MYOCARDIAL PERFUSION IMAGING FINAL REPORT

Guide and Checklist for ICANL Report Compliance by MYOCARDIAL PERFUSION IMAGING FINAL REPORT Patient Name: DOE, JOHN D. Gender: M Date of Study: 4/2/2013 Date of birth: 6/28/1962 Age: 50 Medical Record #: 45869725 Ordering Physician: JANE INTERNIST, MD History: Chest Pain, Abn ECG, High Cholesterol, Hypertension, Positive Treadmill Test Indications: Assessment of chest pain, Positive ETT AUC: Appropriate use criteria met - Indication #38 NUCLEAR IMAGING PROTOCOL: Same Day Rest Stress 5.8 mci of Tc-99m sestamibi was administered via IV injection at rest. Approximately 45 minutes afterwards, cardiac SPECT imaging was performed. A stress test was then performed and at peak exercise, 17.9 mci of Tc-99m sestamibi was injected IV; approximately 45 minutes post injection, cardiac gated SPECT and prone cardiac gated SPECT imaging was performed. Attenuation correction was not used. STRESS PROTOCOL: Exercise Stress Test The patient exercised on a treadmill utilizing the Bruce protocol; they completed 11 minutes & 10 seconds, achieving approximately 12.9 METS. Baseline heart rate was measured at 62 bpm, and increased to 185 bpm at peak exercise; which is 108% of the maximum predicted heart rate. The heart rate response was normal. Baseline blood pressure was 142/78 mmhg and increased to 168/92 mmhg at peak exercise, which is a normal response to exercise. Resting ECG demonstrated normal sinus rhythm with diffuse non-specific ST-T wave abnormalities. During exercise, the ECG showed non-sustained V-tach. At peak stress, the ECG revealed downsloping ST-T depression of 1-1.5 mm. During exercise, Use this Checklist to make sure your Nuclear Cardiology Reports are Compliant with the ICANL Standards

Comprehensive Breakdown of the Standards: 3.4.10A The final report must include a description of the results of the exam including pertinent positive and negative findings including: ICANL / IAC Nuclear Requirement Always Include These Report Elements? Does Your Current Solution Always Express These Report Elements in ASNC Standardized Nomenclature? Does the Template Reporting System Comply With This Requirement? What is the ASNC Standardized Nomenclature For These Report Elements? 3.4.10.1A (Itemized) Resting Heart Rate? YES NO Peak Stress Heart Rate? YES NO Rest Blood Pressure? YES NO Peak Stress Blood Pressure? YES NO Stress Symptoms? YES NO Stress Duration? YES NO % MPHR Achieved? YES NO Reason for Termination of Stress? YES NO Timing of Tracer Administration in Relation to Exercise or Pharmaceutical Stress Administration? YES NO Summary of Stress Test? YES NO Calculated automatically & error-checked for inclusion You choose your default timing of tracer admin; can change quickly via dropdown. Also, a concise Stress Test Summary SECTION is generated for ETT Nuclear Stress Tests for quick reference. 3.4.10.2A (Itemized) & 3.4.13.2A (Standardized nomenclature defined according to ASNC Standards) Perfusion Defects: Size Expressed According to ASNC Nomenclature? YES NO Severity Expressed According to ASNC Nomenclature? YES NO Reversibility Expressed According to ASNC Nomenclature? YES NO Location Expressed According to 17-segment model? YES NO Wall Motion Defects: Type Expressed According to ASNC Nomenclature? YES NO Location Expressed According to 17-segment model? YES NO Wall Thickening Defects: Type Expressed According to ASNC Nomenclature? YES NO Location Expressed According to 17-segment model? YES NO Is Overall LV Systolic Function Accurately Expressed in Accordance with LVEF%? YES NO Perfusion Defects: Small, Medium, Large & Extensive; with definitions for # of segments which constitute different sizes; TID included as well Mild, Mild to Moderate, Moderate, Moderate to Severe, Severe Reversible, Partially Reversible, Partially Fixed, Fixed, Mixed, Persistent All 17 segments are available to choose from, as well as more broadly defined regions (e.g. Inferior ) Wall Motion Defects: Mild/Moderate/Severe Hypokinesis; Akinesis, Dyskinesis All 17 segments are available to choose from, as well as more broadly defined regions (e.g. Global, Inferior ) Wall Thickening Defects: Mildly, Moderately, Severely Decreased Thickening All 17 segments are available to choose from, as well as more broadly defined regions (e.g. Global, Inferior ) Abnormal Overall LV Systolic Function is characterized automatically: (EF = 50-70) = Normal (EF = 40-49) = Mildly impaired (EF = 30-39) = Moderately impaired (EF = less than 30%) = Severely impaired (EF = 71 Or greater) = Hyperdynamic 5

Very well-designed... Quickly and easily produces complete, concise, wellorganized and nice-looking reports that are free from errors. Very short learning curve. Single-page reports are quickly digestible and can t get separated by referring providers offices. Mark C. Goldberg, MD FACC Nuclear Interpreting Physician LEARN MORE about the Template Reporting System Identification of suboptimal or limited examinations and/or deviations from standard protocols. This may include attenuation (general soft tissue, breast, diaphragm), patient/organ motion (limb/body movement, upward creep of the heart), activity in nontarget organs (e.g., subdiaphragmatic activity on cardiac studies), or other imaging artifacts. (3.4.10.3A) An accurate, succinct impression (e.g., normal, abnormal, stable); Comment: This must clearly communicate the result of the study and, when possible, answer the clinical question that was the cause for the examination. This final conclusion should resolve any inconsistencies or discrepancies (e.g., abnormal stress test with normal myocardial perfusion images) or provide guidance for further studies to do so. (3.4.11A ) Any need for additional studies based on the results of the procedure being reported. (3.4.12A) The final report must be reviewed and signed manually or electronically by the interpreting qualified member of the medical staff. Electronic signatures must be password protected and indicate they are electronically recorded. Stamped signatures or signing by non-physician staff is unacceptable. (3.5.15A) Overall study quality and up to 3 imaging artifacts per study may be chosen from prepopulated dropdowns. Artifacts and deviations from standard protocols are quickly accommodated in your final reports For example, you can easily generate a report with no gated study and state that a patient s A-Fib or frequent PVCs make the gated acquisition unobtainable. Or, you could qualify the gated study as possibly inaccurate due to A-Fib or frequent PVCs. The presence of these data elements is error checked for. The presence of a succinct overall impression is error checked for, and the Interpreting MD is notified if it is missing Also, optional dropdowns are included with prepopulated common choices for Answer the Clinical Question, Reconcile Disparate Stress Test and Imaging Findings Optional Recommendations dropdown addresses the need for any additional studies. The Interpreting MD can enter their password to generate an electronic signature on the report. If the report is to be printed and then faxed & scanned into an EHR, then we recommend that you manually sign. If you electronically import your reports into your EHR, then use the password protected Electronic Signature & send the report via EHR task to Interpreting MD for final approval. 6

3.4A (The) final report must be typed or computer generated and must accurately reflect the content and results of the study. This includes, but is not limited to: identification of the name address and phone number of the facility; (3.4.1A) We have a specific placeholder in the footer where you enter all of your laboratory s required contact information. patient s first and last name gender and date of birth or age; (3.4.2A ) The presence of the NAME, GENDER, DATE OF BIRTH, and DATE OF STUDY fields are all error-checked for. The patient s AGE is computed, displayed, and used for calculating MPHR% achieved. requesting health care provider s name; (3.4.3A) You easily populate this dropdown with the names of your referring healthcare providers. Editing dropdowns is quick and easy. The presence of this data element is error-checked for. interpreting physician name; (3.4.4A) You easily populate this dropdown with the names of your Interpreting MDs. The presence of this data element is error-checked for. 7

date of the examination; (3.4.5A) You choose this from a date-picker calendar (usually you simply choose today ). The presence of this data element is error-checked for. date report signed and approved by interpreting physician; (3.4.6A) This defaults to today s date when the MD completes the interpretation section and can be easily changed. The presence of this data element is error-checked for. clinical indications and pertinent history leading to the performance of the examination (e.g., medications, recent contrast, prior administration of radiopharmaceuticals, prior therapy which might affect radiopharmaceutical distribution, results of pertinent imaging studies and facility results); (3.4.7A) All relevant conditions leading to the performance of the exam are included in the History and Indications dropdowns. The Indications dropdowns are geared towards justifying the clinical need for the study, the reimbursbility of the study, and fulfillment of Appropriate Use Criteria. The presence of these data elements is error checked for. name of the procedure [type of examination(s)]; (3.4.8A) All Imaging Protocol Sections and Stress Sections are all clearly titled. Simply set up your laboratory s default templates so that these report section titles match the protocols described in your IAC Nuclear Policy and Procedure Manual. 8

an adequate description of the procedure performed. The description must include the name of the procedure [type of the examination(s) or protocol]. It must also include the specific name specific amount and route of administration of any radioactive or non-radioactive material administered. If applicable, the type of stress, pharmacologic agent, dose and route of administration must be described. If applicable the type and use of attenuation correction must be specified (3.4.9A) Did you know you can get dinged by a Recovery Audit Contractor for failing to document the route of administration of a radiopharmaceutical? Every single report element mentioned here is included in all of our report templates. Dropdown values are prepopulated. The values that are always or almost always the same for every patient (route of administration, type of attenuation correction used, time between injection and imaging, type of imaging (SPECT, gated SPECT, prone, etc.) can be set to default values for your lab s templates. You can quickly change these on an as-needed basis for unusual studies. Also, quick choices for typical dosages of ancillary pharmaceuticals are available in dropdowns (100 mgs IV Aminophylline,.4 mgs sublingual Nitroglycerin, IV Lopressor, etc) We focus on making software with: A simple & intuitive interface Error checking which allows for no omissions, no contradictions, no violations of ICANL standards, and no departures from ASNCstandardized terminology Sentence output that is totally accurate & grammatically correct Layout and design that presents relevant information in a quickly digestible, visually appealing format for your referral base. (All templates have been tested, improved, and tweaked on a daily basis, by the developer, over the course of 4 years in an ICANL accredited lab. There are no logical, grammatical, punctuation or sentence flow incongruities present to the best of our knowledge.) Very helpful addition to our nuclear lab It is intuitive to use, report creation is quick, and the final report looks nice. I would recommend the software to any size physician group reading Nuclear Cardiology studies to standardize the final report, which is the most important part of a myocardial perfusion study. Chris Gilles MD ABNM Medical Director, ICANL Accredited Lab GET STARTED 100% Fully-Functioning, No-Risk 30-Day Trial 9

3.3A (The) final interpretation of examinations must be based on quality images/data as well as relevant clinical information. This includes, but is not limited to: The Template Reporting System enables final interpretations to be based on all aspects of the patient / study The entire demographics, imaging protocol, and stress test sections of the report will be fully completed and viewable by the Interpreting MD when they open the final report to interpret the images - If prior completion of the Stress section of the report is not possible due to time considerations, the Interpreting MD can easily glean relevant patient history and stress test results from our quickly digestible comprehensive 1 page Stress Worksheet. Also, there is a Technical tab of the Image Interpretation User Interface in which the processing nuclear technologist describes the overall study quality, up to 3 artifacts, and a freetext area where they can communicate with the Interpreting MD about any unusual or noteworthy aspects concerning the technical quality of the study. (All of these entries can be edited or erased by the Interpreting MD, and the freetext comments never appear in the final report.) Relevant clinical information (3.3.1A) Our clinical history dropdowns include just about every relevant condition seen over the course of 4 years in an IAC-Nuclear Accredited Nuclear Cardiology Lab. If you happen upon something odd, you can add it to the dropdown or type it in quickly. Clinical indication/question (3.3.1A) Our Indications dropdowns include the history as above, plus other entries which are specifically geared towards phrasing things in a way that justify the need for the study, justify reimbursement, and show how the indications meet Cardiac Radio Nuclide Imaging Appropriate Use Criteria (AUC). Relevant patient response to stress (exercise or pharmacologic) or other pharmacologic intervention (including but not limited to symptoms, rest and stress heart rate/blood pressure data, rest and stress ECG findings etc., as appropriate for the type of stress or pharmacologic intervention). This information must be included in the final report as noted in 3.4A. (3.3.2A) All of these patient responses to stress are included in the stress worksheet, and are easily inputted into the final report These findings are already integrated into the final report by the time th Nuclear Interpreting MD lays eyes on the images themselves. He/she will open the final report in progress view the completed demographic, imaging protocol, and stress sections and THEN go on to interpret the nuclear images. 10

Acceptable quality radionuclide images and/or derived quantitative data including acceptable: (3.3.3A) count density (3.3.3.1A) processing/filtering (3.3.3.2A data display [includes image data (slice line-up, normalization, color, standardization, as relevant) and quantitative data (including ROI display, graphs, raw data, and calculated values, as relevant) (3.3.3.3A); and lack of artifacts (e.g., patient motion, attenuation, subdiaphragmatic activity). (3.3.3.4A) Other relevant imaging modalities (i.e., echo/ultrasound, CT, MRI, etc.), if available. (3.3.4A) While our solution can t directly improve the quality of your images, it does allow the nuclear medicine technologist who processed the study to select for the presence or absence of artifact(s), categorize the overall quality of the images, and leave freetext comments regarding the technical quality of the study for the Interpreting MD. (These entries can be erased or overridden by the Interpreting MD and the freetext never finds its way into the final report) Options in the History dropdowns are available for relevant pre-mpi imaging studies. Comparison with prior nuclear medicine examinations when available. It is preferable that no previous studies be stated to document that there were none. (3.3.5A) One simple dropdown click generates the No previous studies available for comparison. sentence in the IMPRESSION section. (Note: since this is preferable, there is no error message generated should you choose not to include this element) The integration of imaging and non-imaging information into a final impression that resolves any potential inconsistencies. (3.3.6A) Prepopulated dropdown variables with common resolutions for inconsistent stress test and imaging results. (i.e. Study is positive for evidence of reversible ischemia despite negative imaging findings due to the stress ECG findings. ) You can also always enter any text you want, in the User Interface or in the final report it s a Word document. 11

Other IAC Nuclear Requirements relating to final reports: Specific worksheets for non-imaging studies must be maintained as part of the facility records. (3.1.3A) Comprehensive 1-page Stress Worksheet includes all relevant Stress Test Data (multiple pages tend to get separated and lost). This Stress Worksheet is tightly coordinated to the Demographics and Stress Test section of our Report Templates for quick, accurate, and easy data entry. The final report must be reviewed signed and dated manually or electronically by the interpreting qualified member of the medical staff. Electronic signatures must be password protected and indicate that they are electronically recorded. Stamped signatures or signing by non-physician staff is unacceptable. Comment: In unusual circumstances, when the interpreting physician is not available, another qualified member of the medical staff may sign for them, if they choose to take such responsibility. (3.2.4A) The final signed report must be transmitted to the referring health care provider within two working days. (3.2.5A) There must be a system for identification and retrieval of a patient s prior similar studies for comparison. (3.2.6A) Interpreting MDs can Electronically sign Final Reports through the use of a password. Note: As always, it is the responsibility of your lab that your overall IT environment complies with HIPPA/HITECH. If you are going to be first printing and then faxing, or printing and scanning your final reports it is recommended that you have the Interpreting MD physically sign and date the printed document, and then transmit it. If you are going to import our reports into an EHR, you should use the electronic signature function, but send the report to the Interpreting MD in the EHR system for a final sign-off Using our recommended file management system there will always be an open folder called Ready to be Read and Read containing studies not yet transmitted on the Reading Room Computer. The date of study is clearly visible as a part of the Final Report Filename, so it is easy to see at-a-glance if there are studies that are approaching the 2 working day deadline. While our solution can t help with your image archives, there is quick and easy functionality for building sentences that compare the current study to previous studies in relevant terminology. 12

Benefits of the Template Reporting System: Simple & Intuitive Interface Visually Appealing, Quickly Digestible Reports Extreme Attention to Detail Protects You from RACs, Shows Clinical Justification for the Test & Fulfillment of Appropriate Use Criteria Perfect Spelling, Grammar, Punctuation & Sentence Flow Professional Layout & Design. Comprehensive, Clear & Concise. Single-page Reports can't get separated by Referring MDs. Inexpensive: A Low One-Time Fee, Perpetual Licenses GET STARTED WITH A FREE TRIAL NOW Your 30-day trial is: Free. No credit card required 100% fully functioning No risk. If you need the trial period extended, just contact us Easy to learn - Concise video tutorials on the website precisely demonstrate every aspect of use & customization You keep the final patient reports created during the trial period. Those are yours forever, even if you do not buy the software Remote help is available for demonstration, training, and customization of your templates... extremely professional and dedicated, and goes well above and beyond to provide excellent service. -- Sheena Sharma MD FACC Nuclear Interpreting Physician InterMed Associates... a very well written and supported application that makes documentation for the signing physician easy, clear, concise and correctly communicated. We have been extremely pleased with the software and would recommend to anybody looking for an affordable solution for documentation. We are very pleased with our choice." -- Jeffrey Harris Lead Technical Analyst SSM Integrated Health Technologies 13

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