Welcome everyone to our next webinar with HeartFlow and Coronary CTA. Today, we're going to talk about clinical evidence and guidelines that meet the real world. My name is Jamie Warren. I am part of the MedOxium Care Transformation Team. Today, we have a fantastic panel from both North Shore and from HeartFlow that are subject matter experts that are going to walk us through some of the barriers and challenges that they've overcome with starting and scaling their CT program. Next slide, please. Just a couple of housekeeping items here. First, at the bottom of your screen, you will see a blue button, and this is where you will be able to access the link to download today's presentation. On the right-hand side, you'll see a green button that says Q&A. For this one, this is where you can enter in your questions that you may have. I do encourage you to enter in your questions as you think of them as we go throughout the presentation. We will answer as many questions as we can live at the end, but we will also answer these and have these available on the on-demand webpage if you would like to come back and look for the Q&A. Next slide, please. Here, just briefly do a quick introduction, and then I will turn this over to our panel. I'd like to start the discussion off of where did we start and where we are today. Where we really started with this is with the changes in the chest pain guidelines especially with coronary CTA, and placing this as our frontline diagnostic tool. Next slide. Just a quick summary of some of the changes that were specific to cardiac CT was about our class 1 recommendations with level of evidence A, and our appropriately selected patients that had both stable and acute chest pain syndromes. It is also favored in our patients under 65 years of age, or when less obstructive CAD is suspected. It's a high diagnostic sensitivity tool with a high negative. I'm sorry, I lost my screen for just a moment. There we go. High predictive value, and it has a risk stratification tool. This is used to roll out for low-risk acute chest pain, and then the warranty periods for our CT is what is two years and stress test is one. Next slide, please. Back in 2021, we did a survey with our MedAxia members and we're able to identify a few of these data points. Our first one was, is that we saw that SPECT to CT imaging was at a 58 to 1 ratio. When we looked at our MedAxia members, those that were performing or interpreting CT was at 42 percent. Our SPECT studies saw this at 92 percent. Some of the barriers with starting a CT program that were identified, were being able to have CTA readers and being able to access the technology, as many times the CT cameras were sitting in the radiology suite. The other piece of this had to do with the reimbursement and RVUs that were applied to it. The impact was to the current revenue streams, also with the physician compensation, and then program resource allocation. Next slide, please. Fast-forwarding to today, I was able to pull some data from a recent survey that we did with our provider compensation. What you're going to see is a steady increase in our CT programs. This first slide here is showing how many per 1,000 active patients. Then on our next slide, we're going to see the adoption of being able to offer the imaging modalities. Again, in this, you will see that we have an upward tick in adoption of our CT programs. Next slide, please. When taking a look at our med access data, we've really seen a percentage of change over 2017 to 2022 with the different types of tests being ordered. Now, all of these are still being ordered, but there is a difference in the frequency in how we are seeing these being applied as a diagnostic tool for our frontline patients. Next slide, please. A quick introduction for our speakers. We have Anita, Dr. Mishkal, and Dr. Prasani from North Shore. Then joining us later, we will have Dr. Rogers that is going to help us with our panel discussion. Thank you. Thanks, Jamie. When we transition to the next slide, I'm Greg Mishkal, I'm the Chief of the Division of Cardiology at North Shore. A very exciting day for us at North Shore because we just underwent our rebranding and will henceforth be known as Endeavor Health. But we didn't have time to update the slides since the announcement was just made an hour ago. But North Shore represents an amalgamation or coming together of nine hospitals across the Chicagoland area that services a population area of approximately 4.2 million people. Of that 4.2 million people, which by the way is one-third of the population of the state of Illinois, of that 4.2 million people, we have about 1.2 million of that, and we're the third largest healthcare system now in the state of Illinois, with 2,400 beds and 27,000 colleagues, including in that 2,000 employed physicians. The data that we're going to be sharing with you today really represents the experience of two of the hospitals in the North region. That's the dots in blue, and that's Evanston Hospital and Highland Park Hospital where most of our coronary CT scans are performed. Northwest Community Hospital and Swedish Hospital have a nascent coronary CT program representing the first year of their operations. Next year, Glenbrook Hospital, which will become the cardiovascular hub for the Endeavor Health System, will be getting a new CT scanner as part of that rebranding of that particular site. Next slide. As we thought about a strategy in terms of imaging for the assessment of chest pain, we thought about it in many different ways, but I think ultimately, we thought about it in terms of efficiency and waste. When we look or we think about waste, there's an acronym called TIMWOOD, which is there are seven ways. TIMWOOD, transportation, inventory, motion, weighting, overproduction, overprocessing, and defects. As you think about your various pathways for assessing chest pain, and there are many different ways of assessing chest pain, I think it's interesting to think about what is the most efficient of those pathways? Where is there the least waste? This is just a list of these wastes again, TIMWOOD. Potential inefficiencies or wastes associated with each one of these categories. For instance, if we think about the waste called defects, well, that's anything that generates false positives and negatives. If we think about weighting as a waste, then examples would be pre-authorizations, procedure time, processing time. Similarly, transportation, easily could think about, for instance, nuclear scanning, moving patient from one site in the hospital to another site to get their scan and then back to the treadmill test and so on. Without going through each one of these potential wastes, I think it is an interesting exercise as you look at each of these diagnostic strategies to think about how much waste or how much inefficiency is entailed with each one of those workflows. Next slide. So from our perspective, and we have access to all the modalities, we have stress testing, obviously, stress echo, stress spec, and stress PET, as well as coronary CT angiography. But we've made a conscious decision not to move patients from one of those pathways to CT scanning, but we've made a decision to adopt CT scanning strategically as our primary focus. And what are the six reasons that we chose to do that? Well, number one is, as you're going to learn, there's an increasing body of evidence with guidelines suggesting this is the thing that we should be doing. In our minds, and you're going to hear from Amit Prasannani, there's typically better quality and accuracy. There's certainly less radiation to patients, actually, with respect to, say, SPECT scanning. As it turns out, it's a less expensive test than nuclear scanning. It gives us many options beyond what we see with stress echo or stress nuke in terms of identifying treatment strategies based on the results that we see, as well as looking at opportunities for medical therapy, say, with the recognition of vulnerable plaque. And then ultimately, in our minds, it was a more efficient test and reduced waste. Next slide. This is just an example of the efficiency. This is data that's derived from the PRECISE pathway. And I'm not going to discuss the endpoints, but the highlight of this slide is that if you took 100 patients and you just chose the typical pathway, whether you chose stress echo, a treadmill test, stress nuke, or a CT scan, versus a pathway where CT scanning plus FFR was utilized as the first choice, what ended up to those patients who were being evaluated for chest pain? And what you see from this diagram is that the CT FFR pathway in this PRECISE trial, called a PRECISION pathway, yields less false positives, if you will, higher diagnostic accuracy, and is a much more efficient use of resources because you end up identifying those patients who benefit from a revascularization strategy much more efficiently than in the conventional pathway. Next slide. The other thing that I love about CT scan, it's a two-for-one. Talk about efficiency. And this is two reports from two separate patients all in one week. Both patients either had known coronary disease and were being assessed for progression of disease or had a high likelihood for coronary disease. And both patients presented with dyspnea. And I honestly thought when I ordered the coronary CT scan that I was going to find that their dyspnea was an anginal equivalent. Well, as it turns out, on the lung overread, we identified one patient with a pulmonary embolism and we identified the other patient with an unrecognized lymphoma. Next slide. And I think what this points out is the importance of really developing a strategy of how do you interact with these scans in radiology. And there are many different strategies that need to be undertaken. In our case, the gentleman with the halo over his head is the chairman of the Department of Radiology, who we had a somewhat tenuous relationship with until we undertook a trip to Germany together to look at Siemens' home plant. And this was really an opportunity for cardiology and radiology to come together and bond and talk about how we could be a cooperative venture rather than a competing venture. Next slide. I illustrate this slide not just to demonstrate the growth in our volumes with over 2,000 cases projected this year, but to highlight the increase in volumes after each of the guidelines were updated. And I highlight here that that can only happen if you're driving out, you're driving your car, looking out your windshield rather than the rear view mirror, meaning we anticipated that the guidelines were going to support a CT-first strategy. And we ensured that we had a sufficient install base and reader base to match what we anticipated to be the demands. Next slide. So this, I think, near final slide, highlights what's happened in the, or the next to final slide, what's happened with our various diagnostic tests. And what you see now in the top bar to the far right in 22, we're approaching 25% of all testing for assessment of chest pain. Have I been on, I've been on mute this entire time. It keeps going, I hope I haven't been on mute the entire time. No, I just went to mute. I don't know why. This slide demonstrates what our current ratios are for. I apologize, but my computer just spontaneously goes to mute. So what you see on this slide, I'll watch to make sure I don't get muted again. What you see on this slide is that this year we expect CT scanning to be about 25% of our volume for diagnostic testing for chest pain. And this interestingly enough has not come at what I would consider a major expense of nuclear scanning which has fallen only about four and a half percent which I think is probably less than the national average in terms of the reduction of nuclear scanning. We see that it probably comes at mostly at the. Next slide. And here we see what's happened in terms of, I think this is very interesting because it mirrors what we saw with the PRECISE pathway. Which is we see some reduction in diagnostic catheterizations but an increase in the overall volume of the cath lab because there's a higher, a greater increase in interventional cases. We live in a very fixed population base. There's not a lot of growth in the Northern suburbs of Chicago where we're located. And so this increase in the interventions is almost directly related to a greater identification of patients through the CT pathway and a need for revascularization. So I apologize for the technical problems with getting intermittently muted here and I'll pass the baton off to Dr. Prasannani. Thank you so much, Greg, for setting the stage. And I also wanna thank MedAxiom and HeartFlow for the opportunity to participate in this discussion panel today. So I'll be talking about clinical decision-making and building and optimizing a CCTA program. And next slide. First part of what I wanna talk about is why coronary CTA has really become a first-line approach for evaluation of coronary artery disease. And first and foremost comes its high test accuracy. So why do we need to have a more accurate test than perhaps stress testing or stress echo or stress nuclear? Well, this was investigated in the NCDR registry in a paper in the New England Journal of Medicine back in 2010 by Manesh Patel and colleagues where they looked at nearly half a million individuals who had suspected coronary artery disease and underwent elective cardiac catheterization. What they found was that only 37.6% of those patients actually had obstructive coronary artery disease at catheterization. And if they underwent non-invasive testing, which was essentially stress testing at the time and had a positive result on that stress testing, they were only modestly more likely to have obstructive coronary artery disease than if they hadn't undergone any testing. So this tells us that 60 plus percent of patients end up in the cath lab without obstructive CAD that does not undergo revascularization. So that's the main need for a more accurate test. Now, accuracy has been looked at in coronary CTA in a variety of different trials. And one of those trials that really kind of is a pivotal trial is that of the accuracy trial itself. And in the accuracy trial, the patient population included individuals who were of some risk. These are patients who had an average BMI of 31 and Agatine calcium score close to 300 and a quarter were diabetic. And what they found in the accuracy trial when compared to a gold standard of coronary angiography is that this test had very high sensitivity in the high 90s, as well as a very high negative predictive value of essentially 99%. The specificity was also high at 83%, but not nearly as high as the sensitivity and negative predictive value. And the positive predictive value was modest. So next slide. What about prognostic value? What does the extent and severity of coronary artery disease on coronary CTA tell us about outcomes? Well, we have a tremendous amount of data on this. A lot of this comes from the confirmed registry of many tens of thousands of patients that were followed for years for MACE outcomes. And this is a schematic, I think that really sort of nicely illustrates going from no CAD to one vessel CAD to two to three to left main coronary artery disease and cumulative survival over a two year period. So the greater the extent and the greater the severity of coronary artery disease, the worse the outcome. What about the impact on cardiovascular outcomes? Next slide, please. We know a lot from two randomized controlled trials. On the top here is the SCOTT-HART trial and on the bottom is the PROMIS trial. Both of these trials were similar in the sense that they looked at stable chest pain patients that were randomized to two different diagnostic testing strategies, either an anatomic strategy, which included coronary CTA, or a standard of care stress testing strategy, so by, well, what you can see sort of here in the top slide with the SCOTT-HART trial is that if one chose a diagnostic testing strategy that utilized coronary CTA, there was a difference in terms of the survival of those patients at a two year time point. And what you can see on the right side and what you can see on the right side, actually on the left side here, is that if you account for the implementation delay, and an implementation delay means that first couple of months during which that coronary CTA is performed, results are communicated to the referring physician and medications are instituted, preventive medications based upon the amount of disease, revascularization is instituted, you actually see a significant difference in the overall cardiovascular outcomes based upon what diagnostic testing strategy is chosen. So patients who start with the CTA do better than patients who start with stress testing. And similar findings were seen in specific cohorts of the PROMIS trial. So the overall PROMIS trial looked at two year outcomes, anatomic CCTA versus functional stress testing, and showed no difference in outcomes. But if you splay this out and look at the diabetic cohort, you see that choosing a diagnostic testing strategy of coronary CTA first led to better outcomes. Next slide. So this is a point that I think is very important for referring physicians and for primary care physicians perhaps in particular to recognize is that one can have a variety of different findings on coronary CTA that could lead to the same finding on a nuclear stress test, specifically a normal nuclear stress test. So one could either have no coronary artery disease to the left here, diffuse non-obstructive coronary artery disease involving perhaps multiple epicardial coronary vessels, or have non-obstructive coronary artery disease with vulnerable plaque features. And all of these nuances would not be appreciated on a patient who perhaps kind of underwent a nuclear stress test where all of this would potentially be normal. So again, nuclear stress testing is only gonna pick up patients who have significant obstructive coronary artery disease where there's a perfusion defect and we'll miss the patients who have non-obstructive coronary disease. So I think that's a huge advantage of coronary CTA. And then next slide. And I think, you know, Greg Mischel kind of alluded earlier to sort of the two-for-one, being able to kind of look at incidental findings or lung findings at the time of looking at coronary CTA. But there's another sort of two-for-one that we have with coronary CTA, and that's the incremental value of FFR. So the test is turned from something that used to be considered just an anatomical test, looking for coronary disease, looking for blockages, looking for plaque, is it non-obstructive or obstructive, to a test that also looks at the functional significance of lesions. And we can look at this hemodynamic significance via a non-invasive tool called CT-FFR. So we know, look at the left portion of this slide here, we see from the FAME trial that revascularization decisions that are made based upon the functional significance of a lesion, that is the invasive FFR value, leads to better outcomes than decisions that are made purely based upon angiographic stenosis. And in an analogous way, utilizing CT-FFR, the non-invasive equivalent of invasive FFR, this also results in better downstream outcomes, looking at a composite endpoint of all-cause death non-fatal MI or cardiac catheterization. Dr. Mischel showed this nicely in the schema of the PRECISE trial. Next slide. There's a wealth of data on the use of CT-FFR, and I have a listing of a number of the different trials and registries that have looked at the utility of CT-FFR. DISCOVER-FLOW, DEFACTO, NXT, these were some of the pivotal trials looking at accuracy of this modality with respect to invasive FFR as being the gold standard. The ADVANCE registry is a very large registry of patients who have had CT-FFR done, looking at downstream outcomes in various populations. And then we have more pragmatic trials, including PLATFORM, FORECAST, and PRECISE, the last of which we went over. And then FISH & CHIPS, which is really an interesting population health study, which has looked at the incremental impact in the UK health system of adding CT-FFR and what effects it's had at a population health level. And in fact, the cardiovascular outcomes in the UK have gone down with the addition of utilizing CT-FFR as part of the diagnostic pathway. And all of this has led to the incorporation of CT-FFR as being a class 2A recommendation in the ACCH guidelines. Next slide. So Dr. Mischel pointed out our timeline of CCT-A growth here at our North Shore Endeavor Health System. And you can see essentially exponential growth here with doubling of our volumes of CCT-A cases every couple of years. And we anticipate that in the next year or two we'll probably be exceeding 5,000 coronary CTAs in our system. So I like to break this down into a few different time periods. I've been at North Shore for almost 10 years. And if we go to the next slide, we'll talk about where we were within the early days of the program. And in the early days, I like to time this sort of between 2015 and 2018, we were only doing a few hundred cases. And at this time we had 45 cardiologists, four hospitals, but only had one cardiac CT scanner that was housed at Evanston Hospital that was really our scanner for doing CT-FFR. And we were doing cardiac CTs. We had adequate CT reading and reporting software at the time, but we really had exceptional support, collaboration with radiology to help us to develop this program. My goal around this time was to establish an advanced imaging presence, being available for questions, being available for handling, is this an appropriate patient for the test? And also in terms of communication of results of the test. Look at the coronary CTA results, and if they were positive, make a phone call to referring physicians. And really tried to continue that as much as possible over the years. Our focus was predominantly on quality. There's a lot of nice quality guidelines and metrics through the SCCT website that one can refer to, but we had a really good understanding of what our capabilities were, what heart rates we could scan at, what patients might be best for this modality and following all these best practices. And from a nursing standpoint, we shared resources with interventional radiology at that time. Next slide. Now, when we started to gain momentum was the 2019-2020 ballpark. And really here, our focus was more on efficiency, really worked on our pre-medication protocols in terms of patients being orally beta blocked beforehand, specific IV beta blocker protocols when the patient was brought to the CT suite. Wanted to get our scanning algorithms in check, when to use prospective gating, what phases to use of the cardiac cycle. We worked a lot on our epic order sets. We developed in conjunction with radiology in the hospital a schema for radiology reading incidental findings, which before this we were doing independently as cardiologists with some radiology help. We had a shared nursing framework for nurses that helped us with both cardiac CTs and cardiac MRIs. Significant increase in staffing, technologists, nurses during this timeframe to help with the increased volume. I think certainly during this time period, we also developed this partnership with HeartFlow and were able to offer CT FFR as an incremental value to the coronary CTA test. You know, as we showed, this is a test that allows for greater accuracy, greater specificity, as well as a reduction in layer testing. We started to see this transition point, you know, from being perhaps a secondary test to being a more mainstream first-line test for evaluation of chest pain, both in the acute and stable chest pain setting. And this also allowed for us to have greater communication with radiology management. Of course, this is also the time around which we had the beginning and the early stages of the pandemic. And we developed a system via which we could remotely read cases. And there was also a greater appeal for coronary CTA because it was a more hands-off test than some of the other testing options. And next slide. And then 2021 onwards, and this is sort of the new era post-ACC AHA guidelines. And really, I would say the big keyword here has been communication. We have lots of meetings with radiology management and hospital leadership. These are strategic meetings that really kind of focus on how we can continue to sort of develop this program, how we can continue to give access to this modality to our patients and do this really in a consistent way across the health system. We continue to improve efficiency by looking at nurse navigators, in-house 3D lab, post-processing units, working with our pharmacy to provide free complementary beta blocker samples to patients who are ordered for coronary CTA, constantly investigating new technologies, including plaque analysis, which can give us a more nuanced understanding of coronary artery disease, as well as newer scanner technologies and lastly, I think a very important part of our program here at Northshore has been education. And this is across all fronts. We even have a advanced cardiac imaging fellowship here and we certainly kind of make it a big part of our institution to educate our fellows in coronary CTA, similar to kind of how they get education and other imaging modalities. Next slide. So here's where we were in 2016. Here's where we are now and here's where we expect to be over the next year. And you can see that this is obviously a huge sort of increase in the number of staff, technologists, nurses, as well as reading physicians, number of hospitals where we offer this modality, educational trainees being engaged in coronary CTA from an early stage and then obviously the hardware component, including infrastructure in terms of hardware and scanners. So I'll end off there. Great, Dr. Bristani, Dr. Mischel, thank you both so much for those presentations and discussion. Congratulations on the new branding for your healthcare system. That's really cool. Amazing timing. It's really neat. It's my privilege to help with the panel discussion now and we have some points we'd like to bring out and we'll certainly leave time at the end for questions coming in from the audience. I did wanna take a second just to introduce Anita Zawodniak who is the Vice President of Clinical Operations and Radiology at Endeavor North Shore. So Anita, thank you so much for joining. I know what a critical part of this journey you've been as well and really look forward to your input during this discussion. And what I thought I would do is start with a question. I'm gonna ask the question and I would love for each of you to answer in whatever order you deem fit. And it's as follows. There was a lot of discussion about the ways in which radiology and cardiology intersect in this journey. And at the beginning, you're establishing the collaboration, defining what a shared program might look like. And then of course, as it grows and the growth you guys have seen and driven is pretty remarkable, I expect it needs to change. So here's my question. As you start the program, what would be the two most important factors needed to establish CTA and FFRCT? Again, with a particular lens on dialogue with partnership, with collaboration, with your radiology partners. So maybe I'll start. Maybe Dr. Birzani, would you take the first stab at that? Two things you think would be most important. Sure, absolutely. So, I see the word clinical champion and pathways here. And I think a lot of folks at my institution would probably turn me the clinical champion of this modality. So I think that's important, but it's obviously a team effort here. And as you saw, it takes really radiologists, readers, cardiologists, readers, it takes technologists, it takes nursing staff, and it takes really kind of a whole team of administrators and other folks to really kind of make this work. But I think kind of at some level, I think it takes an individual who has a lot of passion for this modality. And I've been in the CT field or the space for I think over 15 years now. And this is kind of something that I'm super sort of passionate about and really kind of do my best to really educate many kind of the folks kind of at our institution about this. I think one of the things that I've done that I think has really kind of helped with our growth, has been really just being involved in conferences, being a point person for cases that come up and for questions that come up, being a point person for educating the rest of the group in terms of the clinical trials and the needs. So I would say the teamwork, the clinical champion piece of it. And I think what ties in with that also is education. And education is something really kind of at all fronts, that we really kind of strive to work at here at Northshore. And then maybe next to Anita, let me ask you, how would you think about that? The critical factors for success? So a couple of things, first of all, thank you for having me, I'm thrilled to be here. You're gonna hear a lot of discussion about the collaboration between radiology and cardiology, but to Dr. Persnani's point, when I think about a clinical champion, I think that is one of the biggest components of this. And when I think about that role, I think about it from an educational standpoint and educational or educating the staff. And as the program grows and different things become available, Dr. Persnani has been instrumental with my radiology staff in educating them on scanning techniques and image quality and just ongoing that has made them better technologists and really able to provide quality work. So I think without that, we would be in a big struggle. The other piece, I think from the very beginning, and I say this a lot in a lot of different arenas, what's in the best interest of the patient, right? When we come together and we talk about developing a program, what are we looking to get from that program? What are the outcomes we're looking for? And what are we trying to provide as far as patient experience and patient outcomes go? And I think we did that early on and that was just, you know, some brainstorming discussions that we had that really helped us put the pillars of this program together and determine timelines and that type of thing. And that's an ongoing conversation. We still meet every couple of weeks, once a month, whatever that timeframe looks like to talk about where are we, what does the growth look like? What have we missed? What do we want to see moving forward? So it's not just a one and done. It's an ongoing conversation. So for me, the two biggest things are the physician champion and looking at what is in the best interest of the patient. Great. Thank you. And Dr. Mischel, your thoughts? Well, it's an all encompassing list, but you forced me to pick two. And I think what I would do is I would piggyback onto what Anita said, and I would pick the bottom of barriers to overcome alignment with hospital or system leadership and strategy. Because in a way of this, you know, the biggest issue that faces cardiology or administrators is how much cannibalization is going to be going on here. And to Anita's point, we did sit down very early on after I came and we talked about, you know, we were charging, I think, $750 for a coronary artery calcium score. And we said, listen, this is a lost leader. You know, we do over 6,000 now, this is a lost leader. We have to understand what's really going to drive growth for you as a system, but what's also in the best interest of the patient. And frankly, hearing Anita say this, not just once, but I've heard her say it repeatedly, really was helpful in terms of driving this strategy forward, because the system said to us as a doctors, what do you think is best? But it is crucial to deal with your hospital system, because you're talking about capital equipment cycles, and then install times, and coordination and education of staff. You know, this is not just, this is a team sport. So that's number one would be alignment with a hospital or system leadership and strategy. You'll meet a great partner with Anita, and I want to thank her publicly for that. The second thing I would pick would be the physician compensation and the model for physician compensation. And maybe actually, I think I had a prepared slide. If we go to the next slide, Campbell. One of the things that we had to acknowledge, particularly when we were getting up in terms of the number of scans, was the amount of time that it took in terms of the readers for CT scans, say, versus reading, say, a stress echo. And so we fortunately, or we revamped our comp model. It went into place in July, but it took a year to do. And one portion of the comp model now has moved from work RVUs to time value RVUs, where we acknowledge that certain diagnostic imaging just takes more time and should be valued higher at the expense of other imaging modalities that take less time. And so the person who's doing structural TEs, helping to guide the mitral clip, gets paid a much higher value than the person who just does a regular TE, because they're completely different services. And this will be something that we address every six months to a year to make sure that our time value really represents reality. But this is important in terms of buy-in from our physicians. Our 60-odd physicians understood this. Some were impacted negatively, meaning they've lost RVUs in this. Others will be impacted positively, but everyone understood that as a division, we wanted CT scanning. And the same analysis is going to have to occur with the overreads for radiology. So that's extremely interesting. I'm glad you brought that up, Dr. Dimitrico. It really strikes me that some looking at this transition for the first time might think, in terms of the professional RVU world, that this is something which is cut and dried. It is what it is. Somebody's declared these values, and we just need to implement them. And hearing from you, there is this plasticity that you have the latitude to do this as you please, as long as you get buy-in from people. And also what I heard you say is, and actually I heard each of you say this, which is super interesting, is that this is not a one-time, okay, here's what you do, do this, and then forget it. Don't think about it again. I heard this need to revisit it, and you said meeting every so often, and that ongoing education, Greg, talking about revisiting what we see on the screen right now, doing it periodically so that it's evergreen. It's really interesting. It's not just, okay, we're going to go CT first and whatever, and just everybody's going to start on Monday. Let us know how it goes. This really takes an ongoing engagement, which is, I think, a very important point out of this. Anita, let me come back to you. Let's talk about this switch, and Dr. Mischel brought up this, there are some ways in which you're offsetting higher revenue procedures with lower revenue procedures, at least at one point in time. Leaving aside the physician piece, which Dr. Mischel just spoke about, how do you think about that? Honestly, some might term it as cannibalization at a system level, and realizing, of course, as you said, patients come first, patients at the center do what's best for the patient, listen to the clinical champion, but there also is, of course, the reality of that potential cannibalization. How did your system think about that, comes to terms with that, and accommodate that? That's a really good question, and that really goes back to when we started to have these conversations, we looked at the vision of our system, right? The vision of our system is rooted in four main pillars, and so everything we really do or decide to do, we go back to that vision, and we say, how does that match up to what our vision for the organization is, and two of those four main pillars, one of them is care model redesign, which talks about, is this going to advance clinical outcomes, is this the right thing to do for the patient, does it fall into what we're trying to do as a vision, and the other thing you heard Dr. Mischel talk about earlier is efficiency and productivity, are we eliminating waste, and so it's not always about the dollar amount of the difference in the procedures, but what that waste equates to as well, from a resource standpoint, staffing standpoint, when you talk nuclear stress, you're talking sources that need to be brought on site and all of that, so I think when we look at things as an organization, we look at them based on the vision that we put together for ourselves, and so there is that difference in financial reimbursement, that type of thing between the procedures, but when we look at what we were trying to do, all the while, too, creating a state-of-the-art cardiovascular institute for our organization, which of course, this is a huge part of that, so we had to weigh those options. You know, the other piece I would say, from a CT scan standpoint, is we now manage our radiology service line by modality, so by that, I mean we have several hospitals, right, so we are able to say, okay, we're going to look at CT as a modality across the organization, not specific to each individual facility, so in order to be able to provide the cardiac CTA services at two of our hospitals, which are time-consuming and the program is growing and we need more opportunities there, we then can look at the other CT scans, the other procedures that we do, and move those to different places, so we're able to do that with a lot of different things because of the way we manage across the modality line, but again, it all goes back to the vision of our organization and how does this play into that, and is it the right thing to do, and long-term, it will be the better outcome, given the decisions that we made. So that's interesting, and I have a follow-on question. As we do that, I'm just going to ask Jamie, if you come back on, and I think we hopefully will have some time for some questions from the audience, but as we're doing that, Anita, one follow-up question is, does that same, what I heard you saying a little bit, is flexing across different service lines, how does that apply to staffing? Because obviously, everyone in healthcare during COVID, post-COVID, there is this ongoing battle to find well-trained technologists and nurses. What are some creative solutions that you've been able to implement to help? I think that's one of our biggest challenges, I'm sure it's everybody's. We feel like we're competing for that same pot of individuals, and there's always somebody down the street offering a little more money or a lot more money, so we came together and said, okay, how can we creatively help ourselves and really not only create what we need from a staffing standpoint, but create a win-win for our staff as well, give them the opportunity to grow in their careers. And so we did that in nursing with taking some of our radiology nurses, our interventional radiology nurses, some cardiology support as well, and giving people the opportunity to cross-train into these areas. That was one piece, but the one piece I'm really proud of is what we did to satisfy our CT shortage was we took our x-ray technologists that had an interest in cross-training in CT, because that was our biggest struggle with CT techs, and so we worked with our learning and development program, and we developed an internal CT training program that has definite metrics, definite timelines, and we were able to offer that to our CT techs that were already employed in our system that really wanted to learn another modality, gave them the opportunity to do that, and expand their careers all the while helping us. We've had almost 20 people, 20 technologists now go through that program and cross-train into CT, and I'm pleased to say we haven't lost one of them to another organization. They're valued by us, and they're thrilled to have that opportunity. So that was one of the ways that we did that, and it's been very successful for us. Great, thank you. Thank you for sharing that. It's interesting, both the investment in your people and also the fact that by making that investment, they have a tendency to stay around and pay you back by staying around and providing their expertise. That's neat. Great. Jamie? Just to dovetail really quickly, I also think it goes back to what I said earlier, and that is the fact that Dr. Persnani, in the development of this program, was very hands-on with the staff, and still is, to work with them and be able to teach them and make them better scanners. I think that, as opposed to throwing them out there and saying, okay, go do this and do it well, and I think that's been very valuable for the team. I've gotten a lot of feedback on that, so I just wanted to mention that as well. Great. Well, thank you for that panel discussion. Jamie, if you're able to come back on and let us know if there are questions from the audience, that would be great. To all of our panelists, thank you for the discussion. We could go on and on. Jamie? Thank you also to our panels. We do have a couple of questions that have come in. The first one is regarding the adoption of an ED pathway for acute chest pain. The question is, what is needed to establish this pathway? Sure. I'm happy to start with that. The ED or acute chest pain pathway for coronary CTA has honestly been something that's continuing to evolve at our institution. We do have some innate challenges within our system, being several different hospitals, not all of the hospitals having a CT scanner that's capable of doing cardiac CTs, not all of the institutions having CT technologists or nurses that can support this program. It has been challenging, but we have now devised a program where we have an integrated pathway that includes heart score, which looks at various risk factors and EKG findings and high-sensitivity troponin. In those patients who have intermediate heart scores and intermediate high-sensitivity troponins, they fold down a pathway of cardiovascular imaging. Within that cardiovascular imaging, we have worked with our ED physicians in terms of prioritizing coronary CTA as being the first modality to look at. This has obviously been validated and looked at in a number of clinical trials from MCAT 1, 2, CT STAT, ACRIN PA, and so on and so forth. I think there's a lot of buying from our emergency department physicians, but I think what they would love to see is an institution where we have a CT scanner at every hospital, same algorithm everywhere, 24-7. That's something that I think is a little bit futuristic and we've been working within the capacities that we have to be able to offer it. I'd offer a couple of thoughts. The first was, there's now guidelines or a document from multi-organizations, multiple organizations saying that CT scanning should be considered a first-tier test for the emergency room. That's number one, is look at that document from the Society of Cardiac CT. Number two is start with data. Is the juice worth the squeeze? How many patients are we actually talking about who would have an intermediate heart score that aren't like crazy chest pain, go home, we don't need any testing, or you've got a cardiac issue, you need to go to the cath lab. We got our utilization folks involved very early on, and we did some modeling looking at how many patients were being held in the emergency room, awaiting some form of additional testing or waiting for results. Based on that analysis, we said, yeah, there is a significant number of patients, maybe four, five, six, seven a week, that this is something that's worth examining. Then the third thing was really to pull together a multidisciplinary group of folks, our hospitalists, our ED physician, our system executives like Anita, because I said to Anita exactly what Amit said, is that we want, I want a CT scanner in every emergency room in our system, but it all starts with the data and determining is the juice worth the squeeze. Very good. Our next question is, it was mentioned about a couple of different patient types where CCTA and FFR is appropriate for suspected evaluation of CAD. Are there other patient types where this would be appropriate? Yeah, so maybe I can speak to that. Certainly from what we have evidence for heart flow, and they include, for example, use in patients who are being considered for solid organ transplantation for whom coronary disease screening is quite important and often relies on invasive angiography, you know, patients who are awaiting renal or liver transplantation, for example. So that's one. Another I would point to is patients, and I know Dr. Prasani has really led on this, patients who are being considered for aortic valve procedures, particularly TAVR procedures. So that's another where this pathway may have relevance, and maybe Amit, you would want to comment on that. You guys have, again, led the way with gathering data in that population. Yeah, no, we have a, you know, super strong structural interventional program and do a high volume of TAVR patients, and these referrals come in from, really, sometimes quite far from, you know, where our institution is. And it makes it more convenient, really, for a patient to be able to, you know, look at kind of whether they've got significant coronary disease on the CT that they're already getting done for TAVR planning, for annular dimensions, and for peripheral vascular anatomy. So it's sort of a free information as we see it, and we have now routinely integrated for every patient who doesn't have a recent invasive angiogram to formally report coronaries on all of those CTA TAVR studies. So we have, you know, pretty good evidence now kind of looking at this and implementing it as part of our clinical workflow that it's safe to do so, and it results in, you know, fairly high degree of diagnostic studies, and we're able to utilize CT FFR as indicated in the majority of them. And then the third I would mention, Jamie, is the patients who have peripheral vascular, peripheral arterial disease, who often present because of that, yet have lurking really significant coronary disease that their activity level has been reduced because of their peripheral disease, and they aren't able to manifest the typical symptoms of coronary disease. So there's a fair bit of evidence we've been able to gather in that population that looking at their coronaries can identify critical coronary disease, and doing it with CTA, and especially people with peripheral disease, is obviously a relatively safer undertaking. And I think we can squeeze in one more question. Any best practices or suggestions on the shared RVU COMP model between cardiology and radiology for the rates? I'm glad we left that with only one minute to go. So when we started doing this, I worked with Anita and the COO of our system, advocated for the radiologists, and we assigned bogey RVUs for the overreads, because they are not reimbursed through most payers. And I think that has worked up until probably now, and maybe Anita can take it from here. I think my powers of advocacy probably have been exhausted, but bogey RVUs worked to a certain level because the system ended up paying for those bogey RVUs without any revenue. Anita, thoughts? So yes, this is very timely, as you know, Greg, because we're working on this now. That did work, and it worked well when the volume was lower. As now we're growing our program, and it's getting more and more complicated. Obviously, the lung overread is critical for the patient. So we're in the process now of working with our radiologist leadership and the organizational leadership on what that should look like. Everybody recognizes the importance of those overreads, and there's significant volume of them now. So I don't have a solution to share with you, but we are in the process of trying to develop that as we speak. We're ending on a tough question there. I wanted to, as we're wrapping up, send a very big thank you to our panel and to HeartFlow for today's session. To those that are listening, please note that this presentation, the recording will be available on the MedAxium website, and any questions we were not able to get to today will be answered by the panel and be also available on that site. So thank you very much for joining us today, and thank you again to everyone for attending, and have a great day.

coronary CTA program

radiology

cardiology

clinical champion

education

communication

cannibalization

hospital leadership

financial impact