The Importance of Accreditation-Compliant Nuclear Cardiology Reports, and How to Successfully Generate Them
Posted by Jim McGee, BS RT(R)(N) CNMT
JanauryÂ 17th, 2018
Nuclear Cardiology is an important specialty because it evaluates coronary artery disease, which affects a large percentage of the U.S. population.
The nuclear cardiology final report has received increasing attention in recent years. The terminology used in these reports can be hard to understand, yet the final report is often the only information the patientsâ€™ future healthcare providers will have with which they can make treatment decisions.
To make certain the final report results in accurate treatment decisions and repeat testing is kept to a minimum, highly standardized final reports have become a requirement of some nuclear cardiology accreditation agencies, particularly IAC Nuclear/PET.
This article will provide background about the importance of nuclear cardiology final reports and accreditation. Additionally, a description of what is required to achieve high quality, accreditation-compliant nuclear cardiology final reports is reviewed.
Nuclear Cardiology is Important
Nuclear Cardiology is important because it diagnoses and monitors the progression of Coronary Artery Disease (CAD). About 13% of Americans die from Coronary Artery Disease.
Our coronary arteries are the vessels through which our heart pumps blood to itself. People with Coronary Artery Disease have coronary arteries that are clogged up with cholesterol deposits and are narrowed; thus, the circulation through those arteries is impaired. When our heart muscle tissue doesnâ€™t get an adequate supply of blood, we get ongoing symptoms such as chest pain, shortness of breath, fatigue, fainting, and other symptoms as well.
When a piece of cholesterol (â€œplaqueâ€) breaks loose from an artery and becomes lodged in a narrowed coronary artery, it may completely shut down circulation to a part of the heart muscle, causing a heart attack, or myocardial infarction. Heart attacks can lead to cardiac arrest, which, if not corrected by a defibrillator in time, generally results in death.
Every year about 735,000 Americans have heart attacks, and every year 370,000 Americans die from Coronary Heart Disease.
There is a widespread misperception that nuclear cardiology has been a field in decline. This misconception is due to many factors, including a crackdown on overutilization, the emergence of alternative cardiac imaging modalities, declining reimbursements, prior authorization, and Appropriate Use Criteria.
The fact is, nuclear cardiology is critically important for patients with a moderate pre-test likelihood of having Coronary Artery Disease and for patients with known CAD. For this large patient population, nuclear stress tests remain the most appropriate way of diagnosing and monitoring CAD.
Bottom line: until we all get down to our ideal weight, limit cholesterol intake and begin exercising an hour a day, nuclear cardiology will remain widespread and very important to our longevity.
The Nuclear Cardiology Final Report is Particularly Important
The reason the final report is critical to the management of coronary heart disease was clearly described in a 2011 article about ICANL Report Compliance in the Journal of Nuclear Cardiology:
â€œThe report from any testing facility to the requesting physician is the single most important part of the test as it communicates the result of the test to the patientâ€™s health care provider, allowing them to act on the result and provide meaningful care.
The importance of this communication has been emphasized in both the cardiology and the radiology literature for more than a decade and has recently received increased emphasis in an effort to reduce repeat testing and control cost.
Myocardial perfusion imaging serves as the â€˜â€˜gatekeeperâ€™â€™ for an increasing number of invasive cardiology procedures that are performed as a result of the myocardial perfusion imaging study. Therefore, it is essential that the results are reported accurately and concisely to reduce the need for unnecessary and repetitive testing and decrease patient risk.â€
The nuclear cardiology report: Problems, predictors, and improvement. A report from the ICANL database. Peter L. Tilkemeier, MD,a,b Eva R. Serber, PhD,a,c and Mary Beth Farrell, MSd, June 2011, Journal of Nuclear Cardiology
The entire test culminates in the final report. This report is the result of everything from the proper installation, maintenance and tuning of the cameras by the technicians at Universal Medical, to the proper performance of the test by technologists, to the interpretation of the images by the physician.
Moreover, the report is the only thing that remains of the test once it is completed. Nobody will ever look at the stress test worksheet, the ECG tracings, or the images again (at least, 99% of the time).
Therefore, it simply doesnâ€™t matter how well you perform the test, or how well the interpreting physician understands the results, if the results are not communicated accurately and clearly.
This is critical: the final report must mean the same thing to the physician who is reading the report as it did to the physician who created it.
- This is known as the â€œsecond interpretationâ€ of the test.
- The final report must use terminology that is the agreed-upon standard; it must also be comprehensive, accurate and clear.
The Importance of Accreditation-Compliant Reports
Reports must also meet accreditation agency requirements. Otherwise, your nuclear cardiology lab cannot collect reimbursement from Medicare or insurance companies.
Accreditation is a stamp of approval from an agency who certifies that your nuclear lab is meeting quality standards. In 2008, Congress enacted theÂ Medicare Improvements for Patients and Providers Act (MIPPA). It went into effect January of 2012.
MIPPA requires that labs billing CMS/Medicare for â€œAdvanced Diagnostic Imagingâ€ (CT, MRI and Nuclear/PET) are fully accredited by an approved accreditation organization. Insurance companies also require accreditation.
There are four Medicare-approved Accreditation Organizations:
- The Joint Commission (â€œJCAHOâ€)
- Hospitals are typically accredited by JCAHO
- This is a newer accreditation agency, it is not widely used yet
- ACR (American College of Radiology)
- Imaging centers owned by Radiologists are usually accredited by ACR, some Cardiology Practices are as well
- IAC Nuclear/PET (formerly known as ICANL)
- Most cardiology practices are accredited by IAC Nuclear/PET
IAC Nuclear/PET is the accreditation agency known for the stringency of its reporting standards; therefore, the rest of this article will focus on the IAC report requirements.
It is worth noting many ACR accredited labs also try to comply with the IAC report requirements because they represent the standard that cardiology practices follow.
IAC Nuclear/PET, a Division of the IAC
The Intersocietal Accreditation Commission (IAC) has been around 25 years; they are a non-profit corporation headquartered in Maryland. They accredit all kinds of labs, from Nuclear Medicine/PET, CT and MRI to Dental CT and Vein Treatment clinics.
The IAC Nuclear/PET staff is generally comprised of technologists with considerable experience.
The IAC Nuclear/PET board is comprised of leading physicians and technologists from organizations such as the American Society of Nuclear Cardiology (ASNC), the Society of Nuclear Medicine and Molecular Imaging (SNMMI), the American College of Nuclear Medicine (ACNM) as well as many other organizations.
The board meets once a month to review applications for accreditation and re-accreditation. Labs must re-apply every 3years. The staff processes the applications and presents them to the board, who then make the determination to grant or not grant (re)accreditation.
Responsibility for IAC Accreditation
Often the chief nuclear medicine technologist (Technical Director) is chiefly responsible for securing IAC accreditation. The Technical Director must create and maintain a very detailed policy and procedure manual and conduct regular quality improvement activities on final reports and other aspects of the lab, as well.
Every three years, technical directors must fill out a lengthy application and submit case studies to be re-accredited by the IAC. They are regularly audited between applications in the middle of the accreditation cycle and could be randomly audited or site visited at any time.
Technical Directors must be given adequate time and tools to achieve and maintain accreditation, including appropriate reporting software. Practice managers and department administrators also typically bear some responsibility for ensuring that accreditation is always in place.
The Gravity of Accreditation Lapses
A lapse in accreditation can occur if a re-application is denied or delayed. If your accreditation lapses, you cannot get reimbursed for any studies performed during the lapse, nor can you retroactively bill when your accreditation is re-instated. In effect, your nuclear lab is completely shut down until you can get the IAC to approve your amended application.
Non-compliant reports have always been and are still the single biggest cause of delayed (re)accreditation. Even smaller labs can easily forfeit hundreds of thousands of dollars in revenue because of non-compliant reports.
Unfortunately, many labs are still using inadequate reporting solutions (such as voice dictation, text templates, EHR templates, or outdated nuclear cardiology reporting software) that are simply not sufficient to meet the IACâ€™s rigorous reporting standards.
The Challenge of IAC Nuclear/PET Reporting Requirements
Challenge #1: Clearly Understanding the Requirements
The IAC Nuclear/PET reporting requirements for Nuclear Cardiology are notoriously difficult with which to comply with. This has been the case for quite some time, and since March 2017, it has been even more difficult to maintain report compliance as IAC has added new report requirements.
The 2017 reporting requirements are comprised of 7 pages of fine print. Unless you intend to devote yourself to a very close study of those 7 pages, youâ€™ll find it difficult to understand the report requirements.
Not only that, but the IAC Standards recommend a â€œstandardized reportâ€ according to the new 2017 American Society of Nuclear Cardiologyâ€™s (ANSCâ€™s) reporting standards. These ASNC reporting standards are another 65-pages of fine print.
Just understanding all these report requirements can quickly become overwhelming.
Challenge #2:Â Complying with the Reporting Requirements
A study published in the Journal of Nuclear Cardiology in May of 2017 revealed that a high percentage of IAC-accredited labs have report deficiencies in their applications.
Researchers found in facilities that have applied for 3-consecutive IAC accreditation cycles, the percentage of labs of with reporting issues was 66% for the first cycle (initial accreditation application), 36% for the second cycle (first re-application), and 43% for the third cycle (second re-application).
In other words, 43% of labs applying for IAC Nuclear/PET for the third time had reporting deficiencies in the case studies which they submitted with their application for re-accreditation.
The researchers found many reporting deficiencies in quantifying (properly describing) myocardial perfusion defects, documenting report approval date, and integrating the stress and imaging reports.
The bottom line is, compliant reports cannot be created by accident, they only result from rigorous discipline and attention to detail.Â This painstaking attention to detail cannot generally be achieved without sophisticated automation.
Without compliant reports, no accreditation and no revenue from MPI scanning.
How to Clearly Understand the Report Requirements
Because it is so difficult to understand the raw IAC reporting standards, our company has created a very user-friendly white paper called â€œThe Definitive Guide and Checklist for IAC Nuclear/PET Report Compliance.â€ We went through the requirements with a fine-tooth comb and painstakingly categorized and itemized every report requirement. Then we segmented the requirements into 9-meaningful categories.
Every individual required report element is clearly explained and gets its own
–box for you to check if you are complying with that individual requirement. There is also plenty of room for your notes regarding any action steps you may need to take to achieve full compliance.
The latest 2017 ASNC Standardized terminology for imaging findings is included in our white paper. Itâ€™s important to include the current ASNC terminology in your reports: for accreditation purposes, for patient well-being and safety, and for liability reasons too.
Inadequate Ways to Create Compliant Reports
Many nuclear cardiology labs are still creating reports in a sub-optimal fashion. Voice dictation, non-automated text templates and EHR customization are common methods that canâ€™t create compliant reportsâ€”at least, not in an efficient manner.
Voice dictation demands that Interpreting physicians dictate the entire report, consuming too much of their time. Even more physician time is consumed correcting transcriptionist errors. It would be impossible to include all ICANL required report elements using dictation.
Report turnaround time can take days due to back and forth with transcriptionists, and reports tend to vary widely between different interpreting physicians. In addition to all this, transcription is expensive.
Some labs use non-automated text templates to create reports. This demands up to 10 -15 minutes of total staff time per report to type in all ICANL required report elements. Reports will inevitably contain errors, since proofreading is manual. The final product rarely complies with ICANL or ASNC standards, and again, reports vary widely between different interpreting physicians.
You can sometimes pay your EHR vendor a hefty sum to customize special nuclear cardiology report templates, but this usually turns out to be a very bad idea.
First, they demand your time to tell them how to construct the templates. This takes a lot of your time and simply feeds back to you what you stated.Â You need to be an expert at producing compliant reports to follow this path.
Second, there are no error-checking algorithms to make sure your reports are correct and compliant.
Third, EHR templates generally yield poor results: inflexible templates unable to be further customized and non-compliant, awkward and ugly final reports. If you decide you want improvements, youâ€™ve got to pay your EHR vendor again.
Structured Reporting Software is the Answer
To create 100% IAC-compliant nuclear cardiology reports in an efficient manner, you need automated structured reporting software that is built specifically for IAC Nuclear/PET and ASNC compliance.
Standards-based structured reporting templates allow for consistent, organized and clear communication of nuclear stress test findings to the patientâ€™s healthcare providers.
When evaluating specialized nuclear cardiology reporting software, make sure that it is truly IAC Nuclear/PET and ASNC compliant, because not all solutions are. Our Guide and Checklist is ideal for determining compliance.
Itâ€™s also important to have comprehensive Error-Checking and Corrective Messaging algorithms that will ensure 100% compliance. Your reporting software should make it just about impossible for you to create a non-compliant report.
Additionally, reports should be one-page long. Referring physicians appreciate brevity, precision, clarity and relevance.
Have you ever received a long, wordy document from a physicianâ€™s office that you must scrutinize at length, flipping back and forth between pages, to find what you seek? If you have, then you know how unhelpful that is, and how valuable clear and concise communication is.
The user interface should be simple, intuitive and uncluttered. It should minimize the amount of mental effort required to create reports. Many user interfaces in this industry are cluttered and confusing, the last thing a cardiologist wants to deal with at the end of a busy day.
Nuclear cardiologists are very busy people, and report creation should be quick. No more than a minute, even for highly abnormal images, and normal studies should take just a few clicks. Report turnaround should be immediate.
As soon as the physician reads the images, the final report should be immediately available for situations such as same-day office visits, quick surgery clearances, hospital discharges, and urgent referrals to the catheterization lab.
A great deal of flexibility should be built into structured reporting software to accommodate the interpretation preferences of multiple physicians. You should be able to describe defects using clinical language such as â€œinfarct with peri-infarct ischemiaâ€ in the Impression while maintaining ASNC-compliant descriptors such as â€œpredominantly reversibleâ€ in the Imaging Findings section.
You should also be able to pre-load unlimited custom sentences that you like to use into dropdowns so you can quickly choose them during report creation.
Finally, the visual hierarchy of reports should be attractive and clear, appropriately emphasizing the most important findings through the expert application of design principles. Spelling, grammar, punctuation, spacing and alignment should be perfect.
Because the final report is the only aspect of your nuclear lab that the outside world will see, it should provide maximum utility for all of the patientâ€™s healthcare providers and it should emphasize your practiceâ€™s professionalism.
The IAC Nuclear/PET report requirements are very stringent, but for a good reason. Namely, the final report is the single most important part of SPECT MPI tests, as it is the basis of future treatment decisions.
By providing compliant and standardized final reports, nuclear cardiology labs do a service to their patients as well as their patientsâ€™ healthcare providers by communicating test results with maximum clarity. Accurate treatment decisions can then be made and the need for unnecessary repeat testing is eliminated.
Much flexibility can be built into structured reporting software to satisfy the demands of multiple nuclear interpreting physicians. They can state their findings in their own
, way and emphasize what they judge to be important depending on the clinical situation, while simultaneously maintaining 100% compliance with the latest reporting standards.
When evaluating structured reporting software, our Definitive Guide and Checklist for IAC Nuclear/PET Report Compliance will help you determine whether the solution youâ€™re considering is truly compliant with the latest IAC and ASNC standards.
Structured reporting software neednâ€™t be complicated, time-consuming or constraining for interpreting physicians. In fact, the right software can be very easy to use, provide tremendous flexibility, and be a real time-saver for busy cardiologists.
Is there anything you would like clarification on regarding report requirements?
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