I am honored to assume the Presidency of the American Society of Echocardiography (ASE). I follow in the footsteps of many distinguished cardiologists and echocardiographers, beginning with Dr. Harvey Feigenbaum and extending through 22 more to Dr. Patricia Pellikka. The ASE has 38 years of tradition—representing the best in academic and clinical echocardiography, now with 16,000 members worldwide. Our annual budget is over six million dollars, and with such strength come great responsibilities. Membership in the ASE, and especially for over 1,400 of our members who are recognized as Fellows of the ASE, indicates a personal commitment to excellence in the practice of cardiovascular ultrasound. In a parallel way, accreditation of an echocardiography lab by Intersocietal Accreditation Commission (IAC) Echocardiography (formerly ICAEL) indicates that lab’s commitment to excellence. To provide a framework for progress this year, let me review six areas in which ASE will work on behalf of our profession. These fall under the rubric, “Improving the Quality and Consistency of Echocardiography Worldwide.”
Monitoring and Reducing Suboptimal Studies: The first step here is monitoring the percentage of suboptimal studies in each echo lab. A suboptimal study may be either incomplete or poor in quality.
Incomplete studies: These may be minimized by assuring well-educated sonographers and physicians—sonographer licensure, physician certification by the National Board of Echocardiography (NBE), and working in a lab that is up-to-date on ASE Guidelines and accredited by IAC Echocardiography to provide such assurance. Studies from such quality labs are protocol-driven and are not lacking in areas such as the assessment of mitral regurgitation or diastolic function.
Poor-quality studies: Even if equipment and sonographers are excellent, patients may be difficult to image. When left ventricle (LV) image quality is inadequate, the use of echo contrast should always be considered. Monitoring the percentage of poor-quality studies and studies in which contrast is actually used is now an IAC Echocardiography requirement, and ASE strongly supports its appropriate use—through contrast sessions from Echo Hawaii to the Scientific Sessions, and at the Contrast Zone on our ASEcho.org website.
Advancing the Frontiers of Echocardiography: Our research committees and several taskforces continually pursue exciting new applications of echocardiography.
Research grants totaling over $165,000 were awarded by ASE in the past year. We also held our second Cardiovascular Ultrasound Technology and Research Summit at the American Heart Association last November. Representatives from National Institutes of Health, industry, and applied science gathered to develop an ASE research roadmap outlining a vision for the development of cardiovascular ultrasound technology and clinical research by 2020. This roadmap was published in the April 2013 issue of JASE to serve as a resource for practitioners, researchers, and national funding agencies.
Strain Standardization: In a fashion parallel to our previous work on the Digital Imaging and Communications in Medicine standards committees, ASE is working with an international committee to establish standards for echocardiographic strain imaging. Although it is providing exciting new insights in areas like monitoring chemotherapy patients for cardiotoxicity, strain imaging is presently a “Tower of Babel” whose measurements must be standardized to become a part of routine clinical practice.
Telemedicine: The great humanitarian efforts at the ASE Global-Focus on India medical camps last year demonstrated to all of us at ASE the power of telemedicine to provide instantaneous and accurate echocardiographic diagnoses at a vast distance. Now we want to expand the applications of this technology to improve the care of more underserved populations worldwide. Aggressive translation and distribution of our Guidelines, provision of web-based education, and ASE Foundation-funded humanitarian outreach projects will be pursued this year.
3D Zone: An ASE task force assembled the materials for this educational website on 3D echocardiography this year. In the coming year, our aim is to make it operational from our ASEcho.org website.
Making Echo Transportable with Patients: Insurers justifying new pre-authorization requirements focus on the 10% of patients who undergo a repeat transthoracic echocardiogram within one year. A substantial reduction in repeat studies could be achieved if the echocardiograms performed initially could be viewed on demand by consultants at other hospitals after patient referral or transfer. Health Insurance Portability and Accountability Act requirements complicate image transfer between hospital systems, but ASE continues to work towards a demonstration project in this area to prove that this can increase practice efficiency and reduce U.S. healthcare costs.
Improving Consistency across Labs: In addition to a lab’s following ASE Guidelines in its daily practice, self-examination is crucial to this effort. IAC Echocardiography quality assurance requirements play a very important role in standardizing the practices of its 3,281 labs. But benchmarking is also important, and ASE has funded the Pediatric Echocardiography Laboratory Productivity Study—in which participating labs reported key elements of their operations which, when collated, may help define the practice of pediatric echocardiography nationwide. ASE, along with the American College of Cardiology Imaging Council, is also considering development of an adult imaging registry—recognizing that the American Society of Nuclear Cardiology has initiated a limited registry of nuclear cardiology labs this year. Providing a defined, consistent product is essential for payer negotiations as it is important to patients expecting high-quality care in every echocardiography lab.
Standardizing Echo Reporting: In addition to work on strain standardization, ASE is participating in the Standardized Data Collection for Cardiovascular Imaging Initiative with collaborating imaging societies and the U.S. Food & Drug Administration—developing agreed-upon definitions for the key data elements reported by different cardiac imaging modalities. This will facilitate the use of clinically acquired echocardiographic data in research studies. Another area to be pursued is improving the reproducibility of clinical echocardiographic measurements; ASE awarded a research grant in 2012 toward this end. Building ASE guidelines into the software of echo instruments is one possible avenue for improvement – with text and image clips demonstrating not only normal value ranges but also proper caliper and sample volume positioning for LV outflow tract echo and Doppler measurements at transcatheter aortic valve replacement evaluation, or proper LV endocardial border measurement for LV volume and mass calculation by 2D echocardiography.
Reaching New Echocardiography Users: The ASE New Practice Applications Taskforce continues to work collaboratively with new users in the emergency department, intensive care unit, and general practice arenas in developing practice standards and educational materials. It is critical for ASE to be involved as these new applications of echocardiographic technology evolve. We will have a booth at the Transcatheter Cardiovascular Therapeutics conference in October to focus attention on ASE’s new products for this special market, and we will formally participate in the Transcatheter Cardiovascular Therapeutics sessions.
Of course, because advocacy and education are always the top priorities when ASE members are surveyed, advocacy remains a top priority in the coming year. A practice environment supporting our commitment to excellence must be assured, and challenges are always on the horizon! Developing a Current Procedural Terminology code for interventional transesophageal echocardiography which reflects the time and intensity of echocardiographic decision-making during transcatheter aortic valve replacement, device closure of septal defects, and mitral valve interventions is a laborious but essential process for our Advocacy team. And, an aggressive effort to prevent further spread of pre-authorization requirements for echocardiography continues, encouraging Appropriate Use Criteria or “gold-carding” through IAC Echocardiography accreditation or NBE certification as alternatives.
Finally, growth of the ASE Foundation in the coming year is a real priority. Its funding for ASE’s humanitarian and research efforts gives ASE Foundation a special place in the hearts of all who love echocardiography.
We’re off on a great year! Enjoy it by participating in one of our many ASE activities. Remember, the best things in life happen when you’re on your way to something else!