this technology is the
"compare" option. The physician is able to compare the current
study to multiple previous studies. The studies appear in
side-by-side mode on one monitor, and on separate monitors in a
dual-monitor setting. This modality represents significant
improvements in patient management and time savings. For example,
in a patient in whom there is the suspicion of endocarditis, a
comparison can be made between the current and previous studies to
assess the size, location, and mobility of vegetation. Comparison
of ventricular function, size of pericardial effusion,
transvalvular gradient, etc. is crucial information for the
clinician. Recently, a wide calculation package was added to the
system. This has enabled the echocardiographer to perform online
calculations in the same form it is being done on the
The system can also be used as a great teaching tool. Different
teaching files are created according to different diagnoses. Once a
study is marked as high-quality for teaching, there is a
possibility to identify and retrieve any studies under specific
diagnoses. This is very helpful in the teaching of new fellows,
visitors, residents and medical students. Using digital imaging and
storage is also helpful to physicians to prepare talks,
presentations, and lectures.
The major concern of the sonographers was the psychological fear
of converting to a tapeless laboratory. We noticed a relatively
short learning curve among our sonographers that ranged between 1
to 2 weeks. Once they were familiar with the digital system, none
of the sonographers wanted to go back to the old tape technology.
There is no limit to the number of clips that could be acquired.
Assessing complex anatomy in congenital heart disease is sometimes
challenging and requires long loops. But this has never represented
a major obstacle for this technology. We have determined that loops
up to 8 seconds long are sufficient to fulfill any requirement from
a long sweep. We are currently using a 2-beat or 2-second clips on
regular basis. When a long loop is required, it is easy to switch
to a 6- to 8-second loop. A major advantage of this system is the
capability of the sonographer to receive quick feedback from the
physician. Again, there is no need to key a tape to the right spot
and observe a 25- to 30-minute study. Loops can be reviewed
continuously within a shorter time without losing any accuracy.
Using the system to review and compare studies, the sonographers
believe that they are more prepared to assess a child with
congenital heart disease. Refreshing of basic anatomy and surgical
details will yield a better study in assessing a child with
congenital heart disease following intervention. The sonographers
find the compare feature is one of the major advantages of this
system; it helps in diagnosis, interpretation, and
In the pediatric population, complete sedation is used
frequently. This provides a window of 20 to 25 minutes to complete
the study. If a longer study is needed and/or incomplete sedation
is achieved, it can result in an incomplete study. Calculation
usually takes a significant amount of time from the actual scanning
time. With the availability of the calculation package on the
digital system, the imaging part of the study can be completed
first and then the sonographer can use the workstation to finalize
the calculations as needed. Because of the nature of digital image
acquisition there is no degradation of image quality and/or signal
to noise ratio. This results in appropriate and very accurate
Patients also benefit from the installation of the digital lab
in our center. Better communication is established between
physicians, patients, and the patients' parents. It is extremely
helpful to review the study with the parents and to show them the
comparison between the previous and current studies. We were
surprised to see the depth of the parents' understanding of their
child's disease and their desire to review new data with the
physician. Specifically in our fetal center, we found that it is
easier and more informative to explain the cardiac defect of the
fetus when reviewing fetal images on the workstations.
Even though the initial investment in digital technology is
substantial, it pays back quickly. Savings in physician and
sonographer time, increased efficiency, and savings in storage
space and tape/VCR cost have easily demonstrated a significant
return on our investment within a 2-year period. Since there is no
need to store tapes, that space can be used for other needs. As
technology improves, the server storage capacity continues to
expand, while the cost for the storage unit decreases dramatically.
The server can be extended by using DVD technology.
Communication and connections
The digital echocardiography laboratory is not an isolated
island within the cardiology service. The ultimate goal is that
clinicians will be able to review all imaging modalities on the
same workstation using digital technology. Currently, we have
installed the capability of reviewing angiograms on our KinetDx
system in the same fashion as we review echocardiographic data. In
the near future, we hope that digital images from magnetic
resonance imaging, computed tomography, X-rays, and nuclear
medicine studies will also be incorporated in the system.
There were questions about connectivity between different
echo-cardiographic equipment and the KinetDx system. Different
digital echocardiographic equipment from Seimens Medical Solutions
(Erlangen, Germany), Philips Medical Systems (Bothell, WA), and GE
Medical Systems (Waukesha, WI) have been connected to the KinetDx
network without problems. Once the images are stored to the KinetDx
system server, all manipulations and calculations are available
independent of the type of echocardiographic machine used.
The digital system has improved our communication with referring
physicians. We have the capability to transfer images via the Web,
which allows referring physicians to review the actual studies.
This could be used as the next generation of telemedicine and it
will help to facilitate second-opinion consultations.
The conversion of the echocardiography laboratory to digital
technology was a major milestone. It has made us more efficient and
accurate, and we believe that it has improved patient care. We
expect the digital lab to become part of a total cardiology
solution that will allow us to better serve our patients at the
Michigan Congenital Heart Center. *