Table of Contents
It is important that nuclear cardiology stress results are communicated in a way that all healthcare providers can understand.
Accreditation reporting standards ensure that findings are conveyed using standardized terminology, and that all relevant information is included.
Accreditation-compliant reports serve patients for the rest of their lives, allowing future physicians to provide appropriate care & not perform unnecessary repeat testing.
Compliant reports also safeguard cardiology practices’ reimbursement.
The challenges of compliant reporting are discussed, as well as solutions.
Nuclear Cardiology Is Important
Heart disease is the leading cause of death in the U.S.
Nuclear Cardiology is important because it diagnoses and monitors the progression of CAD.
There is a widespread misperception that nuclear cardiology is in decline. However it remains the most appropriate & widespread means for diagnosing and monitoring CAD.
The Critical Importance Of The Final Report
The reason that the nuclear cardiology final report is so important was stated here:
“The 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 patient’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 ‘‘gatekeeper’’ 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.”
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, to the proper performance of the test by technologists, to the interpretation of the images by the physician.
- Moreover, the report is, practically speaking, 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 (it is very rare for anybody to look at those – the report is pretty much the only thing the patient’s healthcare providers base their decisions upon).
Therefore, it simply doesn’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.
- The 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 “second interpretation” of the test. The final report must use terminology that is the agreed-upon standard; it must also be comprehensive, accurate and clear.
Accreditation Agency Reporting Standards
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 the Medicare Improvements for Patients and Providers Act (MIPPA). It went into effect January of 2012.
MIPPA requires that labs billing CMS/Medicare for “Advanced Diagnostic Imaging” (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 (“JCAHO”)
- 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 accredited by ACR
- IAC Nuclear/PET
- 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.
Many ACR accredited labs also try to comply with the IAC report requirements because they represent the standard that cardiology practices follow.
We’ll address the IAC here, since they accredit most cardiology practices.
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 3 years.
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 IAC’s rigorous reporting standards.
IAC Nuclear/PET Report 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, you’ll find it difficult to understand the report requirements.
Not only that, but the IAC Standards recommend a “standardized report” according to the new 2017 American Society of Nuclear Cardiology’s (ANSC’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: 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 that in facilities that have applied for 3-consecutive IAC accreditation cycles, the percentage of labs with reporting issues was:
- 66% for the first cycle (initial accreditation application
- 36% for the second cycle (first re-application),
- 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. This painstaking attention to detail cannot generally be achieved without sophisticated software.
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 can’t create compliant reports–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. 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, you’ve got to pay your EHR vendor again.
Structured Reporting Software
Creating 100% IAC-compliant nuclear cardiology reports in an efficient manner requires standards-based reporting software that is built specifically for IAC Nuclear/PET and ASNC compliance.
It’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.
Reports should be one page long. Referring physicians appreciate:
The user interface should be:
- Intuitive and
Many user interfaces are cluttered and confusing, making for extra work at the end of the day.
Report creation should be quick.
- No more than a minute, even for highly abnormal images
- Normal studies should take just a few clicks
- Report turnaround should be immediate
Reports should be immediately available for:
- Same-day office visits
- Quick surgery clearances
- Urgent referrals to the catheterization lab
A great deal of flexibility should be built into structured reporting software to accommodate multiple physicians.
- You should be able to use clinical language such as “infarct with peri-infarct ischemia” in the Impression while maintaining ASNC-compliant descriptors such as “predominantly reversible” in the findings.
- Custom sentences of your choosing should be pre-loaded into dropdowns
The visual hierarchy of reports should be:
- Emphasizing the most important findings
- 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 patient’s healthcare providers and it should emphasize your practice’s professionalism.
It is essential that nuclear cardiology reports are accreditation compliant, for the sake of patients & cardiology practices.
Creating these reports needn’t be complicated, time-consuming or frustrating 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.