Remote Cardiology Consultations Using Handheld Devices

1. Innovation Initiative Remote Cardiology Consultations Using Handheld Devices Facility: DVA Medical Center Initial Idea Submitted by: Edward Employee

2. Problem Statement • Currently, emergency room clinicians must request specialty consultations by cardiologists and allow for travel time either to the Department of Veterans Affairs (DVA) medical facility or to access a computer – this process can be unnecessarily time consuming. • Treatment is impeded by lack of immediate access to specialists review of electrocardiograms and other diagnostic studies.

3. Description of Idea • Our idea is to develop a method for cardiologists and other subspecialists to provide immediate reviews of diagnostic information in order to provide consultative services. • On call specialists would be provided handheld devices to enable the review of diagnostic reports such as electrocardiograms (ECG). • Specialists would not have to waste valuable time commuting to the DVA medical facility or to accessing the Virtual Private Network (VPN) via a computer to perform their consult. • Treatment could begin in a more timely manner thus avoiding further medial complications.

4. Strategic Goals • Improve Care Quality • Veterans will have more timely treatment avoiding complications of delays in providing treatment informed by a cardiologist • Improve Efficiency and Access: • Reduce time from presentation in the emergency room until initiation of treatment for cardiology patients. • Reduce inpatient beds days of care • Impact Many Veterans: Acute coronary syndrome affects approximately 100,000 veterans per year • Meet Organizational Requirements - Joint Commission requirements for 2011 mandate emergency department specialty consults for acute coronary syndrome within 26 minutes of arrival.

5. Success Metrics • Functional Prototype Success Metric: Cardiologists will be able to view text-based lab results, static ECGs and other dynamic wave forms on a mobile device in a test environment. We will evaluate the applications usability and ability to support accurate diagnoses via a set of sample cases of variable complexity. • Expected Results: Reduce the time to obtain a specialty consultation in the emergency room. At the end of 2009 the average time from presentation of acute myocardial infarction in the emergency room to initiation of treatment by the cardiologist was1 hour. After remote cardiology consultation to the emergency room is implemented the average time from veteran presentation to initiation of intervention will be reduced from 1 hour to 23 minutes.

6. Impacts • Veterans • Will have improved cardiac outcomes • Will experience more timely intervention when presenting to the emergency room • VA Employees • Will spend less time waiting for cardiology consultations • Will spend less time getting to a computer to perform cardiology consults • Will be able to treat more patients in the emergency department with less delays • Additional support needed • Coordination with OI&T to ensure handhelds and connectivity can support diagnostic images.

7. Technical Approach • Our approach involves creating custom applications for the blackberry to access CPRS, VistA Imaging, ECG and other live physiologic wave form data from monitoring devices. • We will use a two-way SCP-ECG to HL7 aECG converter to increase range of equipment whose output can be accessed via our applications. • VistA data access will be accomplished via web objects developed by the Aviva program • Data security will be accomplished by using VA standard VPN clients for the chosen platform. Authentication and single sign on capabilities will be extended from current VistA

8. Team and Environment • We have created a strong team with VHA and OIT staff and University collaborators: • Dr Willem Einthoven is the clinical lead. Dr Einthoven developed one of the first accurate ecgs and is responsible for distinguishing and naming the five characteristic deflections (P, Q, R, S and T). See Einthoven W. Ueber die Form des menschlichen Electrocardiogramms. Arch f d Ges Physiol 1895;60:101-123. Dr Einthoven has lead the Cardiology Division at our VAMC since 2004. • Charles Babbage is the projects technical lead. The "father of computing" is widely known for his mechanical Calculating Engines, both the table-making Difference Engines and the Analytical Engine. He is less often credited with invention of the smart phone. • Other team members include William Osler, Grace Hopper and Ada Lovelace. • Our environment is supportive and capable. The VAMC Director and CIO have expressed their strongest support for this project. We have recently completed a similar project to display high resolution medical imaging studies on the iphone and demonstrated improved timeliness of diagnosis with no compromise in diagnostic accuracy.

9. Implementation • Requirements will be gathered from DVA cardiologists and emergency room clinicians • Workflow analysis of the emergency room process will be completed • User testing will occur with a volunteer group of cardiologists and emergency room physicians • Handhelds will be rolled out to the volunteer group of providers and a review of the quality of the diagnostics images on the handheld devices will be assessed

10. Timeline • Definition of Above Steps: • Step 1: Acquisitions process • Step 2: Development of mobile client • Step 3: Development of display application • Step 4: Integration VistA applications • Step 5: Testing

11. Budget Narrative • The main cost of implementing a pilot of the Remote Cardiology Consultations Using Handheld Devices : • The cost of developing and deploying the software to support the image presentation $100,000. • The cost of the handheld devices and the activation services $100,000. • After the handhelds have been deployed, operations and maintenance costs will be approximately $25,000 per fiscal year.

12. Budget Proposal - Optional

13. Challenges & Risks • Risk: If the innovation proceeds beyond proof of concept to use in actual patient care, Veterans personally identifiable information (PII) will be communicated over the internet . • Implement security with sharing PII over the internet. • Ensure that all security protocols are used by the cardiologists as the receiver and the personnel in the emergency department as the sender. • Challenge: Clinicians may not embrace the handheld technology. • Create an outreach campaign about the quality of the diagnostic image and the system performance of the connectivity. • Educate cardiology and emergency room staff in the use of the technology and the benefits of the change in workflow.

14. Supporting Diagrams: Mock-up for ECG Display on Blackberry

15. What Do You Really think? • Veterans deserve prompt access to cardiology expertise when presenting in VAMC emergency rooms whether this is during normal business hours or on nights or weekends • Our facility is particularly well suited as our physicians have a proven track record of embracing technology and testing new innovations • We will know we are successful when we can produce a diagnostic quality ECG on a handheld device • Ultimately implementation of our innovation will save patient lives with more timely cardiology consults • Please also take the time to review our video presentation which can be found at vaww.va.gov/testURL/…