………………..……………………………………………………………………………………………………………………………………..………………..……………………………………………………………………………………………………………………………………..
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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Se
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
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Imaging: Empowering Patients
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