MITAMedical Imaging and Technology Alliance

November 27, 2007

STRUCTURED REPORTINGA Critical Need in Cardiac Imaging

Robert C. Hendel, M.D., F.A.C.C.

Clinical Cardiologist

Midwest Heart Specialists

Fox River Grove, Illinois

Chairman, ACCF/UHC SPECT MPI Appropriateness Criteria Evaluation Pilot Study

Member, Working Group for ACC Appropriateness Criteria

Co-Chairman, Quality in Imaging Task Force of the Cardiovascular Imaging Collaborative, ACC

WHY DO WE NEED QUALITY-BASED IMAGING INITIATIVES?

• Marked growth in procedural volume, cost

• Inconsistent use

• Inadequate definition of “quality in imaging”

• Poor quality imaging can do harm

• Limited evidence of impact on outcome

AMERICAN COLLEGE OF CARDIOLOGY Imaging Initiatives

• Cardiovascular Imaging Consortium (CVIC)• Duke/ACC Think Tank I and II• ACC/AHA guidelines• Appropriateness criteria• Evaluation of imaging appropriateness (“Pilot”)• ACC/AHA data standards for imaging • NCDR imaging registry• Integration with other key ACC committees

–PAR3–Advocacy–QSDC–BOT

• Collaboration with other organizations–Subspeciality societies, radiology organizations–Participation with AQA–Alliance with ICA

Duke-ACC Think Tank

DIMENSIONS OF CV IMAGING QUALITY

January 30, 2006 - February 1, 2006

Pamela Douglas Linda Gillam

Harlan Krumholz Robert Hendel

Ami Iskandrian Jamie Jollis

Eric Peterson

QUALITY METRICS FOR MEDICAL IMAGING

Patient Patient Selection

Image Interpretation

Results Communication

Improved Patient Care

Image Acquisition

Appropriateness Structure

Process (timeliness, pt-centered)

Reproducibility

Reproducibility

Accuracy

Sensitivity

Specificity

Timeliness

Interpretability

Clinical integration

JACC, Nov 6, 2006

WHY APPROPRIATENESS?Right Test, Right Patient, Right Time

• Unprecedented focus on assessment and improving quality

• Explosive growth of CV imaging

• Substantial regional variation

• True nature of utilization unknown–Overuse/ Under-use/Appropriate

• Clinicians, patients, and especially payers seeking guidance

APPROPRIATENESS CRITERIAThe ACC Queue

√ Nuclear cardiology (SPECT)October, 2005

√ Cardiac CT/CMR September, 2006

√ Echocardiography (TTE, TEE)

–July, 2007

• Echocardiography (Stress)–Fall/Winter, 2007

• Percutaneous coronary intervention–Winter, 2007-8

• CV imaging cross modality (efficiency) evaluation

• Revised SPECT Criteria

PILOT PROJECT FOR THE EVALUATION OF APPROPRIATENESS IN SPECT IMAGING

PROJECT GOALS

• Quality improvement–Effective patient care–Efficient care

• Assess validity of appropriateness criteria–Provide data for revisions/updates–Determine threshold levels of performance

• Assess practice patterns–Feedback to practice & individual physician–Identify areas for improvement

• Analysis of decision making–Correlation of level of appropriateness and image findings/patient outcome

SPECT AC EVALUATION PILOT

Data collection

paper form

Duke-ACC Think Tank

IMPLEMENTING CV IMAGING QUALITY

October 8-10, 2007

Pamela Douglas Linda Gillam

Greg Hundley Robert Hendel

Fred Masoudi Manesh Patel

Eric Peterson

Duke-ACC Think Tank

Broad Stakeholder Representation

• Professional societies

• Academics - ‘quality mafia’

• Government- CMS, FDA, NHLBI, VA

• Payers- UHC, Aetna

• Accrediting organizations- IAC, IHE

• Industry

• We acknowledge ‘special interests’

• Critical issues–Creation, Endorsement, Dissemination–Supporting tools, Compatibility–Universal implementation

• Industry and societies must work together–ACC/Societies to endorse mandatory use

DUKE-ACC THINK TANK - IIImplementing Cardiovascular Imaging Quality

October 8-10, 2007

DATA STANDARDS AND REPORTING

DUKE-ACC THINK TANK - IIImplementing Cardiovascular Imaging Quality

October 8-10, 2007

• Data elements and standards– In progress, anticipated completion 12/07

• Structured reporting–Collaboration with equipment manufactures and software vendors

–Recommend mandatory use by 2010 (?)

• Imaging databases and registries–Proposal for feasibility of imaging registry completed

– Integration with other registries

–Potential to provide true outcome data

DATA STANDARDS AND REPORTING

IMAGING REGISTRY PRINCIPLES

• Ultimate goal; May be needed for reimbursement

• Data elements embedded in software

• Central certification

• Interface with disease and procedural registries

• Claims data for outcomes

• ?? Workflow

• ?? Business model

DUKE-ACC THINK TANK - IIImplementing Cardiovascular Imaging Quality

October 8-10, 2007

National CardioVascular

Data

Registry

1998….. 2004 2005 2006 2007 2008 beyond

CathPCICathPCIRegistryRegistry

ICDICDRegistryRegistry

CARECARERegistryRegistry

ACTIONACTIONRegistryRegistry

IC3 CADIC3 CAD

ImagingRegistry

HFRegistry

PracMgtRegistry

PADRegistry

EPRegistry

Ped.Registry

Congenital

Registry

Building a true…Building a true…ICD LongICD Long

AchieveAchieve

NCDR is…Physicians Leading the Effort To Quantify Quality

A PROPOSAL (1)

• Using data standardization and structured reporting, facilitate the design, creation, implementation, dissemination of resources supporting imaging quality

• Examine the possible integration of structured reporting into a national cardiac imaging registry

A PROPOSAL (2)

• Create working group of industry and MD/society leadership – Industry leaders: Technical, marketing, Decision makers

• PACS, reporting, IT, equipment, IHE/DICOM, NEMA/MITA

– MD/societal leadership • ACC, ASNC, ASE, SCMR, SCCT, ACR

• Develop resources, potentially include branded commercial products – Reporting software, educational materials, etc. – Capable of supporting QA and QI efforts (appropriateness criteria evaluation,

lab accreditation and imaging and other registries)

• Explore funding challenges and opportunities

• Advocate for use of structured reporting and registry data to improve the evidence base supporting the value of CV imaging

A PROPOSAL (3)

• Initial steps

–Kick off meeting in winter ‘08–Review of lessons learned from DICOM and IHE regarding collaboration, consensus

–Evaluate economic potential including branded/accredited products

–Discussion with NCDR regarding registry integration–Project plan, timeline and budget

QUALITY IN CARDIAC IMAGINGConclusions

• A critical ACC priority–Large allocation of resources (“Think Tank”, data standards, appropriateness

criteria, evaluation pilot, registry development)

• Data standards structured reporting EMR/PHR databases/registries

• Collaboration with MITA/NEMA, IHE/DICOM, allied societies, and industry to develop structured reporting and image registry.

–Same audience, same market

• Overall goal of improving patients outcomes with a consciousness of cost