Building a Robust Lung Screening and Incidental Program

Dr. Aki Alzubaidi:
Hello everybody. My name is Aki and I am the co-Ceo of Eon, formerly known as LungDirect and we just recently rebranded to Eon. We did not get bought, like a lot of people think. Our approach is that our passion is really pulmonary nodules. However, in doing this, we found out that there’s more than just pulmonary nodules that need to be tracked and so we wanted to create a mechanism in which we could actually go beyond just pulmonary nodule tracking to other disease states and that’s really why the name change to Eon

Today, we’re delighted and honored to have Amie Shea, who is the Oncology Screening Program Manager at the Medical Center of Aurora. So I remember meeting Amie very vividly for the first time. We were in a little cafe area over at the Medical Center of Aurora and Amie, you were in a business role at that time, correct?

Amie Shea:
Yes, so I was in a business role, like a business nodule coordinator, non-clinical.

Dr. Aki Alzubaidi:
And so, I remember you were just ready to go after it.

Amie Shea:
Yes.

Dr. Aki Alzubaidi:
I remember it vividly and I was like “oh this is amazing,”  somebody who is a non-clinician from the business world; who actually understands the problem and wants to jump in and tackle it. And since that point I’ve just been impressed with how you behave, how you act and then your passion for the patients that you serve.  What you’re going to share with us today is really how you started a program from scratch. Basically there was a little bit of framework, but from scratch you grew it, and now the program is being emulated really throughout the whole Continental Division and HealthOne. So, you should be very proud. Congratulations on what you’ve accomplished

Amie Shea:
Thank you.

Dr. Aki Alzubaidi:
I’ve learned from somebody who’s actually in the trenches. You’re actually the one coordinating the care, helping the physicians and the providers manage these patients and do it in a timely way. One thing that I’ve seen is that HealthOne Continental, HCA. They’re just really excellent at patient navigation and patient coordination and this is just the next step that elevates their commitment to that.

Amie Shea:
I agree 100%

Dr. Aki Alzubaidi:
And so without further ado, Amy I will let you take it over and I’m looking forward to learning today.

Amie Shea:
Great! Thank You Aki. I’m really excited to be here, so thank you for this opportunity.

Welcome everybody. Thank you for joining, I really appreciate it. I hope that you guys walk away with some tips and tricks for starting a thoracic oncology program in your hospital.

Before we begin, I’d like to talk about the importance of understanding “the why” behind why you’re doing this. You know for me the why cancer touches everybody in some way or another and early detection is key. A lot of times with lung cancer the symptoms come too late. My father was diagnosed with colon cancer about 10 years ago, he’s since passed on, but prior to me being in healthcare, I worked for a bank; a large bank here in Colorado and I left the banking world to enter into the healthcare world so that I could help cancer patients whether it be pre, post or right in the trenches. So my “why” is definitely for cancer patients. I’m here to help them in their journey. So as we go through these slides just try and remember you’re why and why are you doing this and why do you want to start this program at your hospital.

What are the elements of a thoracic oncology program?

So, the elements include lung nodules, lung cancer screening, a thoracic surgeon, a pulmonologist or pulmonary group, nurse navigation, technology, nodule clinic can be an option, smoking cessation program, multidisciplinary meetings and a marketing plan.

Some of the challenges

As I was preparing for this I kind of thought about what are the things that were a challenge for me when I started this program. Definitely finding the right person to be in this position is key. I came from an oncology and radiology background as well as business. So looking at who you want to develop as a nodule coordinator; start thinking about what their history is, somebody with oncology and radiology experience is really going to be able to jump right in and understand what the physicians are talking about and understand how radiology works with lung cancer screening and lung nodules. So, when I first started, software was not available for our lung nodule program. I have to give a shout out to our nurse navigators in our division because they really identified a gap in this and we were working in a very manual state prior to software and so software is a challenge if you don’t have it, to do this program.

Dr. Aki Alzubaidi:
That’s Jessica, Melissa, Sally anybody else you care to have a shout out to.

Amie Shea:
Yep. Basically the navigators that paved the way for this program to be created, so thank you.

Communication, a lot of your challenges with lung cancer screening are around education with the primary care physicians. A lot of times they don’t necessarily understand the criterion that needs to be met so a lot of education needs to be front-loaded when you start this program and then developing work processes, that’s a huge challenge because there’s a lot of moving parts especially in a hospital. So, developing that work plan is key.

Let’s talk a little bit about the lung nodule coordinators roles. Obviously we can’t put everything that they do in this slide but I just kind of wanted to point out the key things. Obviously, a nodule coordinator is going to act as a liaison between the physician and the patient. They’re really the glue that holds that relationship together; implement screening and incidental nodule processes to manage patients as well as manage our patient tracking software, EonDirect (formerly LungDirect).

So, with this wonderful software that Aki and Christine have built, it’s a great way to be able to manage the patient’s nodules in this software. They’re going to help coordinate patient follow-up so those patients that need to come back in for a follow-up scan, those nodule coordinators are going to be the one that makes sure that those patients get back in.

Continue to grow and enhance the program, I just want to let everybody know that this isn’t just a desk job where you sit and click on yes, we want to follow this patient or no we do not, it really goes outside of that and really have to get out in the public to get out the sessions.

Another thing that lung nodule coordinators will possibly do is smoking cessation. You know creating a program around that offering smoking cessation being able to understand the screening criteria is huge, so make sure that you definitely understand that.

Screening results, you know, that’s something that a process you’ll have to figure out and how you’re going to relay those results to the physician.

No one understands the flight nurse guidelines that are kind of our Bible that we live by. Recommendations and follow-up and the importance of early detection, this is also part of the role of the nodule coordinator.

The next thing that you want to do is identify your champions and their roles. And so, for me my physician champions are very supportive and without them there would not be this program. You want to look for an administrative champion somebody who’s going to advocate for that long nodule coordinator and the overall program, the thoracic program. It’s key to have a pulmonologist champion. My pulmonologists that I work with is wonderful very approachable, I can ask them questions, especially clinical questions that I may not understand or know. Your thoracic champion or thoracic surgeon, mine is excellent and gives me ideas and offers support at all times, she really helps me understand the screening criteria and kind of the link between screening and patients. And then the last thing you want to do is find a radiologist champion. Preferably somebody that’s chest certified, in our case our radiologist champion is chest certified and they’re there to help clarify any characteristics of the nodules that you may have questions about where it’s just unclear radiology reports that can sometimes happen.

The other thing that’s really key to a thoracic program is creating a multidisciplinary conference. You’ll hear it referred to as an MDM as well multidisciplinary meeting. This meeting consists of a team of specialists so pulmonologist, oncologists, radiation oncologists, thoracic surgeons and of course their nurse navigator. As a team they review cases and help develop a plan of treatment for your patient and follow-up. At our MDM we present lung rads 3 & 4 so that we can figure out what we want to do next steps for the patient. In our conference, I present any nodules that are 8 millimeters or greater and that’s just the threshold that my physician champions came up with, you can obviously be different in your market. They talked to me about repeat recommendations and then you know whether this is going to be a possible surgical candidate.

One thing that we decided to do early on in this program and it’s definitely an option and I recommend it, if you have the capability is, opening up a nodule clinic. This is a clinic that is for patients to be able to be seen by a specialist to learn more about their nodule and how they’ll follow it. The specialist, the pulmonologist that staffs the office can really dive deeper into the patient’s history and get a better understanding of their history and kind of next steps for the patient. We also use our nodule clinic as an option for patients who do not have a primary-care just so that they don’t get left behind.

Let’s see, workflow before EonDirect (formerly LungDirect). So this is, I laugh now but when I was working in it wasn’t funny. There’s a lot of work, a lot of manual data input; very time-consuming but basically I would skim the reports from radiology or the ER, looking for nodules. Our natural language processing as tight controlled as EonDirect. So we got nodules of all sizes and of all locations, so we could be looking at a thyroid nodule, a nodule, adrenal nodule, anything of that sort so that was time-consuming to kind of skip through all of those reports and see what do I really need to focus on and what can I discard. Obviously printing off the paper it was very hard on the eyes so with EonDirect, it’s a lot easier because it’s user friendly and you can read the reports just as if you were looking at him on paper.

I had sticky notes everywhere, they were my reminders because I didn’t really have a system in place where we could say, okay this patient needs to come back in two weeks or six weeks or six months so it became a sticky note nightmare. The manual entry of lung cancer screening registry was probably the hardest. My background is PET CT and so I did a lot of you know per registry, so luckily I had that a little bit of training. Registries are not easy to get through. They’re very time-consuming, a lot of questions but with EonDirect it’s much easier, so lots of spreadsheets and data. I think my spreadsheet had over 600 patients on it. So most of my time I was searching for the patients.

Dr. Aki Alzubaidi:
A lot of columns

Amie Shea:
A lot of columns yeah! Probably 25 columns. Adding in patient demographics took time, patients phone numbers, patient’s physicians, the nodule size and location which is key to follow-up. We have to know those things that were hard. Lots of manual input there and then adding the recommendations was also part of that spreadsheet.

Now we get to the fun part about workflow after Eon directs. So I was super excited when I met Aki and I was able to have this awesome software presented. It’s fast easy and very manageable. Now with EonDirect I can search in the search bar up on top of my screen by the patient’s name and it comes up and everything I need to know about is in that one search. The demographics populate over from our EMR, our hospitals EMR on EonDirect which makes not adding in patient demographics obsolete. So that’s great!

The radiology report lives inside of the patient’s charts so it’s easy viewing, I can print it if I need to but it’s very easy to read and they actually highlight the words nodule, mass, those types of things so you can easily point them out. The smoking history is captured which I think is great. Prior to Eon I would have to go dig through multiple dictations in our EMR systems, kind of find the captured history of smoking here it just auto-populates over. The nodule characterization size and much more is captured which makes it easy especially if you’re non clinical and sometimes not knowing what to look for is a challenge. Easy setup phone call reminders, so if I have a patient that I called and they were like I’m right in the middle of something I need you to call me back in a week I could easily put in a reminder for me to call that patient in one week versus a sticky note on the side of my desk.

Create follow-up for any additional scans or biopsies. This is huge because I think prior those patients could get lost to follow-up. I mean if I lost the sticky note or if something happened or I didn’t write down the right information, we could not be capturing those follow-ups so with this software definitely makes it easier. My favorite part of EonDirect is the one click submit’ to lung cancer registry. Before it was probably four pages of entering data now all of that is captured in EonDirect and I just clicks click the submit to lung cancer registry and I love it because it comes up and says submitted and that like the best feeling in the world.

The other part of it is the analytics if you’re in a management role and you’re managing the analytics of your nodule program, it’s at your fingertips. Its great graphs lots of information from the analytic site.

So, I wanted to talk about a couple of things that I felt were really important to establish right away when you start your program so and unfortunately, most of these ideas came from them happening without a process in place and I was like, ‘oh I should have that process’. So I’m letting you know up front that these are small things that will actually impact you in your program.

Coming up with a discounted plan for low-dose CT screening scans for the uninsured. Our community where our hospital is there’s a lot of uninsured patients and so we had to make sure that we were able to offer an affordable price for that scan. Working with your CT text to develop the low-dose CT scan protocols is huge and you want to make sure that information is captured properly. Really you need to decide whether you want to do letters or phone calls. I think in the beginning we did a lot more letters whereas now I actually call the patients and I call the primary care because I’m looking for a fast turnaround I want to make sure that those patients get the best care that they have up front and they know that somebody is watching out for them.

Referral process, the pulmonary or the nodule clinic, so you know start working on a process like how are you going to refer these patients over what is your process for that and who are you going to refer to. Referral process for primary cares to send you screening patients you know. This is something you can go and work at your screening program but you’re going to go down to the dirty work and say well how are we going to intercept those referrals, what process does that need to be laid out how is it going to work for the primary care and how is it going to work for our Hospital. And then the biggest thing is who’s going to be doing the authorizations, you know are you putting that back on the responsibility of the primary cares, it’s a service that you’ll offer at your hospital so really defining that program is going to help.

Then the next thing that’s a slide that’s coming up, I’m going to show you an example of a physician order for lung nodule follow-up. This was created to help follow-up patients get back into your hospital system easily. Just to give you an example a patient comes through, we find an incidental lung nodule and the recommendation for Fleischer’s guidelines is to follow-up in six months on that nodule. We now have to work to get that patient back in so that we can follow that nodule but we want to make it as seamless as possible for that primary care office. So we developed a form that we would send to an office and say hey your patients up due for a nodule follow-up. Here’s the order we’ve already filled it out, you add your stuff, sign it, send it back and we’ll make sure that this patient gets taken care of. As well as lung cancer screening order will be in the next two examples. One quick thing I want to mention about the lung cancer screening order. We made the decision to have the criteria listed on the order because we want to make sure that the shared decision-making visit was getting done, that the patients did have the appropriate pack history in place, so think about that when you’re creating your program and your screening order.

Dr. Aki Alzubaidi:
Noise frustration, I think, a patient that’s not eligible that they show up, right, it can cause emissions.

Amie Shea:
Right. So here’s an example of our lung nodule order. So, this would be, if a patient’s coming back in for a follow-up of an incidental nodule. We pretty much fill out the demographic part of it and then we let the physician fill out the rest. We want to make sure that we include the comparisons, we want to make sure that we get that data in there that we found the nodule so that our radiologists know to look back and get that comparison.

Dr. Aki Alzubaidi:
How much of this do you fill out?

Amie Shea:
Basically, just the patient information. We recommend in our cover letter to the office, we’ll say this would be ideal for a low-dose CT scan without contrast but obviously we only want to let the physicians feel that important part out just to make sure that we’re in line with what’s appropriate.

This is the lung cancer screening assessment and order form. Like I mentioned we fill out the patient demographics up top and then that screening assessment in the middle is definitely for the primary care or whoever is referring the patient to you. These are all things to make sure that we as the hospital get paid and the patient doesn’t get a bill for a scan that they didn’t meet criteria for. So it’s really important I think to make sure that the screening information is on the actual order form and then obviously, the primary care which would, what if it’s an initial screening or subsequent. Sometimes they may not know and you know we can go ahead and help out with that information.

Share decision-making. A lot of times, primary cares do not have time for that, it’s not able to fit into that time that they have with their patients. So a lot of our physicians will put, No. If I see that a shared decision-making visit wasn’t completed then that’s when I’ll give them over to the nodule clinic and that our PA or our pulmonologist could go ahead and do that shared decision-making visit.

So, the biggest thing with the thoracic program is we want to make sure that we are visible and we have all communication lines open.

When I first started it was a new hospital, I had been with health one for ten years but this was a new hospital that I joined and so I wanted to make sure that I met all of the key players. So I attended a lot of meetings to promote my program. I wanted to talk to ED leaders, I wanted them to know that we are watching their ED reports and that we are servicing those patients that have incidental modules. Attend radiology meetings letting them know that, hey we’re going to be looking at these reports; get your radiologists to quote Fleischer’s guidelines in the radiology report. Just stuff like that just keeping that communication open. Attending Grand Rounds, I do that often to meet the primary cares just to kind of give them a face with the person who’s following their patient and develop that relationship.

The other thing that you can do to be more visible and to get ideas for your program is get involved in your community. I belong to the Colorado lung task force which is great a lot of bright intelligent physicians and key leaders and the market get together and they talk about options and stuff for patients and just how to get that education out. I do the lung force walk every year which helps me to reiterate why I do this job and create that passion for it you get to meet people that actually you know have gone through cancer or loved ones that have passed away from lung cancer. So just get involved in your local committees and activities.

Let’s talk about the marketing. So, for me I think marketing is huge. This program will not grow unless you get out and meet and beat the streets. You want to meet with your primary care physicians regularly. You want to make sure that they know that you’re taking care of any patient of theirs that come into the ED, with an incidental module. I recommend doing program packets, so create a packet. A folder with your marketing brochures, your order sets and your process; how are these patient, are these physicians going to refer to you, is it a direct fax line, is it email. You know what are those communication lines. Smoking cessation is huge, it’s a great benefit for patients not only that but it also helps with your lung cancer screening program. So provide a one-page flyer about your program and how to refer. Your EMR may be able to piece out you know who’s been admitted in your hospital recently that could definitely use smoking cessation you know current smokers. So, you use those as leads to get in front of those patients to talk to them about lung cancer screening. Talk about how early detection can save lives. When you go to an exam or you go to your physician’s office and you go into an exam room you see all kinds of posters, make one of yours and put it in that exam room so these patients can see, “wow there’s a lung cancer screening program out there, I used to smoke. I smoked for thirty years”, have them talk to their doctor about it. It just makes that visibility constant.

Dr. Aki Alzubaidi:
The PCPs visiting offices regularly, I just wanted to kind of emphasize that too. What’s been the response from PCPs because I think that there’s a lot of unknown about it they think there’s like this you know their turf and that’s the ownership of the patient. What was the response back from visiting the PCPs and you basically tell them you’re going to remove a big headache.

Amie Shea:
Right exactly, a lot of the primary care are so thankful that there is this program out there. They don’t have the time or the software to manage these patients and their biggest fear is that these patients can fall through the cracks.

 

Dr. Aki Alzubaidi:
It’s hard to sleep at night. I think right for me provider to and knowing that there’s somebody there to help and remove that headache, I think that it’s been very well received by PCP’s programs like this and just wanted to make sure that you had the same experience.

Amie Shea:
Definitely the same.

Last thing I want to touch base on really quick is there were referrals from hospitals so when I started this program, you know, we weren’t getting as much through the ED I wanted more volume. So I worked with our hospitals to create a program where they could input an order through our EMR for me as a nodule coordinator to come out onto the floor and visit a patient that had a nodule that needed to follow up but it wasn’t a nodule that necessarily warranted a pulmonary consult at that time, so it was just a way for them to assure that this patients nodule was going to get taken care of and followed. So definitely room to grow on your end patient side.

So for the patients, provide education in your hospital waiting rooms. A lot of time is spent in waiting rooms and they’re looking around for things to read, so make sure you’re marketing in your own waiting rooms. Especially like a one-page flyer about lung cancer screening, you’ll generate a lot of leads that way. If it’s not them that some of they know exactly yeah and I would even gear your marketing to say if you’re a former smoker or current smoker or if you have a loved one because a lot of times somebody’s going to need that screening scan it may not be them and maybe so just getting that information out is key. We hold community seminars once a quarter so our pulmonary champion and our thoracic champion lead a screening seminar for our patients to come in and so that they can kind of give a presentation and patients can ask questions and get feedback from the experts themselves. So it’s a great way to get involved in the community.

Mailers is huge. You can identify patients who in your community or that are smokers or a heavy smoking population, just give them a 5×7 information card about your screening program. Our marketing can even target people who are between the ages of 55 and 77 which are the criteria for the screening program.

Reach out to corporate wellness programs so you know we live in an era where wellness is beginning to grow and preventive medicine is huge. And a lot of businesses want to offer you know great wellness programs to their employees. So reaching out to them, letting them know that this is something that they can do in the community, they work in your city, have them come you know see you and get taken care of, posters in break rooms as well.

So, this one is this is an idea that we are playing around with locally, you know, we want to promote our straining skin and we were thinking recently maybe we can get a local celebrity to do a lung cancer screening just like Katie Couric did a live colonoscopy a long time ago. You know just don’t be afraid to look outside the box and reach for those for that impactful statement for the community because people need lung cancer screening it’s such a powerful thing and early detection is key.

Now that we’ve created all the elements and we’ve talked about it, it’s time to hit the pavement. You know you want to definitely start with primary care physicians those are going to be your biggest generators of referrals for lung cancer screening and then just to let them know that you are definitely taking care of any patients that have incidental nodules.

This is a brochure that we created just for the primary care physician, so this is not something that we give out to the public but it is for primary cares to understand what we offer. So we established the Center for lung health you know encompassing everything that we do. It gives a map of our nodular clinic that’s located on our campus our Hospital Cancer campus, it obviously gives my information as a lung nodule coordinator that they can reach out to. Talks about our multidisciplinary team and that we tackle that as a team. And then the next page in this brochure kind of talks about our comprehensive lung program. How does the program work one of the biggest things that you want to make sure is that our primary care offices don’t feel like we are stealing their patients in any way. So they really have an active role in the patient’s follow up in their care plan, so just reiterating to the physicians that they know their patients and we want to build off of what they represent. That’s pretty much it for that brochure, it’s all-inclusive.

Education for lung cancer screening is such a big challenge, it’s our job as lung nodule coordinators to kind of be the expert on screening. So make sure you know your criteria, if you don’t know you know ask one of your physician champions. You will see a lot of challenges with primary care that just do not understand the whole concept of the criteria.

Dr. Aki Alzubaidi:
Not just primary cares.

Amie Shea:
True

Dr. Aki Alzubaidi:
Education is very important.

Amie Shea:
It is and you know they have so much to remember as is, so just being that expert for them will help definitely. And then marketing represents your program so why not offer education within your marketing, try to make a comprehensive marketing plan so that you can capture the education as well referrals.

Dr. Aki Alzubaidi:
Just I see some Q&A popping up we’re going to have a full Q&A session at the end.

And there’s one thing that you said real quick is that you had become the expert and I think that there’s you know the best way to lead anything is to become the expert and I just think that’s something that if you are a nodule coordinator or any stakeholder that’s in your program, just really become the expert and that’s really how you can lead and then actually affect the patience that you’re serving.

Amie Shea:
I agree 100 %.

And this is a poster that we created for the exam rooms of primary care offices. So it’s a lot larger than it is on your screen, but this is just a quick demonstration of you know you’re educating the physicians about the criteria so that’s constant reminder about the criteria plus you were educating the patient who’s sitting in there waiting for the doctor to come in and they’re saying to themselves yeah I smoke you know back in the you know 70s and you know I didn’t know this was an option to me. We decided to use just very simple formatting with people because I think that’s a great visual of the 1 in 7 chance of getting lung cancer for women and the 1 in 15 for men, using those kind of numbers didn’t really jump out of the patient.

Dr. Aki Alzubaidi:
And for me I think that the one number that jumps out of me are the list of one in four cases are found early. You know the mortality rate in terms of a five-year mortality is so different between somebody who’s found early versus somebody who’s found later and you can have curative intent vs non curative intent. The mortality rate and lung cancer doesn’t need to be what it is currently and there’s a lot of effort and funds that are actually going into you know Pharma and you know targeted therapy you know pharmacogenomics all these different things and in terms of that, that’s really those are solutions for who are later stage diagnosis. As a nodule coordinator I think that we’re going to see a bigger impact on mortality for nodule coordination and patient care management than anything that’s going to come from Pharma at least in the next three to five years. So you’re going to have a huge impact I think on the patients that you serve just by trying to change that one number from less than one in four to something that’s different your facility and that’s why I think that you know people become really passionate about it as you see true lives saved as you start to coordinate some of these patients care.

Amie Shea:
Absolutely. So, in closing I just want to say thank you for listening I know we’re gonna do Q&A. One of the things that I say to myself every morning when I walk into work is the three F’s: find It, follow it and fight it. Ultimately we are saving lives with this program and I hope that you can emulate a program in your hospital or change it up so that you guys have success as well.

Dr. Aki Alzubaidi:
Absolutely! So thank you so much I really appreciate you coming by and sharing this information with us. I think that we’re going to have quite a few questions. I already see some there, let’s get to them. So this is really like for you guys, like the webinars I’m glad to be doing this again take a little break for 2 months. This is about knowledge share and knowledge transfer, we all are in an alignment with a goal you know for us it’s you know domestically first in the United States is to really ensure that every single patient who has a nodule or has a lung cancer screen, 100 percent of those patients have the opportunity to be followed up appropriately and they’re not going to be missed. And for us it’s I think that’s the impact that we’re really looking to have and so whatever we can do to help anybody in terms of helping them start a program we’re there for.

Q&A section:

Question:
When did you start the community seminars for the physicians after the program started?

Amie Shea:
Yeah so Thank You Angela that’s a great question. The month of November is actually lung cancer month. So last year is when we kicked it off we had already started our program but we kicked it off in November. That’s a great time to do a community seminar because there’s loads of marketing already out there, advertising about the lung cancer month, so we do them now every quarter but we did kick it off in November.

Question:
Okay so then this is talking about the minimum education requirements for a lung cancer screening coordinator. This is an interesting question I think. What do you think about that?

Amie Shea:
I would say for me it’s more experience. You know obviously, any kind of degree is always a great thing but I wouldn’t necessarily say that you have to have a degree to be a screening coordinator. Somebody that is not afraid to talk to physicians definitely kind of a go-getter, thinking outside to the box, somebody that has some type of radiology background helps and then obviously oncology but somebody that’s not willing or not afraid to learn as they go.

Dr. Aki Alzubaidi:
I think that for us we have people you know from all the way to nurse navigators, who do a true novel coordination and I think that each institution needs to look at their resources and determine who the best person would be to do that and then you know. In terms of training I think that that we’ve seen success with people of all types of education levels. I think that you should not be afraid to seek out non-traditional folks for at least some components of the nodule coordination if not all, so I think it just depends on that.

Question:
Coming from the report EMR packs do you recommend a PAC system?

Dr. Aki Alzubaidi:
So Joey, you can extract out multiple fields from the EHR and the PAC system. It’s not an or. I think that there are multiple feeds that have to happen to extract out as many feeds as possible. In terms of computer-aided detection I think that what that means is that they’re the Radiological tool that a radiologist uses which would aid in detecting nodules. Now radiologist actually do a very good job of detecting nodules I think. Yeah if you look at though you know studies too they don’t miss nodules. I think that there’s also segmentation of those nodules which means that the nodules are then characterized in terms of their size, shape, volume whatever it may be and there are many different applications that can do the segmentation. Segmentation of pulmonary nodules is technology that really you know was back in the early 90s and 80s they used to do this for prostate and do segmentation if moved to memo and you know now they’re re-purposing that technology you know just recently because lung cancer screening became in both. So I don’t have a problem with segmentation technology or computer-aided detection. My problem is the workflow problems that create. One is that a radiologist is sitting at a viewer and then if they want to go and do computer-aided detection or segmentation they have to go to a separate workstation and you got to think for incidentals that they’re looking at everybody who comes in to the ED and they’re not just looking for pulmonary nodules. It’s not feasible for a radiologist to stand up from the workstation and go in do computer-aided detection. They don’t really have a problem the tribulation doesn’t solve a problem. Turning now the segmentation in terms of volumetric growth or greater reader to reader variability, I think there’s still not enough value that’s given by segmentation tools or computer-aided detection to justify the price that the companies who are offering that. I do think that there’s things in the horizon that will add value to that particular offering. I don’t think that it’s computer-aided attention or segmentation that’s my personal thing and then you know if you ask the radiologists to change their workflow, they will say no. It’s just not pragmatic and we’ve seen those systems end up in the corner of the radiology department.

Question:
What was your approach with institution and players to get discounted pricing on LDCT studies to make it more accessible for the uninsured and under-insured population.

Amie Shea:
So I worked with our revenue cycle director you know don’t. For me one of the things was is definitely use your resources you know that’s understanding the players and the pricing and all that wasn’t really my forte. But definitely getting connected with the right people is I think is key because you can’t get wrapped up and all every business aspect. So I would definitely reach out to whomever in your hospital, runs that part of it to figure that as far as the pricing is it goes.

Question:
How long is your program been in place?

Amie Shea:
about a year and a half

Question:
And what kind of growth have you seen

Amie Shea:
So I don’t know exact numbers per say. I am following over 700 patients, because I did see a question how many patients are can you navigate.

Dr. Aki Alzubaidi:
I’ve seen 2600 by one person.

Amie Shea:
And I can see that. It is possible with EonDirect. So, I’m over I think 700. I would say it really depends on the person the nodule person and the resources but really with the software, it’s so easy.

Question:
Are you having difficulty with your radiologists flagging nodules?

Dr. Aki Alzubaidi:
So, Amie thankfully does not because they use a system called patient ID which flags in the system for them and that actually has the patients that go in for incidentals so she had does not have that problem. So, Amanda for you I think that I was actually going to reach out to you but on August first you won’t have that problem either. We just did a study I was just going to release the numbers to you and Skibo, we did over I think six thousand reports in which we had radiologists have flagged nodule because a lot of places what they do is they say hey I want you to flag every nodule and ER that comes up and then I’m going to have a bucket of these nodules and I’m going to manage right and so really they miss about it’s about tenfold more nodules than what radiologists are actually flagging. I thought that flagging nodules was the way to go personally about three years ago, two years ago and there was a guy named Bart Daugherty who was like this isn’t gonna work and so really looked into other mechanisms. You have to have different mechanisms for flagging incidentals then asking radiologists to flag them. There are certain places National Jewish health, they have a where I work at, they have a tracking system but that is just really I mean they really beat down that every single patient has to be tracked. I haven’t seen it work at many places where it’s where it works really well.

Question:
We do not have a thoracic surgeon on staff, do you have recommendations to go around this?

Amie Shea:
So, I’ve actually worked with a lot of hospitals that don’t have a thoracic surgeon and the motto at that point is kind of build it and they will come. Most of the time the hospitals that I’ve worked with or they built this program so a thoracic surgeon would want to come. This is definitely known to thoracic surgeons these programs and so it would definitely be a selling point if you’re trying to get a surgeon to come over to your hospital.

Dr. Aki Alzubaidi:
Thoracic surgeons are tough and they’re not adequately distributed especially to rural areas. I was at a rural area we’ll be in a general surgeon who didn’t do bats lobes they just did opens. The complication and mortality rate can be higher and so I think it’s important to try to find an option for patients who are willing to travel if you don’t have a thoracic surgeon to give a refer to a thoracic surgeon for a surgical procedure. However, pragmatically right you have to be able to offer what’s best and the best offering for your particular patient based on this situation. So you know trying to trying to connect with a thoracic surgeon even if it’s 30 miles away, 60 miles away I think is important to try to do so but that can be difficult in a rural area it could be tough.

Question:
LDCT scan that needs six-month follow-up and then the guidelines say rekey with a LV CT scan is the icd-10 code for a solitary woman.

Dr. Aki Alzubaidi:
I think it depends on if they have a solitary versus multiple pulmonary nodules. So one of those two codes would be what you would put and then you know if it’s a screening patient you just got to make sure that the right dosing protocol and the right CT scan is ordered as well.

Question:
How did you go about finding PCP who are not affiliated with your hospital to visit?

Amie Shea:
Again, I reached out to my resources. So we have physician relationship directors for our Hospital and so if they’re not affiliated with us we already know about them and we compile the list and we went out that way. We also are working on an outreach program now to go out to the rural areas of Colorado, to be able to offer them a referral process to cut for their patients to be screened in our hospitals. So I think the internet is going to be your best bet if you don’t have a physician relationship director, you can go out to the city’s website and pull a list of businesses and those that will show you who those primary cares are.

Question:
Any idea, what to do with patients who don’t have a PCP when you don’t have a nodule clinic?

Amie Shea:
One of the things that I would do if you don’t have a nodule clinic is, I would maybe look at two clinics that you have within your hospital system and see if they would be willing to take on new patients and just kind of developing a referral process for those two primary care offices.

Dr. Aki Alzubaidi:
Absolutely! I think that assigning a PCP is something that is important and that process is usually well adopted because you know there are certain PCP’s who are into this as well so its pretty simple to get a PCP to refer to.

Question:
Does EonDirect integrate with power scribe?

Dr. Aki Alzubaidi:
Modem power scribe anything and you know they have to dictate and there is a report that’s generated we can integrate it with it.

Question:
The icd-10 codes to put in the follow-up scan.

Dr. Aki Alzubaidi
I think it’s important to add a radiology level to create a universal text identifier and a code that makes it very simple. So if it’s a CT screen, you have a baseline you have a follow-up and you have an annual right and so this is important because the way it’s reported to the CMS registry and so the baseline has to be a specific order and then the follow-ups have to be nested or associated with that baseline especially when you report to the CMS registry and then the annual stands on its own very similar to the baseline; so the ordering of those tests is very important for screening. The reason is that sometimes patients may migrate from site to site and how you report the registry is really important on whether it’s a baseline, a follow-up or an annual. And so that’s something that we usually work with radiology departments Sharon and if anybody else has that issue we think that we can send over what best practices is.

Question:
How do you implement the hard copy orders into an EHR system?

Amie Shea:
So that is it is difficult because a lot of the primary care offices are EMR and they want to use their own. We have a particular primary care that does send us a lot of referrals and I worked with their office manager to create an order template within their EMR so that’s an option as well but you wouldn’t be able to get, I can’t get my orders in their EMR. Generally, the referral coordinators who I work with at the primary care office, they would just use our order set.

Dr. Aki Alzubaidi:
Your hospital should have an intake of how hard copy orders come over from outlying hospitals or EHRs and then that is usually something that just gets routed to that department in which the orders go to scheduling and preoff. so, Karen, you can definitely implement a hard copy into an EHR and like Amie said giving them the template and then guiding them on how their EHR can connect to your hospitals EHR is something that I think is important to the best time and especially if you’re visiting that PCP and part of what you’d be doing in laying that groundwork.

Question:
So something I’m working on changing is having lung rads 4 called to the ordering provider as a critical read with a recommendation automatically being on the console as well; being sent to me as they do now currently the radiologist recommending three months CT and the PET but I disagree I’m wondering what your thoughts are?

Dr. Aki Alzubaidi:
So for 4A, 4B’s and 4X’x right. so the 4A could technically be a pat a three month or something else right. So I don’t think they’re wrong and calling a 4A and putting in options and in terms of having, if I’m reading this right, the ordering provider if you’re saying that you want all fours call to the ordering provider as a critical read. Share like what I’ve seen best and probably what Amie has seen best is that those patients that are either a 4A, a 4B or 4X, automatically go to a review process, that review process could either be a multidisciplinary team or it can be just a champion of the program in which there is a discussion on a weekly or bimonthly basis that cinches down what the recommendation should be for those high-risk patients.

Amie Shea:
So any threes and fours we actually take to our MDM support

Dr. Aki Alzubaidi:
So 3s, 4As, 4B’s , 4 X’s; so in some places do significant findings to where those get presented so that they ensure that somebody follows those up. but really what it is Sherry is that I think that what we’re trying to do is change the paradigm from data entry for these lung Rad’s ones and twos and even threes because they’re low-risk patients and these are the patients Sherry that we want to humans to focus on the end users to focus on is exactly these lung rads fours. Now in terms of a process for how you do it whether it’s you know sending it as a critical read to the ordering provider. I don’t know if that’s really right I haven’t seen that. I think that the best thing for me would be that you have a formal recommendation come from your hospital nodule program that states what the recommendations should be and what we get at our Hospital is I get a list of patients who that month are due for their follow-up or they’re critical and they need a decision and I think it’s very helpful to receive that list okay.

Question:
This question contains pertains to follow up LDCT after lung cancer screen; if the initial recommends a six month your results are reported in Lung rads I’ve talked with different facilities some use Lung Rads reporting as a follow up on lung cancer screening some consider the follow-up imaging diagnostic and use.

Dr. Aki Alzubaidi:
It should be a lung rads, it should be a follow-up. They shouldn’t be in my mind should be doing it as Diagnostics current. If it’s an actual follow-up that was scheduled based on a lung rads right because a lung rads needs to be re-designated on the follow-up especially for registry. Now a patient could come in and go to the ER for another instance right and that may be a regular diagnostic CT in which that incidental comes in and at that point that’s a patient who should be looked at because their cycle may need to be changed at that point based on the timing of when that CT scan was done. would you agree?

Amie Shea:
I agree!

Question:
Is there a gross estimate of the cost of the software?

Dr. Aki Alzubaidi:
it’s cheap.

Question:
Do you use a dedicated structured type of template for CT reports?

Amie Shea:
okay I’m not sure…

Dr. Aki Alzubaidi:
So I’m working on this for you actually too. Excuse me, you guys do have a dedicated structure type of template for CT reports for screening not for incidentals. now the zero entry submission, we have some places where there’s zero entry whatever. the screening patients come in every feels filled in. all the dosing, the nodules, the lung rads everything’s populated that’s because there’s a very specific templated CT screening report that can be used that would allow you to have access to the information is very difficult to grab.

Amie Shea:
We do have this really quickly on that question. as far as like the dosage and stuff we do have a temporary so our CT Tech, anytime there’s a lung cancer screening that comes through, we’ve created a one page for the dosing so that and then they scan that into packs and so when it’s time to enter that information and the EonDirect for the registry I can go into packs and get that information about the dosing since I’m not clinical and I’m not a technologist they make it easier.

Question:
Who’s determining high versus low risk for incidental freshly followed guidelines once in the program?

Amie Shea:
Well I mean I think that really depends on smoking, I mean there are so many things that come into play, obviously smoking history. But we basically follow, I mean, the Fleischner grid that we use it determines it for us based on characterizations.

Dr. Aki Alzubaidi:
So we pull in that we do pull in the history of the patient and that the smoking is for your previous history of cancer falls in line with a definition of high versus low risk we have a nodule calculator that can be tied to the Fleischner 2017 guidelines and based on the information that’s placed in the system that’s automatically done via the evidence-based guidelines that’s recommended by Fleischner.

So, in terms of how we work you know for people that are interested in it! We have I think 31 to 35 customers currently who are active, with HCA we’re expanding and all of continental health one are using the product. Now the program you know we have there’s my point and many others, Cleveland Clinic, has expanded out. So we have a very good customer base that’s expanding out over the next year. In terms of cost what we do is there are an implementation fee and then a subscription fee. I think that one thing that I wanted to get away from was that you buy something and then in three months it’s old and you have to pay for upgrades and twelve months for software to buy whole new brand new software. And we do both you know volume and site pricing subscription-based. just holler at Reece and Christine and myself and we can talk to you more about what your setup is because it depends on if it’s an outpatient radiology center or an acute care hospital or critical access hospital.

Our goal is to make this as cost-effective as possible and there’s a solution for you, we want everybody to be managing pulmonary nodules.

So, I think there are no more questions at this point. Amie thank you very much I learned a lot anything too close.

Amie Shea:
No, I think I think this is awesome. I’m thankful for the opportunity and good luck to everybody out there.

Dr. Aki Alzubaidi:
Good luck! If you guys want just reach out any granular detail that you want knowledge shared knowledge shared, knowledge transfer; we’re all about it. Talk to you guys soon. Thank you so much.