Author + information
- Received December 22, 2015
- Revision received February 8, 2016
- Accepted February 16, 2016
- Published online October 1, 2016.
- Pamela S. Douglas, MD, Chaira,∗ (, )
- Manuel D. Cerqueira, MD, Co-Chairb,
- Daniel S. Berman, MDc,
- Kavitha Chinnaiyan, MDd,
- Meryl S. Cohen, MDe,
- Justin B. Lundbye, MDf,
- Rajan A.G. Patel, MDg,
- Partho P. Sengupta, MDh,
- Prem Soman, MD, PhDi,
- Neil J. Weissman, MDj,
- Timothy C. Wong, MDk,
- ACC Cardiovascular Imaging Council
- aDuke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina
- bImaging and Heart and Vascular Institutes, Cleveland Clinic and Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
- cDepartments of Imaging and Medicine, Cedars-Sinai Medical Center and the Cedars-Sinai Heart Institute, Los Angeles, California
- dDepartment of Cardiology, William Beaumont Hospital, Royal Oak, Michigan
- eChildren's Hospital of Philadelphia, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
- fDepartment of Cardiology, Hospital of Central Connecticut, New Britain, Connecticut
- gJohn Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana
- hZena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
- iDivision of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- jDepartment of Medicine, MedStar Health Research Institute and Georgetown University, Washington, DC
- kCardiovascular Magnetic Resonance Center, UPMC Heart and Vascular Institute, Pittsburgh, Pennsylvania
- ↵∗Reprint requests and correspondence:
Dr. Pamela S. Douglas, Duke University School of Medicine, Duke Clinical Research Institute, 7022 North Pavilion DUMC, P.O. Box 17969, Durham, North Carolina 27715.
The American College of Cardiology’s Executive Committee and Cardiovascular Imaging Section Leadership Council convened a discussion regarding the future of cardiac imaging among thought leaders in the field during a 2 day Think Tank. Participants were charged with thinking broadly about the future of imaging and developing a roadmap to address critical challenges. Key areas of discussion included: 1) how can cardiac imaging services thrive in our new world of value-based health care? 2) Who is the cardiac imager of the future and what is the role of the multimodality imager? 3) How can we nurture innovation and research in imaging? And 4) how can we maximize imaging information and optimize outcomes? This document describes the proceedings of this Think Tank.
The increasing speed and magnitude of change in health care provide both challenges and opportunities. To successfully navigate the future, it is essential to anticipate difficulties and design strategic solutions. This is as true for cardiac imaging as it is for the rest of cardiac medicine. Dramatic changes have already occurred in imaging, including the introduction of promising new technologies such as coronary computed tomography (CT) angiography and substantial reductions in reimbursement driven by cost cutting and concerns regarding overuse. The cardiology imaging community has responded with an array of approaches, including the convening of think tanks to define and address imaging quality (1,2), radiation safety (3), and other relevant topics; the design and implementation of appropriate use criteria (4); the codification of methods for the creation of technology quality metrics (5); the creation of increasingly robust accreditation standards, such as those from the Intersocietal Accreditation Commission; and the performance of large, outcomes-driven randomized controlled trials (6,7). Additionally, individual societies have issued an array of guidelines and standards documents and have created certification examinations to document competency (8–18).
These efforts have addressed some of the challenges facing cardiac imaging, but many remain. Health care reform is raising expectations about access to care and cost reductions. Reform is mandating new ways of paying for imaging services that emphasize value over volume, a far more challenging standard to demonstrate (19). Although it is easy to be pessimistic about these changes, opportunities abound. A consortium of cardiovascular imaging centers has demonstrated that a partnership with payers can yield dramatic improvements in imaging safety and appropriateness (20,21). The introduction of novel percutaneous devices for valvular and structural heart disease requiring complex imaging has highlighted an essential role for imagers on the heart team. New technologies such as fractional flow reserve derived from computed tomography (FFRCT) and positron emission tomography (PET)-CT offer hope that we will soon attain the “holy grail” of imaging in coronary artery disease diagnosis: providing both anatomic and functional information noninvasively.
Despite such progress, the changing landscape of health care remains challenging to the field of cardiac imaging and to imagers individually. Accordingly, the American College of Cardiology’s (ACC) Executive Committee and Cardiovascular Imaging Section Leadership Council convened a discussion regarding the future of cardiac imaging during a 2-day Think Tank held at Heart House on April 28 and 29, 2015. Participants were thought leaders in the field, including council leadership and experts nominated by the participating organizations (Online Appendix). The charge was to think broadly about the future of imaging and develop a road map to address the critical challenges facing cardiac imagers.
The Think Tank was chaired by Pamela S. Douglas, MD, and Manuel D. Cerqueira, MD, and guided by a steering committee that included representatives from the ACC Cardiovascular Imaging Council and 5 cardiovascular imaging subspecialty societies: the American Society of Echocardiography, the American Society of Nuclear Cardiology, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society for Cardiovascular Angiography and Interventions. Representatives from the American Heart Association, the American College of Radiology, the Radiological Society of North America, the Intersocietal Accreditation Commission, and the Society of Nuclear Medicine and Molecular Imaging also joined the dialogue. Discussion focused on creating a vision for the future on the basis of the current state of the field and sought to develop specific actionable recommendations to ensure a vibrant presence for cardiac imaging in contemporary health care. It was organized around 4 goals: 1) to preserve and enhance the relevance of cardiac imaging in a value-based health care system; 2) to define the cardiac imager of the future; 3) to ensure robust innovation and research; and 4) to maximize imaging information and improve outcomes. This white paper represents a summary of the discussion of these goals and presents the conclusions and recommendations of this Think Tank (Central Illustration).
Goal 1: Preserve and enhance the relevance of cardiac imaging in a value-based health care system
Major trends and challenges
The US health care system is shifting emphasis from productivity to value, whereby value is defined as outcome achieved per dollar spent (22). The economic role of cardiac imaging as a revenue generator is correspondingly changing to that of a cost center, requiring demonstration of value to justify support for its operations. Although the value of cardiac imaging is appreciated clinically, there are several challenges to demonstrating this value objectively in an administrative setting. First, the indirect link between test reports, outcomes-modifying therapy, and the eventual outcomes value of cardiac imaging is often difficult to establish. Second, traditional health outcome measures, such as survival, inadequately characterize the full impact of imaging on medical decision making and health status. Third, reporting of imaging studies generally lacks evidence-based recommendations for changes in treatment that may improve outcomes. Fourth, given their expense and duration, randomized trials answer only a minority of relevant questions, and new, alternative data sources, methods, and evidentiary standards are necessary to generate a more robust evidence base supporting imaging. Finally, national guideline development and local health system care initiatives should include cardiac imaging expert representation, to ensure a robust discussion of alternative imaging modalities, aid dissemination of best practices, and appropriately highlight the potential value (or lack thereof) of imaging studies.
Recognition of the ongoing changes in the health care environment represents a great opportunity for the cardiac imaging community to shape the field’s successful adaptation. The consensus achieved at the ACC Future of Cardiac Imaging Think Tank included 3 strategies focused on strengthening the role of cardiac imaging in outcomes-based patient care (Table 1) .
Create meaningful outcome measures that demonstrate the value of imaging
This is essential to ensuring the appropriate future role of cardiac imaging services. Previous efforts have focused on intermediate measures of quality, such as data reproducibility and reporting turnaround times (19). Although these process measures are requisite for improving outcomes, they are not sufficient in themselves, and we must identify and target factors to specifically assess the effect of imaging on a patient’s cardiac health. Traditional outcomes (e.g., survival, adverse events) are always relevant, but because of the tenuous connections between diagnosis and events and the low event rates in many imaging populations, large data sources and infrastructure are required. Furthermore, a focus on only “hard” events might fail to evaluate other potential major benefits, such as reductions in admission or readmission, improvements in medication adherence, and adoption of healthy lifestyle behaviors, treatment modifications, or efficiency (time to diagnosis) (8,23). Examples of such intermediate outcomes applicable to cardiac imaging are presented in Table 2, but further collaborative metric development is required.
Use these metrics to measure and improve imaging outcomes
A demonstration of the ability of cardiac imaging to improve these new outcomes measures is necessary to further strengthen support for cardiac imaging in the future. Several substrategies were identified that will be essential for success. Internal process improvement, such as standardized and structured reporting, is necessary to provide the infrastructure for research efforts and is further discussed in Goal 4, Strategy 1. Support for clinical cardiac imaging quality improvement and research registries that include data elements for all relevant outcome measures and raw data for machine learning is discussed in Goal 4, Strategy 2. Finally, the creation of a stronger link between imaging results and those changes in therapy known to improve patient outcomes is essential. Regardless of how well a test performs, if the results do not lead to a change in therapy, it cannot improve outcomes. Currently, considerable heterogeneity exists in how imagers report key findings (and how referring physicians act on them), yet there is evidence that inclusion of treatment recommendations provides a form of decision support that can improve care. Heidenreich et al. (24) demonstrated that guideline-based treatment was improved by attaching reminders to echocardiogram reports regarding consideration of beta-blocker therapy among those with low ejection fraction. Similarly, a statement in the test report that includes a recommendation for consideration of aggressive preventative therapy including statins has been shown to add value to the observation of significant coronary artery calcification (25). A tactic to support this proposal is development of an intersocietal consensus statement that identifies those clinical scenarios for which the evidence robustly supports the inclusion of recommendations for consideration of specific therapies and highlights knowledge gaps to guide future research efforts. Recommendations for inclusion of these recommendations for clinical consideration in reports could be incorporated into the intersocietal accreditation of laboratories for cardiac imaging specialties.
To accomplish these goals, consideration should be given to incorporating cardiac imaging into institutional service lines or other proven effective organizational models that reduce the vertical segregation of different physician specialties, focus leadership on disease and population management (26), and foster collaborations between physicians and administrators in accomplishing quality improvement and cost reduction initiatives. The inclusion of cardiac imaging within the service-line paradigm may differ by institution. For example, one model might focus on the creation of disease-specific centers of excellence, in which the cardiac imaging services are matched to imaging needs of specific patient populations (e.g., valve disease, heart failure), whereas another model might focus on a service line dedicated to cardiac imaging, integrating the traditional silos of cardiology and radiology specialties. Regardless of the specific organizational structure at a given institution, a service-line approach that brings together administrators and imagers in different modalities offers opportunities to unify cardiac imagers and to facilitate efforts that improve the impact of cardiac imaging on health outcomes.
Ensure that imaging expertise informs patient care
The integration of cardiac imaging expertise into the development of patient care pathways will assist in the dissemination of best practices. Nationally, the Think Tank recommends that cardiac disease guidelines routinely include information on how to best use imaging, such as summarizing the roles of specific modalities for common scenarios. At the health-system, health-plan, or physician-office level, the implementation of guidelines and the development of local disease-care initiatives should involve local cardiac imaging expertise. Specific imaging modalities recommended by guidelines might not always be readily available (e.g., stress echocardiography, PET, cardiac magnetic resonance), so alternatives need to be considered. Local knowledge of the strengths and weakness of each laboratory, as well as the impact of specific patient characteristics such as body habitus, will better inform decision making. For example, analysis of the PARR-2 (PET and Recovery Following Revascularization) randomized trial results demonstrated that sites with more experience in PET imaging had improved outcomes after viability determination by PET compared with less experienced centers (27). In this setting, improved expertise in PET viability determination and knowledge of corresponding favorable outcomes data might provide leadership with confidence in recommending PET at that particular institution. However, even at the local level, such information might be disseminated heterogeneously within the pool of referring physicians. Therefore, the Think Tank encourages inclusion of cardiac imaging expertise in cardiac service-line leadership.
Goal 2: Define the cardiovascular imager of the future
The rapid and major technological developments in echocardiography, nuclear cardiology, cardiac CT, and cardiac magnetic resonance make the achievement of a high level of expertise in all 4 modalities by 1 person challenging. Furthermore, the time required to achieve such competency could negatively impact training in other areas during a general cardiology fellowship and might still result in inadequate exposure to the individual imaging modalities. Finally, even if such multimodality competence is achieved, it is time consuming and expensive to maintain credentialing and ongoing learning. This is perhaps why the much debated concept of a true multimodality imaging expert has had limited translation into practice and training guidelines (32). Given these challenges of multimodality training, the Think Tank recommends re-examination of the characteristics, training path, and clinical role of a cardiac imaging expert.
The consensus achieved at the ACC Future of Cardiac Imaging Think Tank included 4 strategies focused on redefining the cardiac imaging expert and strengthening the role of cardiac imaging in outcomes-based patient care (Table 3).
Redefine the cardiac imager on the basis of level of expertise rather than number of modalities
As a first step, the cardiac imaging expert should be redefined as one who has a dedicated training path in cardiac imaging and an “expert” level training in at least 1 modality. This path includes sufficient but not necessarily expert-level exposure to the other modalities, so as to ensure a broad-based understanding of cardiac imaging. Thus, the preferred designation is “cardiac imaging expert” rather than “multimodality imaging expert,” to emphasize the expertise of the person rather than the number of modalities. The Think Tank also recommends recasting multimodality imaging as a service characteristic rather than an individual physician’s scope of practice. To create a multimodality imaging service, experts in the different modalities will have to work collaboratively to ensure that patient needs are met.
Define training goals for the new cardiac imaging expert
Prior task forces have made recommendations for the integration of modalities in cardiac imaging training (28). Inherent in the development of training goals for the cardiac imaging expert are the following considerations: 1) the finite time available for advanced training in a 3-year general cardiology fellowship; 2) the clinical and market expectations that general cardiologists will be capable of independently performing functions beyond evaluation and management services after a traditional 3-year fellowship, which forces cardiology fellows to seek interpretive competence in imaging as a strategy to market themselves better; and 3) the need to ensure a uniform standard of interpretive skill, particularly in echocardiography and nuclear cardiology.
A training approach that might better address these considerations is a competency-based definition of expertise. The current metrics of time and volume of exposure should be only some of the factors used to define an expert. Variability among practitioners’ learning curves and interpretive skills can be addressed by this competency-based approach. The goal is to ensure a uniformly high standard of interpretive skill among practitioners of cardiac imaging.
The Think Tank recognized that such an approach will need to be aligned with the Core Cardiovascular Training Statement (COCATS) recommendations for training in cardiology and its subspecialties (29) and suggested that consideration be given to restructuring the existing hierarchy of training levels I, II, and III into “core exposure” and “expert (interpretive competence)” levels. Core exposure to imaging would define the minimum requirement for a general cardiology fellowship and should be required for all trainees regardless of their career goals. It is intended to foster a basic understanding of all imaging modalities. The expert level should ensure interpretive competence and should be required for anyone who intends to independently practice 1 or more of the imaging modalities. For experts who wish to pursue a leadership pathway (e.g., laboratory directorship), additional training in leadership skills, health care delivery, and research would be essential. Thus, the designation imaging expert, which should be mandatory for practice, would require a higher standard than is currently recommended for level II training, and the leadership path would ensure specific training that is not explicitly defined in the current level III. This approach dissociates the leadership and research skill requirements for laboratory directorship from interpretive competency. Furthermore, a focus on a higher requirement for interpretive competence could facilitate the achievement of a uniformly high standard for practitioners designated as imaging experts. The Think Tank believes that separating and standardizing training and leadership requirements in this manner is more suitable than simply redefining the current levels I, II, and III.
In a competency-based approach, the time required for expert-level credentialing could vary on the basis of the individual trainee and the training program. In general, expert competency in only 1 imaging modality can be achieved in the 3-year general fellowship. The addition of modalities could reduce important exposure to other nonimaging subspecialties, such as heart failure, electrophysiology, and invasive cardiology, such that expert-level training in more than 1 imaging modality or leadership-level training could often require additional time beyond the 3-year general cardiology fellowship. However, this approach is hampered by the lack of a general consensus regarding a curriculum for a dedicated fellowship in advanced cardiac imaging, as would be required for an Accreditation Council for Graduate Medical Education (ACGME) accredited fellowship such as is offered in interventional cardiology, electrophysiology, and heart failure. A recent survey conducted by the Imaging Council of the ACC revealed considerable heterogeneity in the curricula of currently offered non-ACGME imaging programs (30). The formal endorsement of ACGME accreditation of an imaging fellowship might facilitate harmonization of programs across the country, enhance credibility as a subspecialty, and provide avenues through which funding may be sought. Because ACGME accreditation usually requires a board certification examination, the multiple examinations currently offered by subspecialty organizations represent a significant hurdle, and this merits further conversation.
Define avenues for lifelong competency
Technological developments in cardiac imaging modalities continue to occur at a rapid pace. A significant need exists to develop mechanisms for practitioners, particularly in non–university-based settings, to keep up to date with these developments. The Think Tank recommends evaluating and implementing nontraditional methods of maintaining competency, for example, online training or focused courses. These programs would need to have rigorous oversight by professional societies to ensure appropriate content and rigor.
Optimally integrate the cardiac imaging expert into clinical practice
With the ongoing shift in emphasis from volume to value, and particularly with the adoption of accountable care organization models (31), the value of imaging stewardship needs emphasis. The role of a consultative imaging service becomes relevant in this context. These consultative services would provide the interpretation of images but should also recommend the appropriate modality to use for a particular diagnosis or difficult case or determine when no imaging might be appropriate. By consulting with expert imagers, providers could potentially avoid unnecessary or layered testing, thereby reducing health care costs while improving care. An emphasis on quality metrics also provides support for a consultative imaging service model, to reduce unnecessary cardiac testing and improve appropriateness and quality of testing. (See also discussion and recommendations in Goal 1.)
Goal 3: Ensure robust innovation and research in cardiac imaging
Traditionally, training in cardiac imaging has focused on clinical applications of existing technology in patient care (19,22). Although cardiologists can readily identify clinical needs, nonclinical scientists and engineers have a better foundation for developing the technology to meet them. However, these 2 groups often have limited interactions. Thus, a challenge exists in the identification and articulation of unmet clinical needs and their translation into innovation and technology development, which could be addressed by improving bidirectional communication between clinicians and scientists/engineers.
Collaboration between industry, engineers, and clinicians is hampered by a number of considerations, including the development of individual imaging modalities in silos and the lack of formal training in research/innovation for cardiologists. Although the primary objective of medical training is to gain clinical expertise, medical school, residency, and fellowship can all provide opportunities to learn to think creatively and interact with experienced mentors. This is especially true for cardiac imaging fellowships.
The consensus achieved at the ACC Future of Cardiac Imaging Think Tank included 5 strategies for excellence in innovation and research (Table 4).
Identification of unmet clinical needs
The Think Tank recommends convening disease-based forums facilitated or hosted by the ACC and other professional societies or industry, during which physicians, scientists, and industry partners can interact and collaborate. We also recommend inclusion of invited papers on unmet clinical needs in imaging journals.
Collaborative academic and industry partnerships
Collaborative academic and industry partnerships can foster cross-fertilized, high-quality results and increase awareness of funding opportunities. The Think Tank recommends addressing this strategy by the creation of special innovation-based sessions at society and/or institutional meetings, as well as by providing opportunities for online networking. Society meetings must consider works-in-progress sessions. Another tactic is to engage the membership of the ACC Imaging Council and engineering societies by creating an online forum and conferences that bring together interested parties. Although such interactions are essential to innovation, potential conflicts of interest remain a legitimate concern. The ACC and other professional societies need to clarify the value of research partnerships relative to potential conflicts of interest and foster a culture of transparency rather than avoidance (32).
Dedicated training in innovation and research
Although the term innovation is most often associated with medical devices and technologies, multiple platforms exist. These include the study of individual- versus population-based strategies for detection of specific pathologies, global health care delivery, clinical trial design, and mobile health research (33). Learning the skills required to take advantage of the various research platforms could require specialized post-graduate training programs or immersion in environments in which such collaborations are valued. The Think Tank recommends enhanced educational components, which might include the following:
• Creation of online courses, CME courses, and symposia for fellows and clinicians at annual sessions directed toward novel technologies, unmet needs, and opportunities for research and innovation
• Development of a research mentorship program by the ACC Imaging Council with identification of qualified mentors
• Modification of requirements of cardiac imaging training programs to include research/innovation with instruction in research design, intellectual property, technology transfer, and regulatory processes (with additional supported training time for interested trainees) and encouragement to pursue advanced degrees in biomedical engineering or physics when possible
• Publishing a best practices white paper by the ACC Imaging Council on an imaging research curriculum for fellowships that outlines collaboration between faculty, various departments, and schools (medicine, biomedical engineering, and physics).
• Including imaging in the “How to Become a CV Investigator” course held by the ACC Education Council
Re-emphasize the value of scholarly activity
Research and innovation result in institutional prestige, aid in funding opportunities, and are critical in moving the field forward. The provision of time, facilities, and financial support by the medical center in which the practitioner is employed must be considered part of the institution’s growth capital. For some institutions, this may represent a shift in values and culture. A number of medical centers in the United States have exceptional systems for stimulating the flow of new discovery by integrating research and innovation with clinical activity and private sources of capital. Leading examples are Harvard/Massachusetts General Hospital and Stanford Biodesign. Both programs benefit from proximity to leading venture capital firms whose private investments early in the development stage accelerates technology transfer to market. The Think Tank recommends the following approaches:
• Advocacy by professional societies for institutions to redefine the value of clinician-scientists
• Assignment of relative value unit (RVU)-type value for scholarly activities on the basis of research productivity, teaching, and other nonclinical activities
• Collaboration between the ACC imaging and academic councils to propose criteria for rewarding physicians for academic activities
Expand funding opportunities
Traditionally, funding has been less available for imaging research than for other forms of investigation, such as new drugs and devices. With decreasing industry and nonindustry funding opportunities, cardiac imaging scientists must refine their approach, including exploring nontraditional sources for research. The Think Tank recommends a renewed emphasis on visibly demonstrating the value of cardiac imaging research, investigating specific cardiovascular diseases, and developing tailored imaging strategies rather than an emphasis on developing a particular imaging technology outside of a specific disease context. The ACC can assist imaging researchers by enhancing awareness of specific funding opportunities and advocating for specific funding programs that address unmet clinical needs in cardiac imaging. Furthermore, exploration of new venues for funding at appropriate stages of research and innovation development (e.g., ACC ventures, societal and foundation fund-raising efforts, an imaging X-prize, and small business grants) could help to increase the amount and breadth of imaging research funding sources.
Goal 4: To maximize imaging information and improve outcomes
Major trends and challenges
The goal of clinical imaging is to improve disease detection and enhance care. In other fields, similar goals can be accomplished through an increasing emphasis on the use of biological and health-related data to enable improved diagnostic and therapeutic decisions at an individual patient level, often referred to as personalized medicine or precision medicine (34). In part, big data analytics, the exponential growth in computational storage and speed leading to expansion in the amount of efficiently mined biological data, have made this possible (35,37). Machine-learning tools and methods allow us to go beyond a mere description of the data. Big data analytics provide in-depth knowledge from large amounts of information in the form of testable models (38,39). Several biological domains in which machine-learning techniques have been applied successfully include the medical world, including genomics, clinical care protocols, patient variability, and clinical effectiveness (40–42).
The growth of computational processing has led to the emergence of new multidimensional and multiparametric techniques in cardiac imaging in which massive amounts of data (also known as big data) are generated during each acquisition. Digital imaging has made this possible. In addition to aiding patient diagnosis, the interaction of imaging data with existing patient electronic medical record data at the population level represents one form of imaging big data. Application at a population level through linkage with existing patient data is another form of big data and could open new doors to disease recognition, disease classification, and effectiveness of therapeutic strategies. However, at present, the application of big data analytics and machine learning in cardiac imaging at either the patient or population level remains limited.
Complex imaging data give rise to 2 types of unique challenges. First, the imaging data need to be easily accessible and standardized for application of suitable machine learning algorithms. Currently, the access to imaging data “anywhere and anytime” is limited. Moreover, the need for imaging data to be pre-processed and organized uniformly has not been adequately addressed. Second, the link between imaging data and its interaction with patient outcomes is a complex field in which big data analytics might have a critical role. However, in the absence of proper organization of data, there are substantial barriers to harnessing the power of analytic techniques. One of the proposed solutions has been to use “cloud-based” imaging and informatics data services as a model for enabling ubiquitous, convenient, on-demand access to a shared pool of configurable big imaging data (43). However, this gives rise to 2 types of problems: first, inadequate safety/security of data, which can be a threat to privacy, and second, the reliability and transparency of data handling by third parties. This further brings in a host of complexities, which include need for authentication, licensing, secure transmission, data encryption, anonymization, and the need for “security as a service.”
The situation presented in the preceding text represents a great opportunity for the cardiac imaging community to improve outcomes by maximizing the value of imaging data and ensuring information formats that permit integration into precision medicine care and research models. The Think Tank recommends 5 strategies to address existing gaps (Table 5, Figure 1).
Define and reinforce minimal standards for image quality, structured data reporting, and work flow for all modalities
Scientific bodies like the ACC, in partnership with subspecialty imaging associations and accrediting bodies, should lead an initiative to standardize imaging information and work flow. The aim is to facilitate the integration of big data analytics into cardiac imaging. The primary motivation for this collaboration would be to define the quality of structured and unstructured data to impact subsequent analyses. The results of these analyses in turn would potentially improve imaging quality and outcomes. To standardize data acquisition and maintain quality, automated techniques that enable multiparametric feature extraction and improved throughput will be an important focus. Industry and vendor engagement in this initiative will be essential. A process of certification, accountability, and endorsement that indicates an imaging modality/work-flow solution adheres to the minimum guideline standards set forth by the ACC and the consortium of partnering societies and accrediting bodies might also be necessary.
Measure and improve adherence to minimum standards in image quality, structured data reporting, and work flow for all modalities by the creation of registries linked to clinical databases to develop imaging data repositories for all modalities
The ACC, along with other organizations, should create registries linked to clinical databases that include outcomes for all imaging modalities along with pertinent clinical information associated with the imaging utilization. Such registries would work as a powerful benchmarking and quality improvement tool, as has been demonstrated in multiple areas of procedural cardiology (44,45). In addition, registries would provide access to information that could be used for research and clinical feedback. An expedited way to address this gap would be by identifying and collaborating with pre-existing registries and creating funding mechanisms that could potentially offset the cost.
Connect imaging data and clinical data to outcomes using big data analysis
The ACC and other imaging societies should collaborate with big data scientists and bioinformatics experts to expedite ways of using imaging data across multiple modalities to validate the value of cardiac imaging in improving health care outcomes. New precision medicine algorithms can help data-driven discoveries and identification of patient phenotypes via the study of clinical and imaging data interactions. Moreover, the use of a machine learning interphase can help automate the analysis and create predictive analytics through algorithms that detect and learn from complex relationships and patterns. Meticulous care will be needed to protect patient privacy. Strategies must use the minimal amount of identifying data required to provide important information about patient populations. Moreover, patients should benefit from this information. Thus, the analysis results should be made public and transparent, with easy access for practitioners and patients alike. One of the challenges of big data acquisition is the development of meaningful outcome measures (see also goal 1). Traditional outcome variables such as mortality rates and length of stay provide some information but clearly do not reveal the whole picture. Other measures such as readmission rates, prevention of recurrent heart failure, adherence to guidelines, and patient safety are emerging that may help determine health quality and effectiveness. Big data analysis (through a multi-institutional registry) has the potential to help link clinical imaging data and clinical reporting to recommendations for care.
Facilitate implementation by removing barriers and incentivizing schemes
Creation and adoption of standards, development of registries, and the use of big data analytics in cardiac imaging requires a buy-in from all stakeholders involved. This includes professional and advocacy organizations such as the ACC but also equipment companies, insurers, practitioners, and regulatory organizations such as the Intersocietal Accreditation Commission. Barriers to successful implementation include inertia around existing data models, cost and resource requirements, concern about proprietary information, legislation, privacy issues, and corporate liability. Furthermore, the imaging community might be unfamiliar with the value of this approach, a critical factor in ensuring buy-in. A good example of successful utilization of big data analysis is the Michigan Advanced Cardiovascular Imaging Consortium, in which many medical institutions in the state share data to improve the delivery and quality of care. Other collaborative quality initiative projects under the auspices of the Advanced Cardiovascular Imaging Consortium Blue Cross Blue Shield/Blue Care Network of Michigan have included cardiovascular consortiums for percutaneous coronary intervention and vascular interventions, an anticoagulation quality initiative, and a bariatric surgery initiative (36). These types of initiatives have the potential to improve the overall quality of health care while lowering costs. The sharing of data allows institutions with less experience to elevate their quality of care and enables lagging institutions to learn from other hospitals that have already fostered a successful strategy to solve a problem. Moreover, successful innovations that are developed at particular institutions can be implemented in other hospitals in a timely manner. A broad range of incentives, from access to useful data, to continuing medical education, to public recognition or certification, to payments or access to patients, can be used that tap into multiple motivations for participation and could be useful to promote these activities.
The future of the Cardiac Imaging Think Tank recommendations presented here contains a distillation of those strategies that the community believes are important, even essential, to meeting current and anticipated challenges and to moving the cardiac imaging field forward. Each topic area provoked substantial dialogue. Achieving a reasonable number of actionable recommendations was not easy. Given the robust discussion and engagement at the Think Tank, further defining these proposals and implementing them is a top priority of the Cardiovascular Imaging Section and Council.
Although the Think Tank recommendations focus on needs and specific initiatives, the discussion was marked by a sense of optimism and excitement about the future. Furthermore, in a field often marked by competitiveness between modalities, the overarching dynamic was of collaboration and inclusivity. Both of these attitudes represent a maturing of cardiac imaging and are critically important to the future of the field. Another important indication of maturation and readiness to change was the universal acceptance of imagers’ responsibility and accountability for the quality and impact of imaging on patient health; aspirations to excellence rather than preservation of the status quo were universal.
Many recommendations for action items focused on common themes, including quality improvement and the need for more and better evidence to inform care. Not surprisingly, this led to some overlap in recommendations. However, this serves to identify and emphasize those areas that are most important and will have the highest impact. Notable among these are the development of imaging standards and tools for quality improvement, the identification of imaging quality and outcome metrics, the creation of an imaging registry, and the use of such a registry to both improve care and drive innovation and research.
Despite all these strengths, much work remains to be done. The recommendations presented here are the result of a 2-day Think Tank that convened a small group of experts. Further deliberations and planning, as well as the thoughtful input of the entire imaging community and its other stakeholders, are needed to refine and improve these recommendations. In particular, determinations of priorities and responsibilities are required to translate these ideas into reality. In keeping with its nature as an initial brainstorming session, the Think Tank took a “blue sky” approach and did not allow the very real considerations of cost or difficulty in implementation to impair creativity or breadth of discussion. Furthermore, although many issues included apply to all aspects of cardiovascular imaging, some important areas, including vascular studies and invasive imaging (angiography, intravascular ultrasound, optical coherence tomography), were not discussed specifically. Finally, many efforts are under way in communities that overlap with those proposed here. Connecting these initiatives, if only to learn from them, will no doubt strengthen our ability to achieve the bright future we envision.
In conclusion, although the changing health care landscape is challenging, the cardiac imaging field is able to envision a future of excellence, quality, and innovation and has outlined concrete steps to realize this potential. Further work is needed to accomplish these goals.
For a list of participating institutions and individuals, please see the online version of this article.
Dr. Douglas has received research grants from HeartFlow and GE Healthcare; and serves on a Data Safety and Monitoring Board for GE Healthcare. Dr. Cerqueira has served as a consultant and a member of the speakers bureau and advisory boards for Astellas Pharma USA and as a consultant (blind reader) for Cardiovascular Imaging Technologies. Dr. Soman has received consultant fees and grant funding from Astellas Pharma. Dr. Weissman has received grants (to MedStar Health Research Institute) from Boston Scientific, Abbott Vascular, Medtronic, St. Jude’s, Direct Flow, and Sorin Medical. Dr. Wong has served as the University of Pittsburgh Medical Center’s principal investigator for the LIBERTY-HCM trial, sponsored by Gilead Sciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Heinrich Schelbert, MD, served as Guest Editor for this paper.
- Abbreviations and Acronyms
- American College of Cardiology
- computed tomography
- myocardial perfusion imaging
- positron emission tomography
- Received December 22, 2015.
- Revision received February 8, 2016.
- Accepted February 16, 2016.
- American College of Cardiology Foundation
- Douglas P.,
- Iskandrian A.E.,
- Krumholz H.M.,
- et al.
- Douglas P.S.,
- Chen J.,
- Gillam L.,
- et al.
- Douglas P.S.,
- Carr J.J.,
- Cerqueira M.D.,
- et al.
- Hendel R.C.,
- Patel M.R.,
- Allen J.M.,
- et al.
- Bonow R.O.,
- Douglas P.S.,
- Buxton A.E.,
- et al.
- Shaw L.J.,
- Berman D.S.,
- Picard M.H.,
- et al.
- ↵American College of Cardiology. Available at: www.acc.org. Accessed June 24, 2016.
- American College of Radiology. Available at: www.acr.org. Accessed June 24, 2016.
- American Heart Association. Available at: www.heart.org. Accessed June 24, 2016.
- American Society of Echocardiography. Available at: www.asecho.org. Accessed June 24, 2016.
- American Society of Nuclear Cardiology. Available at: www.asnc.org. Accessed June 24, 2016.
- Intersocietal Accreditation Commission. Available at: www.intersocietal.org. Accessed June 24, 2016.
- Radiological Society of North America. Available at: www.rsna.org. Accessed June 24, 2016.
- The Society for Cardiovascular Angiography and Interventions. Available at: www.scai.org. Accessed June 24, 2016.
- Society for Cardiovascular Magnetic Resonance. Available at: www.scmr.org. Accessed June 24, 2016.
- Society of Cardiovascular Computed Tomography. Available at: www.scct.org. Accessed June 24, 2016.
- Society of Nuclear Medicine and Molecular Imaging. Available at: www.snmmi.org. Accessed June 24, 2016.
- Douglas P.S.,
- Picard M.H.
- Chinnaiyan K.M.,
- Peyser P.,
- Goraya T.,
- et al.
- Chinnaiyan K.M.,
- Boura J.A.,
- DePetris A.,
- et al.
- Heidenreich P.A.,
- Gholami P.,
- Sahay A.,
- Massie B.,
- Goldstein M.K.
- Abraham A.,
- Nichol G.,
- Williams K.A.,
- et al.
- Thomas J.D.,
- Zoghbi W.A.,
- Beller G.A.,
- et al.
- Narula J.,
- Chandrashekhar Y.S.,
- Dilsizian V.,
- et al.
- Shah N.R.,
- Cullen M.W.,
- Cheezum M.K.,
- Julien H.,
- Sivaram C.A.,
- Soman P.
- Harrington R.A.,
- Califf R.M.
- Yanavitski M.
- Narula J.
- ↵Collaborative quality initiatives. Blue Cross Blue Shield of Michigan website. Available at: http://www.bcbsm.com/providers/value-partnerships/collaborative-quality-initiatives.html. Accessed June 24, 2016.
- Sengupta P.P.
- Barla A.,
- Jurman G.,
- Riccadonna S.,
- Merler S.,
- Chierici M.,
- Furlanello C.
- Larrañaga P.,
- Calvo B.,
- Santana R.,
- et al.
- Cohen A.M.,
- Smalheiser N.R.,
- McDonagh M.S.,
- et al.
- Badawi O.,
- Brennan T.,
- Celi L.A.,
- et al.
- Mell P.,
- Grance T.
- McComb J.M.
- Bhatt D.L.,
- Drozda J.P. Jr..,
- Shahian D.M.,
- et al.
- Poon M.,
- Cortegiano M.,
- Abramowicz A.J.,
- et al.
- Rozanski A.,
- Gransar H.,
- Shaw L.J.,
- et al.
- Nagueh S.F.,
- Bierig S.M.,
- Budoff M.J.,
- et al.