1. MITA Medical Imaging and Technology Alliance November 27, 2007 STRUCTURED REPORTING A 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

2. 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

3. 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

4. Duke-ACC Think Tank DIMENSIONS OF CV IMAGING QUALITY January 30, 2006 - February 1, 2006 Pamela DouglasLinda Gillam Harlan Krumholz Robert Hendel Ami IskandrianJamie Jollis Eric Peterson

5. QUALITY METRICS FOR MEDICAL IMAGING u Appropriateness u Structure u Process (timeliness, pt-centered) u Reproducibility u Accuracy u Sensitivity u Specificity u Timeliness u Interpretability u Clinical integration JACC, Nov 6, 2006

6. 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

7. APPROPRIATENESS CRITERIA The 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

8. 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

9. SPECT AC EVALUATION PILOT Data collection paper form

10. Duke-ACC Think Tank IMPLEMENTING CV IMAGING QUALITY October 8-10, 2007 Pamela DouglasLinda Gillam Greg Hundley Robert Hendel Fred MasoudiManesh Patel Eric Peterson

11. 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’

12. 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 - II Implementing Cardiovascular Imaging Quality October 8-10, 2007 DATA STANDARDS AND REPORTING

13. DUKE-ACC THINK TANK - II Implementing 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

14. 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 - II Implementing Cardiovascular Imaging Quality October 8-10, 2007

15. N ational C ardioVascular D ata R egistry 1998…..20042005200620072008beyond CathPCIRegistry ICDRegistry CARERegistry ACTIONRegistry IC3 CAD Imaging Registry HF Registry PracMgt Registry PAD Registry EP Registry Ped. Registry Congenital Registry Building a true… ICD Long Achieve NCDR is… Physicians Leading the Effort To Quantify Quality

16. 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

17. 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

18. 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

19. QUALITY IN CARDIAC IMAGING Conclusions 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