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Hi, everybody. Thanks for joining us, and welcome to CCTA Operational Efficiencies, the Nurse Navigator Role, and Other Practical Approaches to Program Growth. As you can see, we still have attendees joining the call at a rapid rate since we just opened the call. So we're going to sit tight for just a couple of minutes as more people join, and then we'll get started. So we're looking about another minute or two until we officially kick off the webinar. Thanks for your patience. Okay, we're gonna give it just almost another minute until we kick off. I just wanna make sure that everyone that wants to be here for the start has an opportunity to get in from the get-go. So appreciate your patience. We'll wait another 30, 45 seconds or so. Well, thanks again, everybody, for joining this afternoon, if you are Eastern Time. Today's discussion is around CCTA and really the role of the nurse navigator and how we can encourage program growth. With us today are presenters from two health systems, as well as a Medaxium corporate partner, Heart Flow. With us from Atrium Health is Bill Cunningham. He's the director of non-invasive cardiovascular imaging, and he's involved in the management and the operations and the development of the advanced imaging program at Atrium. We also have from Atrium Rachel Grant. She's a program manager over advanced cardiac imaging. She oversees the nurse navigators and the cardiac schedulers at Atrium, and more specifically the Sanger Heart and Vascular Institute. From Cone Health, we have Dr. Wes O'Neill. He's the medical director of cardiac CT and nuclear cardiology. He's a non-invasive cardiologist, and he's really a driver of the expansion of CT services within the Cone system. Also from Cone Health, we have Sarah Wallace, and she's a nurse navigator and program coordinator. She was the original nurse navigator actually at Cone Health, so she's really helped to shape and expand that particular role inside of the system. Last, we have Christopher Pols from HeartFlow. He is the director of payer relations, and he really works with health plans on coverage and reimbursement for HeartFlow's entire suite of services. I want to give just a thanks to all of those presenters for joining us here today, sharing their expertise with us. To get us started, I'd like to turn it over to Dr. Wes O'Neill. Dr. O'Neill, before you take it away, let me do one thing, and that is tell folks how to navigate the system here. We do have a couple of ways that you can interact. Number one is that if you look at the chat, you'll be able to find the slides. We don't have the chat open for user comments, but throughout the presentation, as new people join, we'll make sure that we repost the slides. If you see that happening over and over again, it's just for folks that are new to the conversation because they would not see things that were posted before they joined the conversation. This gives them an opportunity to download those slides. If you'd like to communicate with anybody that's a presenter and you want to send questions, there is a Q&A button. We will be taking questions at the end of the webinar. Feel free to put them in throughout. If there's one that seems very pertinent that we want to ask in real time, please indicate that. Number one and number two is we will find the right time to ask that of the presenter. If they can wait until the end, then just feel free to put them in at your leisure throughout the presentation. With that, I will turn it over to you, Dr. O'Neill, to take us away. Thank you so much. Okay. Thanks for having me. Happy to be here. Just a little background on coronary CTA and FFRCT and why it's so important, but really compared with other modalities to evaluate patients with chest pain to determine if they have obstructive CAD, CCTA and FFRCT really offer the highest diagnostic accuracy when compared to other modalities. This is a slide that just shows that performance being much better in that pathway. The data presented previously in other studies, there's a multitude of data, have really shifted the focus within cardiology to escalating coronary CTA as the only class one level of evidence A test of choice for the evaluation of patients with stable chest pain symptoms who are intermediate to high risk. This was reflected in 2021 in the ACC AHA chest pain guideline document. FFRCT was escalated or actually showed its face in the guidelines and it was given a class 2A level of evidence B non-randomized for stenosis on coronary CT datasets in 40 to 90% to help determine who needs to be sent to the cath lab. Largely what you get with CTA, you can determine if someone has a flow limiting lesion, but you can also detect early lesions. Scott Hart was a big trial that showed that, made the guidelines. Patients are able to get on preventive therapies in addition to detecting late stage disease. I do want to mention the PRECISE trial, it didn't make the guideline document, but it is worth mentioning here. What the PRECISE trial was, was it as a large prospective randomized controlled trial to evaluate the CTA FFRCT pathway compared with traditional testing in a head to head comparison. Some key results from that study, what it showed, the study did meet its end point showing a nearly 70% reduction in the primary end point or composite end point of all cause of death, non-fatal MI and invasive coronary angiography without CAD, so cases that don't need to go to the lab. Just to summarize some key results, there were fewer false negatives, 78% of patients were more likely to identify patients in need of revascularization in the PRECISION pathway. Fewer false positives, you were four times less likely in the CTA FFRCT pathway to have a cath lab or have an angiogram without obstructive CAD. And when you look at efficiency items from the cath lab, you had a much higher diagnostic yield in patients in the PRECISION arm who underwent CTA and FFRCT, nearly a two-fold higher yield of revascularization in that PRECISION pathway compared with traditional testing. So overall, this trial really showed that this pathway is going to increase your cath lab efficiency and send people to the lab who need to be there, and more importantly, keep those out who don't. Just a little bit about our or my health system where I work as we go into some institution-specific data. I work at Cone Health and we're a large system in the Piedmont region of North Carolina. If you're not familiar with that region, we're sandwiched between all the ivory towers of academic medicine in North Carolina. But regardless, we have a very busy heart and vascular service line. We offer a very robust cardiac sub-specialties, including advanced imaging. The only thing we actually send out is cardiac transplantation. And we've been rather busy. We have nearly 83 providers. And you can see with this snapshot from last year, we're a fairly busy clinical practice. So anytime you talk about how coronary CTA is implemented in your practice and what growth will look like, you do want to look across your service line to determine what imaging tests may be impacted. And this is data over the past five years that looks at coronary CTA volumes as well as SPECT nuclear stress testing volumes. SPECT has been the workhorse for us over the past few years, but we have transitioned to But we have transitioned to CCTA more heavily over the past five years as well. But what we've seen is a 12% decrease in referrals for SPECT stress testing and nearly a threefold increase in coronary CTA volumes. And in between 2021 and 2022, reflective of guidelines, CCTA became our predominant modality to evaluate de novo chest pain patients. We do send roughly 25% of our studies for FFRCT, and this is pretty consistent with what is reported nationally. We absolutely track downstream outcomes. This is paramount as you start to grow a program and look for growth. But what this shows is revascularization rates for elective left heart catheterizations at my institution at Cone Health over the past five years. The far right does show the total, and it shows it by CCTA, SPECT testing, or actually direct referral to the cath lab, I would say non-CCTA. And I do have overall revascular rates for the whole institution as a whole. But what we've seen is collectively a 12% increase in elective revascularizations. But for those who undergo a coronary CTA or in that CCTA FFRCT pathway, you're seeing a nearly 1.5-fold higher yield of revascularization in patients in that arm. And that really highlights what we're seeing in PRECISE, and this is some real-world data to support that. Our site is no different. Atrium has also seen similar productivity or efficiencies in the cath lab. So what are some keys to growing a program? There's a lot, and this is not all of it by any stretch of the imagination. But just some high-level programmatic points to point out. You're really going to make sure that you have to have administrative support who actually get it. They're going to have to understand the pathway, the benefit to the program, track downstream benefits, and help you ultimately acquire and secure really expensive CT scanners sometimes. You need high-quality imaging testing so you can get high-quality images and get good data for your patients and to really improve the value of care provided. One thing we did as an institution, whether it was scheduling, our prior authorization team, our technologists, our nurses, whoever was involved with it, we saw a lot of roadblocks or barriers initially in the pathway or in our program. And what we all did was we all met together and created a process improvement meeting to kind of remove those barriers. And it really helped streamline our workflows to get our wait times down to less than two weeks and it identified all these barriers to remove them. Nursing is key. I'm not going to spend a lot of time on that. You'll hear more about the nurse navigators and their role, but they are very much paramount to the whole idea of exponential growth. Technologists are going to need to be skilled. We've identified at our site a lead technologist who can train other technologists who come on board and that has really helped improve quality of the imaging to maintain high levels. And you're going to need a physician champion like myself to push things along. I'm probably the least important person in the whole thing, but sometimes it does take all of us to identify barriers and move the program along. So I do want to talk about HeartFlow. We use HeartFlow FFRCT at our site and it'll help you immensely with workflow solutions. HeartFlow offers a lot of solutions, not only FFRCT, but they also offer assessments for you to look at your coronary CT data sets to determine anatomic stenosis severity. We use the roadmap to assess anatomy. Roadmap is an AI-based coronary stenosis quantification tool. It's been shown to increase reader efficiency, increase consistency, and make you a more accurate reader. And using that tool upfront can streamline your workday, can help you read faster and more accurately. We're all aware of FFRCT and the ability to keep people out of the lab or send the appropriate patients to the lab. The data is there, as we talked about earlier. And HeartFlow does have a plaque, an AI-based plaque tool that is also coming fast across the country to really have a quantitative assessment of calcified, non-calcified, and low attenuation plaque for preventive purposes, as well as what we're seeing as data comes out to help really refine obstructive lesions. But more data is coming on this every day. Lastly, I'll just talk about the HeartFlow One workflow solution. What this is, is something we utilize at our site. And basically it's all of our studies are sent to HeartFlow and we get the roadmap analysis on everything. Roadmap again is an anatomic assessment tool. It will give you a pre-read, if you will, to aid in your interpretation of coronary CTA. And it'll really streamline your day. At our site, we are a busy practice. Readers can read up to 20 coronary CTs a day. They do need a little bit of help with that. And that's where AI-based tools like Roadmap can really help you. It just allows us to triage studies better. You can focus your cardiology brain where you need to. And more appropriately or more timely, order FFRCT tools if deemed appropriate by the reader. But it really can streamline your day, especially as your program grows. And I'll stop there. That's all I had on my end of it. And Bill Cunningham is going to talk about some operational efficiency items in his next segment. Hey, thanks, Dr. O'Neill. My name is Bill Cunningham. I'm the Director of Imaging for Sanger Heart and Vascular. I'm going to start off with just a little bit of an overview of who we are, kind of our size and scope. Sanger Heart and Vascular is part of Atrium Health, which is also part of Advocate Health. So, you can see that we're a large organization across three states in the Southeast, also across the Midwest, got about 150,000 teammates, 67 hospitals, and we are the third largest nonprofit hospital system in the country. Next slide, please. A little bit more about Sanger. You can see that we're a very large cardiac division. We've got over 120 MDs. We've got about 30 cardiac CT readers and about six cardiac MR readers. We perform over 165,000 non-invasive testing procedures, which our CTs and MRs are part of that. And you can see kind of our leadership team listed down there as well. I thought it would be good just to kind of give you some idea of the scope of our program. We've been doing cardiac CT since 2011. Dr. Shearer is our medical director, who's a big proponent of the system, just like Dr. O'Neill is. And you can see, this is a 10-year growth pattern for us for cardiac CT. You can see that we've had pretty much tremendous growth every year. The only exception, really, 2019 to 2020 was when we ran out of capacity. We added a dedicated cardiac scanner in 2021. And then 2022 for us was some contrast shortage, kind of limited our amount of studies that we could do. And as Dr. O'Neill said, we do about the same amount of cardiac FFR as we do that they perform, somewhere in the 25 to 30% of our cases are sent for cardiac FFR. And so one of the questions we get is, you know, how did we build the program? Where did we start? You know, how did we get our first scanner? So I like to use this slide to kind of demonstrate, you know, where we were and kind of how we got to where we are today. Currently, we've got five shared scanners, which means they're shared between cardiac and non-cardiac scans and hospital-based systems. We've got one dedicated cardiac scanner in our Sanger Heart and Vascular Building. And then we've got two that are shared in an independent testing facility. So we pretty much have all of our billing models covered through these scanners. Most of our outpatients, we try to perform on our dedicated scanner, but we have geographically placed these scanners throughout our region so that patients don't have to drive as far to get a cardiac CT. So one of the questions people ask is, how did you get started? So what we did was in 2011, we had a hospital that's a thousand bed hospital, it's our main hospital in Charlotte. We had bed capacity issues, cath lab issues for capacity. And so one of the things we were trying to accomplish originally was we had a scanner that needed to be upgraded. And our goal really was, how do we justify spending $500,000 extra to go from a non-cardiac scanner to a cardiac scanner? And our theory was, if we did that, we could decrease length of stay for the chest patient cohort. Those patients traditionally were getting SPECT imaging, you know, they would come in, have to get a set of proponents done before they could be cleared for stress testing. We don't have a radiopharmaceutical on site, so we have to bring those in outside. As they all know, SPECT testing takes three or four hours. So we found that those turnaround times were incredibly long. And the nuclear lab was also limited in terms of, you know, if you ordered something after about noon or one o'clock, it wasn't going to get performed until the next day. And we did not have weekend coverage. So really our theory was, if we can add cardiac CTA, we can reduce length of stay, have better outcomes and better turnaround times and decrease length of stay. And so we did that for a couple of years. Internally, we started to see that there was a huge benefit to that model. So we decided to expand to our hospitals up in the north and the south so that we could offer that service. What we found was that it was such a hit with cardiology that we didn't have any capacity to add outpatients. And we ended up doing almost all inpatients because all of those inpatients needed the service and physicians saw the value and the benefit and started converting those from SPECT to CTA orders. So we added our first really outpatient scanner at an ED. The ED was busy, but we found that they had capacity in the morning. So that was really our first place where we started doing outpatient scans. We later moved that scanner to our Kenilworth building and backfilled that South Park ED scanner with a non-cardiac scanner. We were one of the first companies, our healthcare companies, to use FFR. We added it in 2018 before it was even reimbursed. I think Dr. O'Neill did a good job of kind of explaining why that technology is important, but I would emphasize that we also find roadmap incredibly important for our physicians. We have two and a half readers a day. We read about 50 studies a day. And if those readers can't get their entire study done that day and traditionally had to wait on FFR to come back, sometimes that would go into the next day when they were not assigned to read. And so it was very problematic in terms of their workflow and efficiency. So we found that that roadmap product is incredibly efficient. And you can see over the years, we've added scanners to really just support the geographic regions to the west or the east of Charlotte. We're adding another dedicated cardiac scanner next year, which is going to be an alpha scanner in our building. So we'll have two dedicated cardiac CT scanners that we will be able to perform about 44 studies a day on those two scanners at our heart and vascular center. And then we've got another hospital coming online. And really, our goal is over the next few years, we'll probably add another four scanners to complete our CT lineup at all our hospitals, and I think we'll probably be close to 20,000 studies at that point. So one of the things that we get asked a lot is, you know, how do you optimize your study and how do you improve capacity and allow patients in the door if you don't have capital to keep increasing equipment, adding equipment? So I always tell people to use data to drive decisions. And we use three metrics really to determine that demand. We look at wait times. We track these weekly, and I do that for everything that I manage for echo and CT and nuclear. And the reason it's important is we look at the first and third available appointments because sometimes you just look at first available, a patient cancels the next day, and all of a sudden you think you have plenty of capacity, whereas your third available may be 30 or 40 days out. So we track both of those, and that really is what drives our decisions on, you know, do we have enough capacity to support the demand? The next thing I look at is the number of orders generated per day. If we're generating 150 orders a day and I only have 75 slots across the system, obviously I've got an issue. And the way that we really look at the number of slots is not just the number that you have total, but really what's your no-show cancellation rate and make sure that you calculate that into the total number of slots that you have. You know, if you have 100 slots, but you have a 20% no-show cancellation rate, you really have 80 effective slots that you can use. So we always use those three factors to sort of support the need for increasing our capacity. If you see that demand exceeds capacity, one of the things you can do without spending capital is you can move from longer slots to shorter time slots. To do that, Rachel and I think we're going to talk a little bit more about the nurse navigation and scheduling, but it's really important for you to have a good pre-medication protocols. You don't want patients coming in the door that aren't ready to go on the scanner. That will, you know, seriously impact your efficiency. We can also add labor to reduce time slots. We used to have hour-long time slots. We added some labor to decrease those down to 30 minutes, and I'll show you that in just a second. Create a dedicated nurse navigator team. They're going to be really good at making sure that the people who are ordered for CTA are good candidates. They're not contraindicated, that you've got the right patient at the right scanner. Some scanners are better for bigger patients and for higher calcium scores than others. It just depends on the vendor and manufacturer. And then finally, we created a dedicated scheduling team, which again, improved our utilization, kind of reduced cancellations, and reduced our no-show percentage. So if you want to optimize the team, I talked about reducing the time that it takes to do a study. This is an example of how we did that. So originally we had one CT tech, and one RN. They would perform about eight studies a day. And I'm using the CMS hops rate. You know, if you're looking at it for your facility, obviously use your weighted reimbursement rate. So this is going to be a very low number compared to what your actual revenue would be. But you can see if you did eight studies, that's about $1,400. If you add another CT tech and go down to 30-minute slots, yes, your margins will decrease slightly, but your overall revenue per day goes up by almost $1,000 a day. So over the course of a year, if you looked at 254 business days, that's about a quarter million dollars a year. So that's an important way to add slots, increase capacity without spending capital. The next one is really nurse navigation. What we found is when your outpatient volume starts to go up, your utilization rates might start to decline because you've got patients coming in who are unprepared for that scan, or they're not really good candidates for CTA because of high calcium scores, stents, bypasses, those types of things. So we found that our nurse navigation team really helps improve that patient throughput, make sure that we have the right patients in the right space. And then finally, we ended up adding a scheduling team because we found that our central team that scheduled didn't have really the specialization to schedule these. We found that we had about a 22% no-show or cancellation rate. So we added in a dedicated team that reduced that rate down to about 10%. And part of the justification for doing that was we also look at making sure that we move FTEs as we've seen our nuclear spec rates go down. Just like Dr. O'Neill said, we've seen a pretty significant decline. We went from about 15,000 a year to 10,000. So we've taken staff and moved them over to support the advanced imaging, including our scheduling team. But you can see if you reduce your rate from 22% to 10%, looking at a case of 4,000 slots a year, that's about an additional $85,000 in revenue. And again, that's CMS rates. That's not real world dollars. And so I'll finish up with just a quick overview of consider adding this in ways. Be patient. You know, we started trying to support just our EDs, OBS, and hospitals. Once we established that that program was going to be efficient and work well, you'll start to get a lot of outpatient requests. Make sure you don't try and recruit patients before you're ready for them. Otherwise, you'll end up with two or three month backlogs. So we actually, you know, looked at our cardiologists first. How do we get access for them? Then we expanded it to our primary cares. We started looking at weekend coverage, night coverage, and then additional considerations. How do you incorporate cardiac, you know, FFR? How do you do remote reading, scan acquisitions? And then finally, the nurse navigators and scheduling teams really support the program. And I didn't put that one last because it's not important, but because I think it's just a nice transition. I'm going to turn this over to Rachel and let her talk a little bit more about the nurse navigation process. Hi, everybody. I'm Rachel Grant. I'm the program manager at Sanger and I work with Bill. Sarah Wallace and I are going to discuss the nurse navigator role in cardiac CT and also how it's used a little bit differently in each of our institutions. So a nurse navigator is not a new role in nursing, usually generally used in a lot of different areas to coordinate care. But for our purposes in the imaging world, we have a job description that it supports staff, patients, and family for education and information over on non-invasive cardiac imaging, and also collaborates with interdisciplinary teams across the footprint, across the process for the patients that are having their imaging. Physicians, nurses, the technologists and nurses on site to scan the patient and schedulers. We found in both of our institutions, the qualifications that are ideal for this position, a bachelor degree in nursing, a nurse with critical care, interventional cardiology, emergency or cardiac surgery experience. Those experiences in those areas seem to translate well into the detailed technical side of imaging and patient care. Also, an understanding of procedural nursing, not all bedside nurses make great procedural nurses. So understanding the difference between how a nurse works in those different spaces is important. And finally, it's important to have a detail oriented patient focus. We want that for all our nurse navigators, but excellent communication skills in that these nurse navigators are going to be communicating with doctors, with patients, with nurses, with technologists, with schedulers. So from the clinical side to the clerical side, good communication skills are very important. Daily responsibilities. What does a nurse navigator do in this space? As Bill and Dr. O'Neill alluded, appropriateness. Coronary CTA is an awesome, wonderful diagnostic test, but it's not for all patients. There are certain clinical concerns that have to be addressed for a patient to get a diagnostic scan. So, and also we want to address patient safety. So appropriateness is key. So appropriateness and patient safety, the medication protocols that Bill talked about help with scan quality and efficiency, making sure the patients come in prepped and ready to go at scan time. Another responsibility for nurse navigators is optimization of patients that might not fit all those clinical benchmarks. They may have a higher BMI, but they need the scan or a higher heart rate and they still need the scan. So the nurse navigators work with those patients and ensure their meds are optimized, that the scan protocols are communicated from the cardiologist reader through the care team on the radiology side, and also whatever scheduling adjustments that we need to make to get that patient to the right location. The nurse navigator also works to clarify imaging requests from the ordering providers. Often they'll want a coronary CT and then they'll want a thoracic aorta or look at a valve or something along those lines. So the nurse navigator helps communicate that across the care team. And then finally, they're very close to the work on the patient side and on the process side. So the nurse navigators are pivotal in helping us with the program development. How does a nurse navigator help with a cardiac CTA program enhancement? Patient safety. Can the patient's rate be dropped low enough and still be safe? Can the patient get nitroglycerin on the table and it's safe? There's so many areas of patient safety and a lot of concerns when someone's having a coronary CT. So the nurse navigators are the first line of defense in that area. Image quality, making sure patients come in with the right heart rate and the right meds on board, supports getting good images that are diagnostic and helpful to plan care. Nurse navigators also, along with the wonderful tools of heart flow, our readers have very busy days. So helping triage and manage patients and nurses questions from all our different locations, support our readers and allow them to work efficiently. Nurse navigators, I think at both of our systems, provide a lot of radiology support to the CT technologists and the scan side nurses. They help with standardization of practice, which is so important when you're talking about looking at quality outcomes and growing your program to provide access to as many patients as possible to this testing. And just like Bill and Dr. O'Neill discussed, efficiency. Having the right patients at the right scanner ready to go and understanding the clinical considerations of the patients helps with scheduling and efficiency at scan time. Next slide. Medication protocols. Medication protocols, we have an example in the packet when you're done. They are institution specific. Some institutions will okay a certain med and others won't. So there's an example that you can get after the webinar is over. But in general, how do they help efficiency? They help with nurse efficiency both prior to scan and on the table because they're not constantly having to call or check in with one of our physicians for the right medications. If you have those all laid out, they can order them independently based on the clinical considerations of the patient. They help with throughput and scan efficiency. Those pre-meds the patients are given prior to scan, they take those at home and they're able to come in ready to scan. They're not spending four hours at the scan site getting assessed, giving their meds and waiting to be scanned, which also increases patient satisfaction because they're not having to take a whole day off of work or half a day off of work and come in and spend a lot of time on site. And then finally, standardization of practice. Having the same meds given in the same situations across the whole footprint of your program is very important to identify any events or concerns, but also to ensure that your quality is consistent. Next slide. So as far as atrium, our nurse navigator team right now consists of three navigators. They work with patient preparedness and appropriateness. They're experts on deciding whether or not a patient is going to be a good candidate for a coronary CT and also what other non-invasive imaging they might be a candidate for if coronary CT isn't the right test. They are very involved in core care coordination, making sure that patient scans are scheduled in the right time frame prior to a visit, prior to a procedure, and they're also scheduled at the right time. They work a lot with the clinic nurses to make sure that the results of the scan come back to the doctor as requested, and they're big communicators across all the care teams. You have many people that touch these patients, and communication is such a big part of ensuring a quality scan. The scheduling process, we do a clinical review of all orders prior to scheduling. I think we're unique in that way. Our nurse navigators work in an integrative team with our schedulers, and that is because we were finding that patients were getting on the schedule that weren't appropriate for scan, and I'll get into that journey a little bit in a minute, but we also have a specialized epic order set and a specialized workflow for cardiac CT and MRI patients. Utilization rates, I'll discuss in a few minutes, and then some other responsibilities as we discussed in the general overview, program development with developing med protocols, patient pathways, and scheduling workflows, nursing training, helping train the cardiology, helping train the radiology nurses on site, and then also the clinic nurses on letting them be our first screen for appropriateness for some of these patients, and finally, they support sites, the nursing departments at each site when we implement, so they're on site to help show where the information is in the epic orders, and also how to care for those patients that present at a new site. Our journey, our role evolution in 2016, we were scanning about 2,000 scans a year. We were having radiology schedule those patients and reviewing this, reviewing the charts a couple days before. It was a whole total paper process, but we realized, A, that volume was increasing at a rate where we couldn't have a nurse review every single patient, and we also discovered at that time the importance of intervening and on the patient prior to putting them on the schedule, so fast forward to 2020. We were doing about 5,000 scans a year. We implemented a dedicated scheduling team. We decided on a scheduling algorithm what clinical concerns needed to be addressed by a nurse and what could go direct to schedule, so then we started pulling out the patients that actually needed nursing intervention, and the nurse navigator started reviewing those patients prior to scheduling. Next slide, please. So, with that integration, you can see here on this slide and on the next slide, prior to the integrated nurse navigator and scheduler team, our utilization rate in cardiac CT in 2019 was 89%, and then after we integrated those two groups, we increased that to 92%, which doesn't seem like a lot, but it's a lot when it comes to dollars, and then our biggest increase was cardiac MRI. We went from an 80% utilization rate to a 90% utilization rate, so that was a very huge benefit of the nurse navigator team working with the schedulers. Next slide. And finally, here's our numbers in utilization rate comparisons over the last three months of 2019 and 2020, so you can again see the differences in utilization rate and how we improved those. So, that's our experience at Atrium, so I'm going to hand it over to Sarah and let her talk a little bit about Cone. Thank you. Thank you, Rachel. Thank you. Thanks for having me. So, my name is Sarah Wallace. I'm a nurse navigator and program coordinator for Cone Health. So, we have three nurse navigators that work currently in our program. We manage CVT, MR, and cardiac PET, so I'm just going to go over a little brief overview of what we do on a day-to-day basis. A lot of this may be redundant after Dr. O'Neill, Bill, and Rachel have spoken, but basically, the nurse navigator helps to review for appropriateness and necessity. So, if a cardiologist is ordering a cardiac CT, we want to make sure that the order that they've placed matches the indication for the scan. We communicate with the patients for preparedness. This helps to ensure the adherence to pre-medications that the patient should take prior to their appointment. This also helps to reduce cancellations and no-shows. So, if we're able to speak to that patient and help them understand what they're going to expect during their appointment, it may help adhere to their appointment a little bit better. We also communicate with the imaging team a lot like Rachel was talking about. You know, we have a big multidisciplinary team with nurses, CT technologists, MR technologists, PET technologists, or nuclear medicine, excuse me, and we all communicate together on a daily basis about, you know, what patients are expected the next day, what the protocols are expected to be performed, if there's any kind of things to look out for for that specific patient, if they have contrast allergies, if they have kidney disease, they need to know those things ahead of time. We're also the point of contact, and we will also train others in the system. So, we help train our radiology nurses to help them understand medication protocols and the utilization of a cardiac CT. What is a cardiac CT for? What do we use it for? And then, we also educate clinic nurses because, ultimately, clinic nurses are the ones placing orders in the cardiac offices, but also point of contact for the imagers, like the technologists on the ground, nurses, readers, clinic staff, and others. We also have a dedicated schedule. We now have two dedicated schedulers, and we've educated them on the scanner parameters. We now have dual source scanners and Y detector scanners, and so we had to educate them on the limitations and the parameters that each of those scanners can handle, and then, ultimately, the protocol. So, one site handles most of our structural studies. The other sites can handle some of the other simpler protocols. We have a dedicated reader of the day. This helps to minimize the number of people involved in a specific day schedule. So, the nurse navigators also help to triage, as Rachel said, try to minimize the phone calls to that specific reader. We try to gatekeep some of the troubleshooting questions from the nurses and technologists to minimize the phone calls to the reader. We were able to improve our throughput and optimization by getting our scan time or our appointment slots down from 45 minutes to 30 minutes. So, this ultimately increased our daily slots from 12 scans a day to 17 scans a day at our main site. So, not only is the nurse navigator, you know, doing chart reviews and patient phone calls, but we also oversee new site development. So, we help plan new sites when we buy new scanners. We need to make sure that we have the correct equipment prepared for that patient when we start to see patients, making sure there's chairs, tables, vital signs machines, IV equipment, medications on site, things like that. So, that's been real critical in the planning. We're starting to build our new heart vascular tower, which will hopefully open in the spring of 2025. And then, we also meet with clinic staff. So, every quarter, I like to meet with the clinic staff, talk about new protocols that we've created, any new order sets that we've created within EPIC or EMR, or any just updates within the program itself, any new faces, any contact information that needs to be shared. And then, as Dr. O'Neill was talking about, We also help lead the process improvement meetings, which involves the multidisciplinary teams, schedulers, prioritization staff, administrators, leaders of each modality. We talk about barriers and how to overcome those barriers. And then we also coordinate with IT, again, creating new orders and protocols within the system. We are also the liaison to outside facilities. We have a couple non-Cone Health affiliated cardiology offices within our community. And so we've coupled with them to help perform cardiac CTs for their patients, so they're not having to send their patients to other facilities. So there's another slide that we can share that may go into a little bit more detail about that. And then I've also helped Dr. O'Neill to organize a monthly CT conference. And so this, we go over cases, we can compare cardiac CT data to catheterization data or MR or PET. And we just talk about scan quality, troubleshooting, interesting cases, things like that. And so every month we get an hour of CME credit through our local AHEC. And so that's been really good for us too. And then this is just an example of a proforma that we use. So in 2021, we hired our second nurse navigator because our volume was growing so exponentially that it was impossible for me to keep up with the demand by myself. And so with the addition of the nurse navigator, you know, we had to prove that the utilization or the benefit of a nurse navigator was to help improve the preparedness of the patient. So most of our patients arrive at their appointment with their heart rate already at goal. So about 95% of our patients don't even require additional medications on the scanner other than nitrogen in contrast. So no additional beta blockers or anything like that. And then this improved our efficiency on the scanner. So a 20% increase in efficiency on our, so less time on the scanner and better turnaround times. And then it's also helped to decrease the no-shows and cancelization. So this justified the need that we could get a dedicated scanner for our system. Thank you, Sarah. My name is Christopher Powells. I'm going to spend the next five minutes with a CMS policy and reimbursement update for CTA. I'm the director of pay relations at HeartFlow. So I work across our suite of services and advocating for all things coverage, billing, and reimbursement with the health plans, including CMS. Next slide. So the big news coming out of the CMS proposed final rule for 2025 was a proposed policy update in regards to the APC for billing cardiac CTA. Historically, payers, including CMS, and the payer systems have required CTA to be under an APC that lower values the calculation for reimbursement. And as we all know, with CTA, the cost structure is higher than other CTA services, such as a CTA of an organ or a CTA of the abdomen, for example, because of all the additional pharmacological agents, the nurse navigator, and clinical oversight of the patient. So this would effectively double the payment from $175 to $370,000. So this would effectively double $73 in 2025. Where we're at right now is CMS opened for a comment period to ascertain what hospitals are billing in terms of that revenue code. And also, they asked for feedback on any kind of barriers for cardiac CTA in making this decision to change the APC to a higher reimbursing level. So we will find out the results of this in the final rule, and those are expected to be released for 2025 in the first week of November. Really exciting to find out when that is released. Next slide, please. Next slide, please. Another update coming from CMS as it relates to the CTA pathway is for the AI coronary plaque analysis coverage. CMS releases local coverage determinations that act as medical policies for different services. Five out of the seven MACs released draft LCDs in July and opened up a comment period for the medical necessity criteria that was proposed in this LCD. The criteria is on this slide. We do expect now that the comment period is closed that the coverage indications to expand slightly for this AI coronary plaque analysis. The final LCDs are also expected here shortly. We expect them in the end of 2024, and from there, the CMS will have 60 days to release the final LCD as well as Medicare Advantage plans to also get their medical policies released to cover this service as well. Next slide. And I just want to round off this conversation with all these great inputs by the speakers previously, but there's an extensive support network to help in all of these areas that we hit on that HeartFlow offers to its customer base. For example, understanding and leveraging medical education resources for coronary CTA, as well as HeartFlow suite of services products, being able to engage peer-to-peer education and train physicians on the appropriate patients and all of the benefits of the HeartFlow technologies, including CTA. I sit in the market access department, so I lead a team that engages health plans and also works with our customers on proper coding and billing processes to achieve reimbursement and limit denials of all services. And then, of course, anytime you come across a case in which there's an issue, HeartFlow offers a team of ad hoc case support to bring resolution to any issues that you may have. So, this extensive support network is available, and I really encourage you to utilize your HeartFlow resources in streamlining your program. Thank you. And now I'm going to give it back to Joe to kick off our Q&A session. Yeah, thank you, Chris. I appreciate it. We can have all the others come online now, as well, if they'd like. Before we do Q&A, a couple of things. Number one is, remember, down at the bottom of your screen, there's a Q&A button. And if you click that button, you can submit questions. They will come up, and I'll be able to ask those. So, please feel free to do that now. Let me just say, the details, and when you think about a webinar like this, the real meat of those strategies in there was just excellent. So, I appreciate it. There's so much good information, and I'm sure will generate additional questions about how the rubber meets the road. Love the pro forma. Thank you for sharing in that level of transparency and decision-making. The reimbursement update was just fantastic, as well. And I'm sure we'll have a lot more as well. I mean, everything was great. So, I'm grateful for that. We do have some questions coming in. I've got my own. I thought of it as you guys were all speaking here, but I'm going to take some coming in from the audience first. The first one is, do your schedulers also obtain prior authorization? So, I'm not sure that's really directed at anybody. Go ahead, Sarah. I can say, we have a dedicated authorization team that is employed through our heart care offices. And so, they do a really good job of getting that authorization prior to the patient's appointment. We also have a very streamlined communicative process, either through teams or through EPIC, the EMR itself. And there's also a pre-service center who's going through all scheduled cardiac radiology scheduled patients. And they're going through making sure it has an authorization. If they don't, within like four hours of their appointment, they're flagging it, they're telling us. And so, then we are hopefully able to get that authorization before the patient's appointment, so we don't have to reschedule them. But we do have a dedicated team. Yeah, I was going to say, same thing for Atrium. There's a separate authorization team that handles all of that. And then the schedulers just really focus on getting the patient scheduled at the right scan or the right time that works for them. Okay, so we're leaving that with the prior auth team, and that's where it fits in both of your workflows. Chris, did you have a comment there? No, no comment. Okay. Okay. So, as we wait for more to come in, I have my own. I love the pro forma that was presented, and I understand generating the savings and really increased revenue by having a nurse navigator program. What if I'm in a situation where I just don't have that level of dollars available, or I can't make that case in my organization? How can I do all of this without a nurse navigator? How do we move forward without that essential role? And I didn't know if anybody had tips for take that core part of this webinar away. How do I still move forward in terms of growth? Any thoughts? I think you can start with your scan side nurse. You're going to have to have a nurse that's managing those patients at the scanner. And depending on how your volume trajectory is, that nurse can split half time appointments in the morning and order review in the afternoon in coordination with scheduling and things like that. I think there's a way to do that on the scan side. And then also there's probably an opportunity in your clinics with the providers to have the nurses there do a little bit more higher level appropriateness tests to make sure that the patients that are coming to scan are the right ones. I think you just have to keep an eye on your volume. And when the scale tips, then you might need a dedicated resource to do that. And Joe, the other thing I think from a business perspective is if you look at the way that volumes drop in spec and stress echo from traditional testing, what we did was we moved FTEs. So either that person was retrained or if they left, we would take that FTE and move it over to support advanced imaging. So that's another way that you can support the program without adding net new FTEs. And that was very successful in our program. Excellent. Well, thank you both for that. I have another question that's come in. And again, please feel free to continue submitting these questions. But new one that's just come in. I saw one presenter say there are two and a half readers to read about 50 CCTAs a day. How much time does it take per read? And are these readers also reading other studies like MRI and PET? So I think that was us. And we've got two and a half. So one is dedicated to structural heart. Those are going to be cases that are incredibly complicated to read, valve disease and things like that. That person typically will read around seven or eight a day max. The other two readers are going to read somewhere in the 20 number. And they're going to be reading basically the bread and butter CTA studies. So we have two and a half readers every day. They read about 50 studies a day. Those ones are going to average around 20 a day for the CTA bread and butter stuff. Structural heart reader is going to average somewhere around six, seven, eight, just depends on the volume that day. And are those folks also trained to read other studies or are they reading? So they're not reading them in that time period. Those are full CCTA readers, but they may also have the ability to read other MRI, PET, et cetera, but that's not a part of your time calculation. Is that correct? Yeah, that's, yeah, that's not part of their reading day. They're going to be assigned that full day to read nothing but cardiac CT. Now they might also read echo. They might read nuke. Most of them do not read cardiac MR. That's such a specialty that if they have that skillset, typically that's all they do because our program, we do about seven or 8,000 cardiac MRs as well. So we've got a dedicated group that reads those procedures. So our CT readers do not typically read MR, but they can read other modalities, but they would be assigned a day, like every, you know, probably two weeks they read a day of echo. And then they might read a day of CT and then they might have clinic days, general service, that type of thing. So it would be split up for us. Got it. I think that answers that one. If that doesn't, please feel free to do another follow-up question. I've got another one that's come through here. The new high-speed one beat CT scanners reduce or eliminate the need for heart rate reduction meds. Can you speak to your experience with that and how the nurse navigator duties change with a one beat scanner? So I can take that one, Joe. So I'd say it doesn't eliminate the need for heart rate reduction meds. You still have to look at the temporal resolution of these one beat scanners. They tend to be, have lower temporal resolution than dual source systems, but regardless, it does scan in one heartbeat. The thing that we've seen with those scanners is that as long as the patient comes in prepped and we have a 95% success rate with pre-medications, if their heart rate's good to go, it's really easier on the nurses there. They don't need to give as many meds and the technologists don't have to think as much. So I'd say for those sorts of scanners, it does allow you to streamline certain patients as long as you send the right patient to that scanner, but it's not going to obviate the need for heart rate reduction, if you will. So yes, it can make it a little easier. There is a trade-off quality depending on how you want to look at it, but for the most part, you can triage your day. And that's what our nurse navigators are able to do to send patients to the appropriate scanner. Yeah. And Joe, I'd also say that we tend to put those scanners in our regional offices. As Dr. O'Neill said, they're just easier to operate. So you don't have as much error from the technical side, but they don't produce quite as good of quality images as the dual scanners. Got it. I have another question I'd like to ask, but I've got one that came through. I think it's a very quick answer. And it's two questions. So let me fuse them together. And they're pretty much the same question. And it's about overreads. And it's saying, if your readers are cardiologists, are you having radiologists do the overread of the rest of the chest? I have yet to see a program that doesn't do that, but I'll let both of these programs answer either person about overreads. Yeah. We have all of our readers for advanced cardiac imaging at Cone Health are cardiologists, but we do have an agreement with our radiology group to provide an overread. I'm also unaware of any site that is doing it on their own. I think most sites have a rad who's overreading the non-cardiac portions of the exam. Yeah. We're exactly the same way, Joe. Yeah. I've yet to find one yet that isn't doing that. Let me ask you one more question, and then I think we'll have to close out the webinar. But that is, I want to understand about expanding your referral network and how the orders are coming in from outside providers. Because as we talk about growth, to me, it's like, how are you managing that? And that's not an apples to apples across different programs the way maybe overreads would be. So how are you working to expand that referral network, and how do you bring those orders into your program? And I know we're very limited on time, so I'd like to maybe just look to you, Dr. O'Neill, maybe you and Sarah, to answer that. Yeah. Yeah. Sarah, why don't you go ahead and answer that? Because we've worked hard on this. We did. So like I said, we have a couple non-Cone Health affiliated offices in our area. And so we worked with our BDR, our Heart Flow Business Development Representative, Susan, and Tecla. It was previously Tecla, now Susan. We worked with them. Primarily, we worked with Bethany Medical, but we had a dinner with them, kind of explained the utility of a cardiac CT, why it was helpful in helping diagnose coronary artery disease. And we kind of came up with a checklist of things that we would need from their office in order to get that patient scan done. So basically, from a nurse navigator and chart review standpoint, making sure that the patient was appropriate for the scan and didn't have like chronic kidney disease or anything like that that would preclude them from having a cardiac CT. And so it's a completely paper process at this point, because they don't use Epic as their electronic medical record. So they'll fax us a packet of information, including like health and physical, lab work, EKG, and an order signed by the cardiologist. And so once we get all that information, we call the patient and we put them on a schedule. They, since they are the referring office, they obtain their own prioritization. Yeah. And Joe, just to echo that, it's really about developing pathways for outside networks to order these studies. We've even looked at primary care referrals, but really what Sarah's role is to do is to set up a checklist and make sure she talks with representatives from those offices to kind of make sure everything's in line to actually get the order through. And that's kind of what we've done with that whole process. Okay. Well, and there's also a note that if anybody wants to learn more about this, we do see that there's some resources in the appendix of the PDF of the slides, if you want to hear more about kind of outside referral networks. We could go on for hours asking questions of you all for all the great work that you've done and shared with us today, but we do need to bring this webinar to a close. So thanks to all of our presenters for participating. Chris, thanks for representing HeartFlow and helping to put this together. Appreciate you bringing all these talented folks to the table. And thanks everybody for attending today. Again, we will send a follow-up email. You will have access to the slides if you have not yet downloaded them from the chat and of course can follow up through us and we'll be able to pass on any other additional questions you have to the presenters of today's webinar. So thank you all so much. And with that, we will conclude today's webinar.
Video Summary
The webinar, titled "CCTA Operational Efficiencies, the Nurse Navigator Role, and Other Practical Approaches to Program Growth," explores strategies for enhancing cardiac CTA programs. The key focus areas include leveraging the role of nurse navigators, adopting efficient processes, and expanding referral networks to foster program growth.<br /><br />Speakers from Atrium Health and Cone Health detail their approaches and successes. Dr. Wes O'Neill from Cone Health highlights the efficiency of coronary CTA and FFRCT in diagnosing obstructive coronary artery disease, emphasizing the diagnostic accuracy and program efficiency benefits. Bill Cunningham from Atrium Health discusses operational strategies, including efficiently using existing resources to accommodate increasing demand without significant capital investment. He also emphasizes the importance of administrative support, skilled technologists, and a physician champion to manage these programs successfully.<br /><br />Rachel Grant and Sarah Wallace discuss the specific responsibilities of nurse navigators, emphasizing their role in ensuring patient preparedness, appropriateness, and coordination across care teams. The integration of nurse navigators with dedicated scheduling teams has notably improved utilization rates and streamlined processes, enhancing the overall efficiency of cardiac imaging services.<br /><br />Christopher Powells from HeartFlow offers an update on CMS policies affecting cardiac CTA reimbursement, noting potential financial improvements that could also impact program expansion.<br /><br />Overall, the webinar underscores the significance of refined workflows, cross-functional collaboration, and leveraging available tools and resources to maximize cardiac imaging efficiency and program growth.
Keywords
CCTA operational efficiencies
nurse navigator role
program growth
cardiac CTA programs
coronary CTA
FFRCT
Atrium Health
Cone Health
CMS policies
cardiac imaging efficiency
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