Designing cardiac training programs through innovation

Good afternoon and thank you for joining

us today. My name is Melinda Tesca

Mila and I'm the editorial director

for Diagnostic and interventional Cardiology.

On behalf of D A IC and our sponsor

change Health Care. We'd like to welcome

everybody to today's presentation.

Today, we'll be discussing imaging trends,

designing cardiac training programs

through innovation.

The direct impact of COVID-19

is substantial. The resulting

impact of the pandemic has forced

healthcare organizations to cope

with reduced budgets, higher cost

of technology solutions and

ever growing exam volumes.

To keep up with these staggering challenges,

providers must improve clinical efficiencies

and cardiovascular imaging departments

advances in imaging technology have

given providers the tools they

need to develop leading training

programs. This webinar will

outline how you can leverage the latest

technology to respond readily

to the needs of various learners

and adapt to a variety of cardiac

training situations.

Our learning objectives today are

to identify effective ways

to train cardiac fellows. Using

the latest imaging technology

understanding, the main challenges

faced in training. Cardiac fellows

demonstrate how structured reporting

can benefit training programs

and explore new ways to improve

report quality accuracy

and customizations.

And following the presentations we'll

have some time for a Q and A. Please

note that you have the ability to ask questions

and we hope that you do so, we'll

answer as many as time allows.

Our featured speakers today are

Doctor Greg Pressman,

Doctor Eric Peterson and Doctor

Nathaniel Tran.

Doctor Pressman is Director of Academics

for the Division of cardiology and

associate program director for the cardiovascular

diseases Fellowship training program

at Einstein Medical Center in Philadelphia.

His primary research interests involve

mitral valve disease, cardiac

calcification and echocardio.

Doctor Eric Peterson is

a cardiology specialist in Philadelphia.

He received his medical degree from Rowan

University School of osteopathic

Medicine

and is currently a first year fellow at

Einstein Medical Center.

Doctor Nathaniel Tran is a cardiology

specialist in Philadelphia. He

received his medical degree from University

of Connecticut School of Medicine and

has been in practice for six years.

He is currently a third year fellow

at Einstein Medical Center.

So thank you all for being here. And

with that, I would like to turn things over

to Doctor Peterson to begin the presentation.

Uh Good afternoon, everyone. My name is

Eric Peterson. I'm one of the first year fellows here at Einstein

Medical Center in the division of cardiology.

I wanted the global background on Einstein Medical

Center. We are a large level, one

regional resource trauma center located

in Northeast Philadelphia

and we serve a very underserved population

in our city. Um We are a teaching hospital

first and foremost, uh meaning that we have

many res uh many residencies and fellowships in

our program.

Um And that are dedicated to teaching.

We merged with Jefferson Healthcare in

October of 2021.

And we have a very, very busy cardiovascular

division. Um in terms of our numbers

of volume for our images, we performed

over 12,000 studies in the last year,

over 500 echo stress tests,

more than 450 pe

es and over 11,000 transthoracic

echocardiograms which keeps us very

busy in our day to day and means that we use change

healthcare very frequent.

Next slide, please.

So here at Einstein, we have a dedication to our patients

and a vision for brilliance and compassion.

When we talk about brilliance, we mean that we

aspire to shine in everything that we do

when it comes to our clinical acumen for our patients.

And uh we strive to have exceptional

intellectual clarity and grace.

Um When we talk about compassion, we, we

mean that we're treating our patients with dignity and respect,

we care for them and we do everything we can

um to motivate them and give them a feeling

of that. We understand where they're coming from.

Um And we basically

keep all of our internal working relationships of the

organization and our individuals and populations

with the communities in whom we live with and interact

um in order to keep in touch with our patients, to provide

them with the best care.

Um saying all that,

I think it's, it would be good if we gave a demo of how

we use change healthcare in our day to day. Um

And I think doctor Pressman, I'll hand that over to you

now. Hello,

everyone. I'm Greg Pressman.

Uh As already mentioned, I'm the

associate program director for our fellowship

training program.

And I have a long standing interest

in echocardiography. Read a lot

of echoes.

And I'm gonna walk you through some of

the ways we use the change health

care system. Uh

So let me just share my screen

and we're going to start by

going over how

the

change health care software

allows you to pull up and view studies.

So you get a a list here. These

are all uh from our teaching

files. So none of those are real patients.

Uh You click on one of the

studies that you want to read and

it pulls up the images, you can read

one image at a time or is,

is my preference for

images at a time which we

see displayed here.

And you can easily toggle back

and forth

uh between the images

uh as you're reading

or if you want to go

back and uh recheck something.

So here we're going to switch to a single

screen and I'm going to demonstrate

how we can

very easily and rapidly make

a velocity measurement on AC W

Doppler image

and we can change the background

to help read the numbers if we need.

And we can measure a mean

gradient as well as

uh the velocity.

And we can store

that again, we can change the background

to see the numbers better. Uh We

can store that save

those values and then

they show up in the annotations section

and these are then permanently

recorded in the server.

So you can easily go back to them.

And here we have an interesting finding

at the top left. Now, the

top right of a very

large apical thrombus

uh in the patient's left

ventricle. And now the question

arises was that there on

the last study. So we're gonna pull up

the previous study and

put the images side

by side.

I'm gonna switch to a

two screen presentation

or two image presentation

and we're gonna put up

the image from the current study

and then we're going to find the same

image

in the previous study, put the two up

side by side

and you can easily appreciate

that that clot was not

there

on the previous study. So that's

definitely a new finding

and of great concern

going to show you also how

the change health care system

interfaces with Tom

tech which we have running in

the background at all times.

So this is a study where

perhaps we wanna measure

left ventricular global longitudinal

strain.

And we're looking at

these images

um as has already been

demonstrated. Uh But then

I'm going to activate the Tomte

software through third

party application that you just

saw. This will take a few seconds

to load up but not that long.

And then you'll see the Tom Tech images

pop onto the screen.

And here are the Tom Tech images.

So these are the same images, they're just

now being played through Tom

Tech software which is vendor neutral.

So we can make

strain measurements

using Tom Tech on

images acquired by

any vendor.

The only thing you need to do is

find a four chamber

and control click. You'll see the

green check mark appear.

Then we look for a two chamber

view, same thing. Control

click until a green check mark

appears. And finally

in apical three chamber

view

and again, control click

until the checkmark appears. Then

it's a right click and hit auto

strain.

And the software takes over

and again, this is integrated

with

change health care so that

we don't have to close down

the original study or even open

up a different program.

It all operates through change.

And here's our automated

strain measurements. You can see the

moving images displaying

the tracking and you can see

the different strains at the bottom

is the average global

longitudinal strain of 21.2%.

And we can export

this data or save

an A B I file.

And that's being illustrated here.

And these images can even be embedded

in reports if we decide to

do that.

So we're back into the regular

program and I'm gonna show you

uh the same

strain imaging

uh using a different

uh echocardiogram obtained

on different software

will again go into

the Tom Tech application.

And as before it will take just

a few seconds for the Tom Tech

images to activate.

And as before we're going

to choose an

apical four chamber,

an apical two chamber and

an apical three chamber view.

So that's already a pickle four

and our apical too.

And our apical three chamber

view, we activate the autotrain

program.

And in a very short amount

of time,

uh the software will generate

global longitudinal strain

for this patient.

And we see again a normal value

of 18.6 percent.

I do wanna emphasize, you can

change

the uh area, the region of

interest and the tracking if you think

that the software has not done it correctly.

Um This is all very user friendly

and again, integrates very nicely

with the change health care

system.

And now we're back to our regular

list of uh files.

I'm going to pull up one last

study uh just to show you

that the system easily handles

three dimensional images as well.

There's a patient with a MitraClip imaged

here on the parasternal long axis

view.

And I'm just going to quickly go to

the short axis views

and you see the two

Rhys separated by the clip

and very little regurgitation

following the placement

of the device.

And we can also bring up the

three dimensional image up top

left now enlarged

and again, looking from the apex of the

left ventricle, you can see the device

and the two orifices created

in the mitral valve.

And here's a color image showing

that there's virtually no regurgitation.

On the left side, you saw also

two dimensional cuts through

the three dimensional data set.

So at this point, I'm going

to close down this

video and bring

up another one that'll illustrate

how the reporting package

works.

And forgive me, it looks like it wants

me to

sign into my account. No, we can

do it this way.

I think.

No, that's the same one. I apologize.

Yes. So this will demonstrate how we use

the reporting package in mckesson

and the structured reporting that it

contains. So this is

the basic report

and it lists uh demographic

information and the time and date

the reader of the study, et cetera.

And then if we go to the top left

to study conclusions, you'll see

there are different fields that

we can use for generating

the report, the left ventricular field,

the left atrial field, right, atrial,

et cetera.

And if we, we

can pretext into those fields

if we want

and here we go,

or you can choose

from prepopulated

statements and it was trying to recognize

one there. I've put into my favorites,

a phrase that you can

just click on and enter

or you can use prepopulated

statements that are available to everybody.

So you can generate your own

favorites or you can use

uh a list of prepopulated

statements which can be modified

to suit your institution.

Uh And you just click on

them and they appear in the left

ventricular field. And if

you look on the left where it says shared

list, you'll see that there's subcategories

of morphology, systolic function,

diastolic function, et cetera.

So here I'm just putting a few statements

in modifying one of the statements.

And we'll generate a partial report

is already illustrated. You

can also start typing and it will

try to bring up a sentence

that matches what you're typing and

that can be a time saver as well.

And here I'm adding the sentence about

the large mobile thrombus at left

ventricular apex

and we can close this

field.

And if we check

this little bo we can also

check previous reports.

So here's the report on

the previous study, same patient

making no mention

of the apical thrombus.

And then if we check the

little box,

uh we'll add some more statements here,

but you'll see uh shortly.

Um We can carry these statements

into the

summary

field at the bottom.

OK. So I've checked a little box set

next to the left ventricle and copied

that whole section into the

summary. Uh If we decide

it's too much, we can modify it easily

enough. We

can also look at the procedure

type and we can modify that. It

can be a complete TT

E or perhaps it's a limited

echo

or you see any number of

other choices. And that

selection shows up in the final

report,

the patient's status, the

reader, the sonographer,

uh all of those show up

in the patient report and they're just

accessible with simple drop

down menus.

And we've also added

to the

uh structures field

a, a mandated

visual estimate of the ejection

fraction.

So the report won't be generated unless

I put that in which helps

to meet a standards.

If the sonographer has done a biplane

or three dimensional measurement, those

measurements are automatically populated

uh under the ejection fraction

field.

And then once you're satisfied,

you click sign, it asks you

if you want your name added. Uh

That's a double check in case you happen

to be logged in under somebody else's

uh sign in and that's

it. The report is signed and it automatically

goes into the electronic

medical record.

Uh So all of this is very straightforward

and easy to use

uh and generates a lot of efficiencies

at the same time providing

uh flexibility for individualized

report, but structured

reporting to make sure that all of the

important uh structures

and fields within the report

are addressed.

And with that, I will then

turn it back over to

the rest of the group.

And so perhaps uh we've heard

from Doctor Peterson, maybe Doctor Tran

can

uh talk to us a little about his

experience as a fellow

in using this system.

Yeah. Yes, for sure. Thank you,

Doctor Preman. I'd love to give some

of my inputs. Uh I

noticed the inbox has lots

of great questions. I don't know if

the plan was to go to these

uh a little bit later. I'm happy to give

my take on some of these. But uh

in general though, um

I am uh nearing the end of my training,

but I am pursuing more training, advanced

echocardiography. So I'm very much

invested in the technology here

and

uh just to

touch on some of these questions, I mean, they're, they're

pretty uh great and specific. But

uh

you know, uh one of them that comes to mind

is how do you uh what's one

advice you would give to a cardiologist

uh or someone interested? I think that's probably a more general

one that I could uh take. Uh But I'd

say definitely

uh find someone who uh

is a great mentor, but

specifically someone who is on

the leading edge and cutting edge of

technology. And specifically

when it comes to uh cardiac imaging

and the modality of echocardiography, which

is uh bread and Butter for cardiologists.

Uh You need someone who knows the latest and

knows how to navigate

uh

technologies such as change health care, who is

implementing straining and all these

other uh parameters as

well.

Uh an interesting question that I read

was

uh how do you anticipate

you will handle all the increasing volume

of data uh that uh you

are coming across. And along with that was

how do you keep up with the latest technologies and whatnot?

And I think that it is clearly

linked so well with imaging

and especially uh with what change healthcare

is trying to do.

Uh But uh as you guys can imagine

that the amount of data

is increasing, the amount of measurements we can do is

increasing and the complexity is also increasing

as well, which is fascinating, but

it is challenging as well.

Uh But having just come back from

uh a national conference and

a congress on what's going on right now,

uh the trend is that it

will continue to get more complex. But at the same

time, we are really

making use of uh our understanding

of artificial intelligence, machine

learning and convolutional neural

networks to automate all of these

uh data. And I know these are really just buzzwords,

but uh this is really what the

field of cardiology and imaging is pushing

towards. And so all of this will be

implemented ideally through

our current uh

user experience with change health

care. And I think

strain is just the tip of the iceberg. But

with what's coming on with uh

again, automated segmentation

and propagation and all that uh will be

how we could really make use of these increasing

data uh in a very efficient

way uh through uh hopefully

change healthcare. So again,

there's many more very specific questions.

I'm happy to keep going, but I want to

leave it to the other guys as well if they wanna chime

in and maybe we could uh take turns.

So there's also specific

questions about

uh using this system to help train

fellows. Um Let's

hear from Eric about his experience

as a fairly new fellow and then I

can chime in as well.

Yeah, certainly. So um I just started

fellowship about four months ago.

Um I was a resident at Einstein Medical Center prior

to that. So I've had some experience in working

mostly on through a teaching point of

view with change healthcare.

Um I think coming in as a new cardiology

fellow,

um the world with echocardiography is

massive. Um the amount that you have

to interpret and all the different data points

and even just down to reporting properly.

So I think change healthcare has really helped

in the training here. Um for

a lot of the reasons that doctor Pressman went over in his video.

Um Number one, we are able to pre

read the studies

as fellows, meaning that we go through the entire

study.

Um We give our objective assessment

of the study and and the findings and

then we can sit down with the attending and save that pre

read, sit down with the attending and we're able

to go through the study and they're able to point

out things to us and the justice study prior to it

being published and they see all of our work

directly in those

boxes for different structures um

in, in the system.

Um I think being able to pull up all

studies is, is massive for

training. Um So, you

know, you could see how different disease processes

progress in a patient that has uh for

example, you know, known micro regurgitation.

And doctor Preman knows a lot of his patients

their whole course. So they'll say, you know, they three years ago,

they had mild and you could see the clear difference in

their mild me

regurgitation in 2019,

their clearly severe much regurgitation

in 2022 and,

and being able to pull up those two

videos side by side and show a new fellow

who has no experience in looking

at these and grading the severity of much education

has been very, very helpful.

Um So I think the whole system is, is used very

well by us specifically, but I think it can be

used by anybody to facilitate teaching.

And I'll add to that, there was a question

about the teaching file.

The system allows you to

save

anonymized studies in a teaching

file and that we can

draw on those for

specific uh teaching

purposes for use in conferences,

for use in

public applications.

Uh or even just comparison with

an echo that we're dealing with.

I think that's a, that's another great point. The, the web-based

nature allows us to pull up these echoes on not only

when we're on our echo rotation,

um or, or echoes or CS or whatever

studies being looked at, but also throughout the hospital.

So when we're on our consult rotation, if a patient

has had an echocardiogram done in the morning,

but maybe it hasn't been finalized yet, the consult team

can pull it up together, take a look at

it, go over it.

Um, and we have that access right at our fingertips.

And, um, that's one of the, another

great feature that I've run

into and

doctor Tran, anything to add from your end.

Uh Sure. Yeah, I, I was contemplating,

uh, gambling at all these questions. One

that, that stood out from, uh,

user 16074165.

It, it's, uh, how does cardiac training

fells differ on Einstein?

How do you stand out? That's a very, uh,

loaded question. And I really had to ponder

and think about that.

Uh, and I think,

um, the answer to me

wouldn't be that we have the latest technology

or we have access to the latest,

uh, you know, procedures and whatnot.

I think,

uh, a lot of, a lot of programs

have that, um, at that disposal.

But I, I believe though how we stand out

is that we are actually implementing

that and know how

to use it. Uh, specifically, uh, Doctor

Pressman, here.

Uh

I mean, we just did a te uh it's

a, it's a transesophageal

echocardiogram, essentially another uh

uh modally using uh ultrasound

imaging

uh through, you know, uh change of health

care. And he was

literally using every

uh gadget, every little

uh tricks and uh

things to do like that. And I, I think

that what stands out is if you have uh someone

on staff who knows how to do

it and wants to do it and uh enjoys

doing that.

Uh And so, uh

I don't know if that question was more to

uh see how we are using change

health care. And that's how we are just if perhaps

a pa uh that person is interested in Einstein itself.

But I think uh that's my take on, on

that. A

lot of questions.

OK. So I'll

jump in here with a little historical

note and then we're gonna pass

it off to Melinda. I've obviously

been around for a while. I remember the days

of videotape when the

quickest you could read a single

study was 20 minutes

and you had to hit rewind a million

times to recheck something

from the beginning of the study.

Uh Nowadays, we can read uh even

a, a complex study in about half

that time uh with a lot more

accuracy.

And the, it's very important

to have that flexibility

in viewing, in pulling up reports,

et cetera.

Uh The other thing that I would add about

this particular system.

Uh two things that I find

very helpful ones, the interface

with Tom Tech, which I demonstrated.

But the other is the general reliability

of this system when

an echo server

crashes. That's a big problem

for a busy echo lab.

Uh The

uh change health care software

is

pretty much 99.5%

reliable. We have had very,

very little downtime over

a period of many years.

Great. Well, thank you so much doctors

and there are some um audience questions

coming in that I'm gonna go ahead

and um I'll throw out

there for you. First one.

What does the teaching files function

due to the echo?

So we can add

an entire study or just

parts of a study into

the teaching file.

Uh The studies are, and they

go in anonymized and you have the ability

to change the name of the study.

So what I always suggest people do is just

change the name to the diagnosis

and that way you can search the teaching

file for that diagnosis

and immediately pull up all of the studies

in that file with that particular

diagnosis.

Uh And another question here. Do you

use the measuring tool at the individual

field in the change

health care reporting or

only the generic tools

in the viewer?

So I'm not sure I understand

the question. Um But we

use all of the measuring tools

available to us and

these can be linear measurements.

Uh on an M mode

or they can be uh as

I demonstrated velocity or pressure

gradient measurements on Doppler

they can be area

uh measurements or, or volumetric

measurements on two dimensional

images.

Uh And we

do this all the time.

How do you save statements into

your favorites?

Uh To be honest, it was set up so

long ago. I don't recall.

Uh But I do know that it's very

simple and you basically

just type the sentence you want

and with a couple of clicks, it

saves it into your profile.

Uh So you can pull up those statements

uh anywhere in the

uh left ventricular field or

the wording valve field or even the conclusions.

Uh And they

will show up when you're

logged in. But when no one else is logged

in again, there are many

prepopulated statements that everybody

has access to

and those can be

customized for the institution,

but it's a more difficult

process to input

them or change them. And

that's by design because you don't want individuals

uh to change them.

You, you had mentioned favorite sentences.

How useful is it to have your own sentences?

And does it save time?

So I like to do

a lot of customization on my report.

And I'm a, I happen to be a good typist.

So I don't use the prepopulated

statements as much as some others.

Uh I know a lot of my colleagues

use them all the time. It's a matter of

personal preference.

I'm, I'm happy to comment on that. I think.

Um at least for the first couple of months, it's been

a huge time saver.

Um but not only from the time

aspect, it also helps to, to be very clear

in what you're reporting and what you're trying to say to have prepopulated

sentences that

at least the majority of people use.

Um The attendant can always edit it if

they agree, disagree or want

to add something.

Um But having the prepopulated consistent

statements to say what you're trying to say,

um at least in the beginning of my training has been very

helpful. Um So I think they both save

time but they also

um help get your message across.

And what you're trying to say is in a way that everyone is understanding.

Great. And another question just came in.

Um Can you add snapshots of images

to your reports?

Yes, that's

a good answer. Um Here's

another question that probably you all could address.

What tips can you share that help

you stay up to date with the latest training

methodologies and standards of care?

Um I think really

the best way to do that is

to travel um

Virtually if you have to better in person,

go to different institutions, go

to conferences

and talk to other people. And

I, I'm part of a group of

program directors. We share

ideas all the time.

Uh In this way, you figure out

pretty quickly what works and what does not,

what are your plans to address the likely

unsustainable growth of imaging

data?

It, it is a challenge. Um

It's a challenge not just for us but

for our sonographer as well,

they, they have to acquire

many more images than they used to.

And we are much more

particular about

image acquisition. An example being

the four chamber and

all the apical views of the left ventricle,

we need to make sure they are not foreshortened.

Similarly, the, the right

ventricle and the RV focused view,

uh A I

artificial Intelligence is going

to help for sure. It's

coming. Now, a lot

of the machines incorporate

A I to help with

measurements. There are software

programs out there that will

tell you when you've got a good on

axis view.

And

I suspect we will soon have

software that will help

with basic interpretation

or at least allow you

to um

check a measurement to make sure

that it's accurate and

perhaps uh suggest

a an interpretation.

So I think technology

is ultimately going to be

our friend here uh and

allow us

to read more accurately

and more efficiently. Again.

When I started in this business,

it was all videotape and it took

20 minutes to read

an echo, even a

pretty normal echo. And now we

can read complex studies. And about

half of that time, we just need to

keep moving in that direction

and back to a, a more

specific um question

for you. Can you view a Cath

lab image next to an echo to compare

wall motion?

Yes. The

C lab images uh show

up uh along with

the echo images on the same

server and we can put them up

side by side or toggle back and

forth.

Uh And we do that frequently if

uh we see a patient

who has a wall motion abnormality. If

that patient has

a current or prior

a coronary angiogram, I will always

look at that to confirm that the wall

motion abnormality corresponds

to an area of coronary disease.

And if it does not, it's going to alter

my interpretation and my

differential diagnosis

right now, I've got one final question

for you. If you could share one

piece of advice for those who are starting

out as cardiologists, what would that be?

I deal a lot

with

my trainees who are just starting out

as cardiologist. So I don't know if this question

is uh addressing

the new fellow or the newly graduated

cardiologist. But regardless

the most important thing

in this field, which is just

exploding with information

is to get really good at

reading.

You have to read a lot and I always

emphasize reading primary

sources.

It's very nice to read

mm somebody else's review.

Uh But it's good to read primary

sources and make your own judgments.

And then when you see something

interesting,

I tell the fellows all the time immediately.

Read about it that day. Don't even

wait till tomorrow when you're busy

with something else. If you see something

interesting, read about it right then

and there you'll never forget it.

Then the next time you see it, you'll say yes,

I saw this and I remember reading about

it and this is what it means.

And the last thing I would say is again,

travel, meet other people,

talk to other people, go to conferences

and conventions that human

interaction means

so much in terms of learning,

which can otherwise be rather dry.

That's some very good advice. Thank

you so much for sharing that with us

and with that, uh that's

all the time we have for today. So,

on behalf of D A IC and

our sponsor change Health care, we'd

like to thank everybody for their participation

today.

This presentation will soon be archived

for on-demand viewing and the same

URL you use today

um will still be

use. So please feel free

to share this with others and

thank you everyone for joining us and have

a great day.