………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

Strategic Planning for

Cardiovascular Imaging:

Examples of Synergy

Rajesh Krishnamurthy,

Radiologist-in-Chief

Nationwide Children’s Hospital

Professor of Radiology

The Ohio State University

Columbus, OH

Scope of talk▪ Thoughts on collaboration in the modern world

▪ Why integrate strategic planning for cardiovascular imaging?

▪ How does imaging fit into current concept of health and disease?

▪ What is at stake with impending changes in healthcare?

▪ Success stories

▪ Alignment in Philosophy: Patient centric approach

▪ Strategic plan for advanced imaging: CIBA, PAIR, EWI, integrated reading

▪ Research Priorities: DMD, coronaries/ischemia, aortopathy, TEVG, iCMR

▪ Education: flipped classroom, hands-on education, tech/nurses/analysts

▪ Opportunities for improvement

▪ Integrated reporting

▪ Operational integration for improved patient flow and satisfaction

▪ Shared data collection for ACHD2

………………..……………………………………………………………………………………………………………………………………..

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

"These blind men, every one honest in his contentions and certain

of having the truth, formed schools and sects and factions..."

-- Lord Buddha.

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

Comprehensive free-breathing 3D imaging of CHD in 10 min

Lost in Translation!

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

Limitations of Single Center Innovation Studies

▪Inadequately powered

▪Center-specific selection bias

▪Heterogeneous patient sub-types

▪Limited external validity

▪Results prematurely incorporated into clinical

guidelines as ‘best available evidence’

▪Confusion and skepticism regarding value

Virtual angioscopy (left) and intraoperative photography

(right) of anomalous RCA with slit-like ostiumArrow: LCA

Arrowhead: Slit like ostium of RCA

Screening/diagnostic tools in SCD

• Who is at risk of sudden death?

• What is the relative risk of anomalous R. vs L.?

• What are the morphological factors associated with increased risk?

• How good are we at diagnosing/grading risk factors?

• How do we decide management: observation, exercise restriction, surgery?

………………..……………………………………………………………………………………………………………………………………..

16 y male with Ross procedure for congenital aortic valve dz, dilated aorta, came to the ED with acute chest pain. Rule out aortic dissection, PE

Target mode prospective EKG-gated CTA , <1 mSv

………………..……………………………………………………………………………………………………………………………………..

Behind the veil..Before Now

IV access Small IV placed in ED/floor, multiple sticks in

complex situations, new IV needed in CT

Protocol driven. 20G lowerextremity IV after EMLA cream in ED, with radiology ultrasound backup

Coverage Entire chest and upper abdomen Heart and aorta

Type of study Aortic dissection protocol Triple rule out

Technique Helical, retrospectively gated Target mode prospectively gated dual-volume CTA

Radiation exposure 4-5 mSv < 1 mSv

Outcome Dissection ruled out. Separate CTA to rule out PE. If coronary imaging needed, will need cath

Single study rules out dissectionand PE, and diagnoses separate origin of LAD with moderate stenosis

Specialist availability 7a-5p, M-F 24/7, CV trained techs and CV faculty availability

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

Concerns about imaging growth and unselective utilization

▪Medicare Payment Advisory Commission: 2000-2009 – spending on

imaging services grew at TWICE the rate of spending on all

physician services

▪Cost of imaging

▪Rapid rise in high tech use: 1995 - 3-5% of health insurers’

outlays – now-12-15%

▪Shotgun approach: Insufficient consideration of likelihood of

disease, performance characteristics of test, how test will affect

management

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

Imaging as a CommodityAnthem and United insurance out-patient imaging

policies for children >10 years

………………..……………………………………………………………………………………………………………………………………..

Save Our Specialty!

Most technical developments, however sophisticated, have little impact on patients

Focus away from diagnostic volume, to clinical value

Poor track record of showing value

Poor track record of standardization & sharing data

Poor funding for imaging centered outcome studies

Numbers needed to influence management, cost or outcome not possible in a single center

Current Concept of Health and Disease

DNA

RNA

Proteins

Cell

Tissues/Organs

Organism

Behaviors

Environment

Tension between Precision and Complexity: Elias Zerhouni

………………..……………………………………………………………………………………………………………………………………..

Role of Imaging

• Enhancing Precision

• Solving complexity

• By

• Extracting spatially and temporally resolved morphological, functional and multidimensional biological information from humans

………………..……………………………………………………………………………………………………………………………………..

Current Role of Imaging: Enhancing Precision

………………..……………………………………………………………………………………………………………………………………..

Multi-dimensional Scope of Imaging Biomarkers

RegionOrgan

TissueCell

Ultra-structure

Gene

………………..……………………………………………………………………………………………………………………………………..

Vision of the Health Ecosystem

………………..……………………………………………………………………………………………………………………………………..

RISE Model for Impact with Innovation

Krishnamurthy R. SCORCH meeting, 2017

………………..……………………………………………………………………………………………………………………………………..

The search for valueAnswer: Patient-Centric Imaging

Reinventing Cardiovascular Imaging:

A Patient-Centered Vision

ACR

………………..……………………………………………………………………………………………………………………………………..

Imaging Vision

Enhance clinical value of cardiovascular imaging by:

• Develop clinical and research programs focused on institutional strengths

and patient flow

• Break down siloes around specialized care by building and strengthening

partnerships

• Focus on imaging quality, safety and efficiency

• Create efficiency and cost-savings by sharing advanced resources across

enterprise

• Expand community access to proven solutions, complex procedures and

expert care

Children’s Imaging Biomarker Alliance

………………..……………………………………………………………………………………………………………………………………..

25

MorphologyBiomechanics and Function

Flow/ Microvascular

Processing/Workflow

Molecular/ Metabolic

Comparative-Effectiveness Analysis Healthcare Provider Education

Image-guided

Therapy

………………..……………………………………………………………………………………………………………………………………..

Children’s Imaging Biomarker Alliance

Programs PAIR Partners

Quality and Safety Umbrella

Enterprise Wide Imaging & Informatics

ChildrenCommunity

CIBA: Programs in Cardiovascular Imaging

Cardiomyopathy and Myocardial Characterization

Complex CHD

Pulmonary and Systemic vasculature

Research, Education, Technology

• Neuromuscular disease• Stress MR myocardial perfusion, viability, MR functional testing and Coronaries• Multi-parametric mapping of the myocardium for cardiotoxicity

• Single ventricle• Complex 2 ventricle repair• Transitional and Adult CHD imaging• Cardiac CT programs: Neonatal imaging, AAOCA, PA/MAPCAS, Airway

• Connective tissue disease• Pulmonary hypertension• Venous thrombosis• Vascular Malformations

• Radiation reduction with C-CT• Accelerated/abbreviated imaging and workflow to reduce sedation and improve patient satisfaction• Comparative effectiveness analysis: value of advanced imaging biomarkers via pediatric imaging registries• Patient-specific treatment planning and device development• Interventional CMR• Tissue engineered vascular graft program• Biomechanical modeling in CHD• Large Animal Imaging• Interface Informatics and EWI

………………..……………………………………………………………………………………………………………………………………..

Cardiomyopathy and Myocardial Characterization:

Neuromuscular disease

• Combine imaging biomarker development in cardiovascular, musculoskeletal, gastro-intestinal and

pulmonary areas with functional testing, and genetic/lab biomarkers in discrete disease groups to

determine therapeutic choice and outcomes

• Collaborators: Kevin Flanagan, Jerry Mandell, Linda Cripe, May-Ling Mah, Linda Lowes

• Objectives

• Provide expertise for design/selection of MRI outcome assessments for clinical trials in NM disease

• Provide access to uniform and accepted MRI outcomes in therapeutic and natural history clinical trials

• Develop and validate new MRI markers as surrogates for clinically relevant disease progression

• Technological advances:

• Rapid unsedated imaging protocol in young patients

• Multi-parametric mapping of the myocardium and skeletal muscle

• MR functional testing with treadmill

• Explore new markers: Elastography, radiomics, DTI

28

………………..……………………………………………………………………………………………………………………………………..

Pediatric Advanced Imaging Resource (PAIR)

Enterprise wide vision

PAIR

Imaging Subspecialists

Imaging Scientists

Novel Imaging Techniques

Advanced Image Analysis

3D modeling & Printing

Centralized hardware &

Software

………………..……………………………………………………………………………………………………………………………………..

Optimization of Imaging Resources

Employ a data-driven hub and spoke radiology

service model to tailor offsite offerings to

market and service line demands while

decompressing main campus clinic.

PAIR

Location/Space

Patient Flow

Engage Business Process Improvement to

evaluate patient flow processes and implement

an action plan that will:▪ Increase efficiency

▪ Determine need for in-clinic support on a service line

basis

▪ Enhance patient and provider satisfaction

StaffingHire key staff to support expansion in imaging

informatics, innovation, research, and medical

imaging science.

………………..……………………………………………………………………………………………………………………………………..

Resource Prioritization

Impact on Patient

Care

Innovative

Collaborative, Caters to

Institutional Strengths

Aligned with Institutional

Priorities

Passion and Track

Record

Expertise

………………..……………………………………………………………………………………………………………………………………..

PAIR lab: Post-processing• Standardized Post-processing:

– Arterys

– Circle

– Neosoft

– Medis

• Vitrea (6 licenses) 64 bit, access to radiology, cardiology, cath lab, animal lab

• Reporting

– Structured templates, need updating with reporting elements

• Patient Database: not updated since 2012, moving to EWI/EDW based database

• 3D printing

– MIMICS/3-MATIC

– Geomagic Freeform

PAIR lab

Integrated Advanced Cardiac Imaging Reading Room

3D Printer Printer

Cleaning Stations

Design Work Stations

………………..……………………………………………………………………………………………………………………………………..

Children’s Imaging Biomarker Initiative (CIBA)Partners

34

• NCH Clinical Departments

• NCH Research Institute

• Ohio State University

• Pediatric Hospital Network

• Funding Agencies

• FDA

• Equipment Manufacturers

• Software Vendors

The Link: Enterprise Wide Imaging & Informatics (EWI)Imaging Interoperability to Improve Outcomes

Vendor Neutral Archive

Connect

Capture

View

Access

Exchange

Analyze

………………..……………………………………………………………………………………………………………………………………..

Enterprise Wide Imaging at NCHTransformation Overview

Enterprise Wide Imaging

36

………………..……………………………………………………………………………………………………………………………………..

What is needed to scale our services?

Standardize, standardize, standardize…

• Standardized operating protocols

• Standardized imaging protocols

• Standardized reporting

• Standardized metrics

• Integrated HIS/RIS/reporting/research database

………………..……………………………………………………………………………………………………………………………………..

Integration of Imaging Data into the

healthcare enterprise (IHE)

Standards allow exchange of clinical/imaging data:

• HL7 v3

• Cross-enterprise document sharing (XDS, XDS-I)

• FHIR (Fast Health Interoperability Resources)

– Enrich patients’ clinical record

– Provide reliable, authorized access to it across the enterprise (and beyond)

AAOCA Standardized Interpretation Template

A. Type of AAOCA

B. Ostial morphology

C. Location of coronary ostia

D. Ostial relationship

E. Presence and length of intramurality

F. Course through commissure or column

G. Dominance

• Radial location (middle of sinus, juxta-commissural, commissural)

• Vertical location (annulus to commissural edge, commissural edge to sinotubular (ST) junction, at ST junction, above ST junction)

AAOCA Interpretation Template

C. Location of Coronary Ostia

AAOCA Interpretation TemplateC. Location of Coronary Ostia

RCA ostium: 1b, II

LCA ostium:1c, III

RCA

LCARCA LCA

AAOCA Interpretation TemplateD. Right-Left Ostial Relationship

Type 1 Type 2 Type 3 Type 4

• 2 signs of intramurality: Based on oval shape AND absence of peri-coronary cuff of fat

• Length of intramurality measured on coronary cross-section

AAOCA Interpretation Template

E. Presence and length of intramural course

How do we measure intramural length

by CT

Oval versus round shape

Peri-coronary fat sign

Intramural Segment Mediastinal Segment

Right dominance

Anomalous LCA from right sinus

Adjacent ostia in the middle of R sinus below ST junction (1b, II)

Round configuration of both ostia, no stenosis

11 mm intramural course crossing column

AAOCA Interpretation Template

F. Course through commissure or column

………………..……………………………………………………………………………………………………………………………………..

Key Elements

Today’s Readiness Assessment• Volume Review• S-MESA

Problem Accountability• Quick Hits• Complex Problems

Metrics / Goals

CIBA Operational Model: Daily Readiness Huddle

………………..……………………………………………………………………………………………………………………………………..

The Daily Huddle

………………..……………………………………………………………………………………………………………………………………..

Division of Responsibilities• Cardiomyopathy/Myocardial Characterization:

– Kan Hor

• Ischemia/coronaries

– Simon Lee

• Congenital heart disease

– Rajesh Krishnamurthy

• Fetal Imaging

– Corey Stiver

• Pulmonary and systemic vasculature

– Julie O’Donovan

• Cardiac CT

– Cody Young

• Informatics

– Eric Diaz

Advanced Imaging Dyad Leaders

for the Heart Center:

Drs. Kan Hor and

Rajesh Krishnamurthy

………………..……………………………………………………………………………………………………………………………………..

Resources for Dyads

Dyads

PAIRImaging

Scientists

& Analysts

Imaging Innovation and

Research

Office (IRO)

Informatics

Quality and Safety

Education

………………..……………………………………………………………………………………………………………………………………..

Reducing Sedation Rates for Pediatric Chest and Cardiac CT at NCH

Reduce the sedation rate for patients undergoing

chest and cardiac CT studies by 80% during Sep

2017-Feb 2018, when compared to Jan-Jun 2016, and sustain until Sep 2018

Key Drivers InterventionsAim

Target mode EKG gated CT protocol

Patient Selection

“Do Not Harm Me”Uncompromised diagnostic

efficacy without any additional morbidity from

sedation

Utilize 320-detector volumetric scanner to develop target mode EKG gated protocol to control respiratory, cardiac and gross motion artifact

Identify qualifying patients correctly based on indication for CT

Train technologists to use standardized protocol correctly by adjusting for respiration, choosing motionless phase for reconstruction the motionless phase

Measure diagnostic adequacy, objective image quality, and call-back rates

Training and Implementation

Diagnostic Adequacy

………………..……………………………………………………………………………………………………………………………………..

Road to Imaging Value

– Know who we are: We are clinicians tasked with impacting patient outcomes

• Create sustained focus on patient needs

– What will be is already here

• Turn focus from future innovation to existing solutions

– Imaging Value lies in interdisciplinary data

• Break down siloes in data sharing

– Focus on quick hits

• Improve safety

• Meaningful or ‘Smart’ Innovation using scalable biomarkers that enhance precision and clarify complexity

• Create Technology Assessment Group for pediatric cardiovascular imaging

51

………………..……………………………………………………………………………………………………………………………………..

P4 Priorities for Pediatric

Cardiovascular Imaging: Clinical

• Scale programmatic interventions that impact outcomes and cost

• Decrease harm:

– Eliminate the need for sedation for pediatric imaging procedures

– Substantially reduce or eliminate radiation exposure of pediatric imaging

procedures

• Utilize disease-specific imaging biomarkers for functional status,

treatment candidacy, treatment outcome, prognosis for strategic

priorities

• Participate in registries for collection of ‘big data’ for top 3 conditions

………………..……………………………………………………………………………………………………………………………………..

Arterial tortuosity and outcomes in Marfan

syndrome and Loeys-Dietz syndrome

Circulation 2011

………………..……………………………………………………………………………………………………………………………………..

Freedom from Thoracic Aortic Dissection – Marfan syndrome

P=0.008

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

< 20 20-39 >=40

No surgery

Prophylacticsurgery

Surgery forTAD

………………..……………………………………………………………………………………………………………………………………..

• Use wisely: comparative effectiveness research• P4 medicine: Enable earlier detection of disease, prognosis

– Advance quantitative image analyses and computational methods for radio(gen)omics

– Patient specific treatment planning and device development with 3D modeling & 3D printing

• Data mining and AI: – Understand complexity– Reduce variability, improve reliability, throughput

P4 Priorities for Pediatric Cardiovascular Imaging:

Research

………………..……………………………………………………………………………………………………………………………………..

Imaging Research Office Milestones

• Formation of Imaging Research Office (IRO)– Streamlined weekly project intake, feasibility review, and finances; integration with NCH IRB, CRS, and IACUC

• Dedicated research 3T Siemens PRISMA MRI– Dedicated research days; streamlined scheduling and standardized discounted cost for usage

– Advanced and accelerated sequences including CS, GRASP, RAVE, ASL, multiband

– Dedicated reconstruction pathways

• Industry Collaborations– One stop shop for all vendor agreements for imaging research at NCH

• Large Animal Imaging Capabilities– One stop shop for all vendor agreements for imaging research at NCH

– All imaging modalities feasible: MR, CT, PET, SPECT, 3D angio, US

• Misc.– Dedicated imaging research website (external and intra-net)

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

Data Sharing at NCH

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

Pediatric Data Sharing Organizations

▪Patient Centered Outcomes Research Institute (PCORI)

▪PedsNET

▪Pediatric Surgery Collaborative

▪Pediatric Heart Network (PHN)

▪Congenital Heart Surgeons’ Society (CHSS)

▪Imaging Registry of Orphan and Rare Disease (I-ROAR) at the ACR

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

How Can Big Data Help Us?

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

Cognitive Computing Journey

Time Critical

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

Combining Knowledge- and Data-driven Risk Factors

Jimeng Sun, Healthcare Analytics Dept, IBM Watson

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

JimengSun, JianyingHu, Dijun Luo, MarianthiMarkatou, Fei Wang, ShahramEbadollahi, Steven E.

Steinhubl, Zahra Daar, Walter F Stewart. Combining Knowledge and Data Driven Insights for

Identifying Risk Factors using Electronic Health Records. AMIA (2012).

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

Common data driven risk factors for heart

failure in adults

Jimeng Sun, Jianying Hu, Dijun Luo, Marianthi Markatou, Fei Wang,

Shahram Ebadollahi, Steven E. Steinhubl, Zahra Daar, Walter F

Stewart. Combining Knowledge and Data Driven Insights for Identifying

Risk Factors using Electronic Health Records. AMIA (2012).

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

64

Challenges related to Pediatric CV Imaging Registries

Data and Evidence Base

Regulatory and Legal

Clinical Integration

Clinical Utility

• Data inconsistency

• Data instability

• Data quality

• Observational data

• Validation

• Data security

• Patient privacy

• Patient consent

• Implementation

• Reporting elements

• Standardization

• Imaging value

• Predictive accuracy

• Unintended results

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

▪Patients about imaging value

▪Referring physicians about imaging appropriateness and utilization

▪Continuing education for faculty, technologists

▪Hands-on training in technical innovation

▪Core curriculum for students, residents, fellows

P4 Priorities for Pediatric Cardiovascular Imaging:

Education

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

Educational Highlights▪Weekly advanced cardiovascular imaging meeting

▪Online imaging protocols

▪Flipped classroom approach for didactic curriculum implemented

▪Faculty, technologist education program started

▪Advanced imaging fellowship in cardiology with MR focus

▪New 2nd year Pediatric Cardiac Imaging non–accredited fellowship approved in radiology

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

Flipped Classroom

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

‘DORV in your Hands’ Workshop

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

Imaging Metrics in ACOs:Looking beyond Process Metrics

▪ By contributing directly to improved patient outcomes

▪ Reduced mortality from sudden cardiac death in children based on the provision of effective

screening programs

▪ Reduced number of imaging-related morbidity related to sedation and radiation

▪ By contributing to reducing all costs over an episode of care

▪ Accurate and timely diagnosis of neonatal manifestations of CHD not adequately characterized by

echo, which results in reduced need for catheterization, duration of surgery, and intra-operative

manipulation/imaging.

▪ Prompt access to specialist imaging services, which reduces length of stay in the ED and hospital

▪ By contributing to reducing the length of an episode of care

▪ Reducing time to diagnosis with

▪ Early imaging or imaging-guided intervention

▪ Time to initiation of treatment

▪ Determination of short-term response to therapy

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

Sedated Chest

CT21 20 20 20 27 16 27 24 19 24 14 12 14 12 11 12 16 10 8 7 7 5 7 7 6 9 7

Total Chest CT 28 31 37 36 35 25 38 38 25 42 23 35 36 30 39 33 33 33 21 29 21 26 26 40 32 42 46

0%

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da

ted

CT

Ra

te

Chest CT Sedation Rate0 - 4 Years

Monthly Sedated CT Rate Process Stage Mean Process Stages Control Limits

Year - Month

Desired Direction

Chart Type: p-Chart

65.3%

35.2%

November 2016Target Mode

Technique Implemented

July 2017Default Order Changed to No

Sedation

22.6%

Reducing need for sedation for imaging in little children aged 0-4 years

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

Reducing radiation from cardiovascular

CT scans in Children

New Technology

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

72

………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..

Imaging: Empowering Patients