The Clinical Assessment, Reporting, and Tracking System for Cardiac Catheterization Laboratories (CART-CL)
Lead investigators: John Rumsfeld, M.D., Ph.D., and Stephan Fihn, M.D., M.P.H.
Ischemic heart disease (IHD) is the leading cause of morbidity and mortality in the US for both men and women, with $156 billion in direct and indirect costs. It also is one of the most frequent indications for hospitalization within the VA healthcare system. VA's Ischemic Heart Disease Quality Enhancement Research Initiative (IHD-QUERI) was created to help bridge the gap between research and VA operations in order to improve the quality of care and health outcomes of Veterans with IHD. As part of this mission, working with VA Patient Care Services, the Office of Quality and Performance, and the Office of Information and Technology, IHD-QUERI developed the Clinical Assessment, Reporting, and Tracking System for Cardiac Catheterization Laboratories (CART-CL).
CART-CL was developed to address the critical need for a systematic, national method for tracking the use and outcomes of diagnostic and interventional cardiac catheterization procedures, and to implement an associated national quality program. CART-CL has been successfully implemented in all VA cath labs, and is regarded as a model for clinical application development and implementation within the VA healthcare system. Read more about this dynamic initiative–from inception to successful implementation.
How It Began
In the early 2000s, concerns were raised about the outcomes of Veterans with acute myocardial infarction (AMI) that were treated in the VA. One particular area of concern related to the use and outcomes of cardiac catheterization procedures, which had become centric to 'best practice' for AMI care. Practice in this area also was shifting rapidly, including the use of new technologies such as drug-eluting stents and the growth of multi-vessel coronary procedures. There were clear implications for patient safety, quality of care, workload, and costs of care for the VA, all related to work performed in cardiac catheterization labs. However, there were major flaws in data available about the number and types of procedures being performed across the VA, as well as the indications and outcomes of those procedures. Moreover, there was wide variation across the system in the availability and amount of information contained in catheterization lab procedure reports that were being entered into VA's computerized patient record system (CPRS). Finally, there was no national quality program related to cath lab procedures, analogous to VA's cardiac surgery national quality program, and no mechanism to benchmark the care and outcomes of VA cath labs with the private sector.
Thus, as part of the VA Cardiac Care Initiative, IHD-QUERI was funded by VA Patient Care services to develop and implement a national VA reporting system, data repository, and quality improvement program for procedures performed in VA cardiac catheterization laboratories.
Key features of CART-CL would include:
- Standardized data capture and reporting across all VA cath labs. The application automatically creates reports (pre-procedure assessment, cardiac catheterization, and percutaneous coronary intervention) for inclusion in the patient record. The application is tightly integrated with VA's CPRS in order to support providers in generating reports documenting the procedures, and helping to avoid duplication of work.
- Single national data repository for tracking and documenting cardiac procedures performed in VA cath labs.
- Core data elements that conform to the definitions and standards of the American College of Cardiology's National Cardiovascular Data Registry (ACC-NCDR).
- Centralized platform to support quality improvement–both local and national quality improvement programs.
- Extensible database structure to support modification based on input from test sites, updating to evolving standards (e.g. as ACC-NCDR data elements change), and expansion of the clinical scope of the project.
In 2003, CART-CL was piloted in a handful of VA cardiac catheterization laboratories, and was subsequently adopted by the Under Secretary of Health and the National Leadership Board. However, challenges remained, such as coordinating efforts among several organizational participants, including Information Resource Management and Cardiology.
As has occurred with the implementation of other health information technology projects, the implementation of the CART project did not proceed without some barriers and resistance, including:
- Resistance to change and new processes,
- Concerns about adding more responsibility to an already over-burdened staff, and
- Privacy and security concerns.
Thus, throughout the implementation process, success required a balance of attention to technical, clinical, and organizational factors. For example, engaged, clinical champions were key facilitators in the implementation process. Initial testing of CART was completed at VA medical centers where IHD-QUERI clinicians, who could act as "clinical champions," were located. To help alleviate privacy and security concerns, CART achieved national Certification and Accreditation–a security certification developed by the National Institutes of Standards and Technology.1 Individual in-services were done with all sites, to train key clinical leaders at each site on the use of the application, but also to gain their feedback; the application remains open to ongoing modifications, based on both changes in the field of interventional cardiology, but also feedback from VA users.
Following early success and strong endorsement of participating sites, CART was mandated by a VA National Directive (2005-062), spearheaded by Dr. Robert Jesse, who is now the VA Principal Deputy Undersecretary for Health. By the end of 2009, CART-CL had been successfully installed in all 77 VA cardiac catheterization labs. As of September 2010, more than 2,500 VA clinicians had used CART to enter more than 200,000 reports, encompassing pre-procedural, diagnostic catheterization procedure, and percutaneous coronary intervention reports, on more than 125,000 VA patients.
In April 2009, CART was designated as a National Program by VA Patient Care Services. Additional resources have been provided to support new CART module developments and analytics, such as: CART modules for peripheral cardiovascular interventions (CART-Peripheral), electrophysiology (CART-EP), and in-hospital cardiac arrest (CART-CPR).
There is strong interest by VA leadership in expanding CART beyond cardiovascular diseases/procedures.
The CART-CL clinical application is integrated within CPRS, has an intuitive graphical user interface that combines discrete data entry and narrative text fields, and leverages data available in CPRS to create pre-procedure and procedure reports. As such, data is captured within routine workflow to develop customized, yet comprehensive reports that are immediately available in CPRS. This 'model' accomplishes several things, including:
- Efficient report generation,
- Timely report availability,
- Capture of key clinical and quality data as part of routine workflow, and
- Data that can inform national quality assessment and improvement efforts.
In parallel with the development and implementation of the CART clinical application, the CART national Quality Program has been developed. The data in CART are fed back to sites on a monthly basis in the form of local Quality Assurance Reports. In addition, reports on workload and complication rates, along with VA national benchmarks, are fed back to sites bi-annually, and a national data report is generated for the CART system annually. Also, major adverse events (e.g. death, stroke, emergent coronary artery bypass surgery) are reviewed by the national CART Quality Management Committee, as a complement to local peer review. Quality of care collaboration also is promoted via the CART Network, as well as web and e-mail communication. Moreover, VA held a national quality conference on catheterization laboratories in 2009 that was primarily focused on the CART Program, which included training workshops and led to national ongoing efforts (i.e., VA cath lab nurse managers group).
CART-CL Becomes Part of Patient Safety Network
In FY08, VHA finalized a Memorandum of Understanding with the U.S. Food and Drug Administration (FDA) to enable the use of CART-CL for the surveillance of potential safety problems related to cardiac devices. This collaboration established CART-CL as a sentinel patient safety network and contributed significantly to active post-market surveillance. Most importantly, it may improve patient safety through enhanced communications and provider understanding of reportable events.
Also, as part of the initial implementation plan for CART-CL, the data captured adheres to standards of the American College of Cardiology (ACC), enabling VA catheterization labs to join the ACC's National Cardiovascular Data Registry (NCDR). VA's participation in NCDR will support benchmarking of care and outcomes both within the VA and to national data, with feedback to the sites. The VA-ACC contract is now in place, with submission of data to the ACC in process. CART's participation in NCDR can serve as a model of transparency and consistency for comparisons of VHA to other healthcare systems. It also is consistent with efforts within VA to submit data, when feasible, to respected external organizations for quality reporting consistent with community standards.
Enriching VA Research
The CART national data repository, combined with other VA data sources, such as the Austin Automation Center, stand as a rich resource for VA health services and quality of care research. The CART Research and Publications process, in collaboration with IHD-QUERI, is now active. It is expected that this will lead to key insights on care delivery and patient outcomes for Veterans undergoing cardiac procedures, and make significant contributions to the medical literature. It also is intended as a model linking discovery and implementation, whereby insights from research related to CART or utilizing the CART network of sites can directly inform the quality improvement efforts of IHD-QUERI, VA Patient Care Services, and other stakeholders.
Success Reflects Key Collaborations and Clinical Utility
CART represents a successful clinical application development, national implementation effort, and linked national quality program for the VA. Its success reflects the collaborative synergy of VA clinical, quality of care, operational, and health information technology experts working together on the program. Also essential to its success is the clinical utility of the program–embedded in workflow at the point-of-care and not requiring additional personnel for data capture, yet capturing essential data needed to inform local and national quality reporting and improvement efforts.
The CART model reflects VA's ability to lead the Nation in innovative health information technology and quality of care, meaningfully improving patient safety and outcomes.
For more information about CART, please contact Dr. John Rumsfeld, CART National Program Director, at John.Rumsfeld@va.gov, or Dr. Stephan Fihn, Chair of the CART Executive Committee, at Stephan.Fihn@va.gov.
1. Box T, McDonell M, Helfrich C, Jesse R, Fihn S and Rumsfeld J. Strategies from a nationwide health information technology implementation: The VA CART Story. Journal of General Internal Medicine 25(Suppl 1):72-76.