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
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