By Michael Crawford, MD, FACC, ACC.11 Meeting Chair & Chief of Clinical Cardiology and the University of California-San Francisco Medical Center

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Recent conversations online about ACC.11 & i2 Summit have focused on the presence of RFID technology in attendee badges.  The technology allows the ACC to see what sessions an attendee chooses to attend and provides us data on attendance in session rooms.  RFID is a technology that is widely used by large meetings, and many city-wide medical conventions have used RFID for years to assist in the planning of their meetings.

During the meeting, the technology is utilized in two main ways. In the convention center, it lets us know the number of people who attended any given session, so when similar sessions occur in future years, we’ll be able to pick a room that’s an appropriate size for the number of people interested in the topic. We’ll be able to limit our use of “overflow” rooms, as well as limit wasting really large rooms on sessions not that many attendees are interested in. In this setting, the ACC receives aggregate information about meeting attendees (i.e., 546 people attended session #363).

In addition to planning more appropriate room sizes, the RFID technology serves another important logistical function. RFID is used to track what sessions an attendee chooses to go to. This information is aggregated for reporting purposes (ACC is not looking at what a specific physician’s activities were, but rather at patterns of physicians’ attendance). Let’s say that badge #654321 starts the morning by attending the LBCT session. The attendee then goes to a session on appropriate use of PCI, followed by a session on imaging because he or she is interested in new advances in the intersection of imaging and intervention. Let’s also say that several other people in these sessions followed a similar track. In this scenario, the ACC would receive a report of aggregated data, showing a significant level of physician interest in both imaging and interventional sessions.  This tells us something very important from a logistical perspective – these sessions should be located close together within the convention center. Inappropriate room sizes and too much walking are by far the most frequent complaints about our meeting (year after year, no matter the convention center, for the last several decades), and we are excited to use RFID technology to effectively address these issues.

The second way in which RFID technology is utilized is in the Exposition. Exhibitors were able to rent RFID readers from the vendor. They are able to use the data in much the same way as the ACC – to evaluate how effectively their work stations are structured and to improve their offerings to attendees. In addition, they are given access to limited information about the visitors to their booths. The information they are given is the same information that was available on meeting attendees badges in print (name/city/state/institution). No contact information is provided.  ACC’s intention was not to create a revenue source by offering attendee data to exhibitors (in fact, only five out of more than 300 exhibiting companies decided to invest in RFID in their booths), but rather to provide exhibitors another resource by which to understand the traffic flow in their booths and to better align their displays with attendees’ needs. 

Finally, I wanted to address some of the misunderstandings I’ve seen online:

• Attendees at ACC.11 were given the opportunity to opt-out at the point of registration. Nine percent of registered attendees chose to opt out (about 1,200 attendees of our total professional attendance of about 13,000).
• The RFID was NOT used to award CME credit.  As for the last several years, an attendee wanting to secure CME credit has to submit for the credits online using the honor system. If you are mistakenly relying on the RFID to claim your CME for you, you will not receive CME. An e-mail went out earlier this week with instructions on how to claim your CME; see more on the ACC.11 & i2 Summit 2011 website. I cannot stress enough that you still must claim CME credits online.

We have been reminded of a telling lesson from this year’s experience – when we introduce a new procedure/process at Annual Meeting, we have to double our efforts to ensure that all attendees are very clear about what the ACC is trying to achieve and what is involved.   

The ACC believes that RFID technology brings much benefit to attendees, as it helps us to plan a meeting that is even more user-friendly. Over the next few years, RFID will be invaluable to the physician planners as we start to plan future meetings in cities that are new and unfamiliar to the ACC. As such, it would be very helpful to the chairs of ACC.12, as they address how RFID will be used in 2012, to have your feedback. We’ve created a poll in our ACC.11 & i2 Summit Community asking for your thoughts on this (you'll need to log into CardioSource in order to take it). You can comment below, take the poll or, of course, do both.

The Centers for Medicare & Medicaid Services (CMS) last week issued a report that highlights significant trends in the growth of two “pay-for-reporting" programs: the ePrescribing Incentive Program and Physician Quality Reporting System (PQRS...formerly known as the Physician Quality Reporting Initiative or PQRI). According to the report, 2009 Physician Quality Reporting System and ePrescribing Experience Report, 119,804 physicians/eligible professionals in 12,647 practices received incentive payments under PQRS totaling more than $234 million—well above the $36 million paid in 2007, the first year of the program. Under the ePrescribing Program, CMS paid $148 million to 48,354 physicians/eligible professionals in 2009. Results show that participation in PQRS has grown at about 50 percent every year, on average, since the program began.

On average, 2009 bonus payments for satisfactory reporters in PQRS were $1,956 per eligible professional, but $18,525 per practice that participated. Eligible professionals received even more from the ePrescribing Program in 2009: the average bonus payment was just over $3,000 per eligible professional and $14,501 per practice.

The report also shows health care professionals report complying more often with evidence-based care practices. Based on reported data on the 55 measures that have been a part of the PQRI/PQRS program since it began in 2007, providers have improved the frequency for which they deliver recommended care by about 3.1 percent on average. Similarly, of the 99 measures that were part of the System in 2008 and 2009, performance improved at about 10.6 percent on average. In some cases, gains have been even more dramatic. More about the report is available on the CMS website.

The incentives are still trivially small to really move the system. At least our PINNACLE Registry users got fully reimbursed with no hassles through the PQRS program. For 2009, 172 providers from 14 practices used the PINNACLE Registry to report --100% successfully--with an average payment of $8,352 per provider. But the CMS incentives need to be made much more significant if we want these programs to work and to significantly improve quality systematically.

The U.S. Senate Commerce Committee and the Delaware Insurance Commission last Friday released separate reports on the results of their investigations into consumer access to imaging tests in Delaware. Both reports were commissioned in 2010 after the Wilmington, Del., newspaper ran a story on a Delaware man that was denied a cardiac stress test by MedSolutions, BCBS of Delaware's “radiology benefit manager (RBM).”  The man ultimately was admitted to the ER, and then received CABG. NBC Nightly News ran a story on it yesterday, as did TheHeart.org and Cardiovascular Business.

The report highlights ACC's concerns with RBMs, such as the administrative burdens for doctors and patients, the non-transparent decision-making tools, and the chronic lack of best science and appropriate use criteria in their methodologies. Let's face it, RBMs are designed to save money, not improve care. 

The investigation's significant findings were: 

• After an outside consultant reviewed the denied cases, MedSolutions denied a significant number of both inappropriate and appropriate test requests
• The RBM's pre-authorization process is burdensome and confusing for consumers and health care providers, and this confusion is compounded by conflicting “evidence-based” cardiac testing guidelines
• According to their own professional guidelines, Delaware doctors routinely order unnecessary nuclear stress tests

But, there may be a happy ending here:  The ACC is working to implement the FOCUS imaging appropriate use criteria (AUC) tool in many states that are beginning to express interest in saving money AND improving careas as an alternative to RBMs, and we're making great progress! Yesterday's ACC Advocate has more about the findings and "next steps" of the report. The Senate report is available here: Consumers' Access to Diagnostic Heart Tests in Delaware.

Does this report surprise you? Have you had any similar experiences with RBMs?

Today marks my first full day as ACC president. In this role, I am preceded by a long list of impressive cardiologists – Groedel, Fisch, Glover and Goebling, to name the first four beginning at ACC’s start in 1949. All cardiovascular professionals share this common heritage in our cardiology history, making us family in a sense. But our family is bigger than our history, because it includes our patients and the people who have been, or will be, touched in some way with heart disease.

Over the next year, it will be up to me and other ACC leaders to address that doubts I’m sure most of us in the cardiology family share about the future. Among others, these include: how will our practice survive; what will happen with subspecialty boards; what will health care reform bring?  In addition, I plan to focus my upcoming presidential year on education and science – the pillars that make the cardiovascular profession exhilarating, challenging, rewarding, and allow us to make a profound difference in the lives of our most precious stakeholders: our patients and their families. It’s up to us, with ACC’s help, to interweave our practice of medicine with our patients, joined at the hip like conjoined twins. It is up to us to shape this future.

I closed my speech last night with the following except from Lawrence of Arabia, and I will do so again here as a reminder to live life, and practice cardiology, with passion and joy and wonderment. I challenge all of you to dream wildly with your eyes open and make your dreams come true.

"All men dream: but not equally.
Those who dream by night in the dusty recesses of their minds, wake in the day to find that it was a vanity:
But the dreamers of the day are dangerous men,
For they may act their dreams out with open eyes, to make it possible.
...This I did."

*** Image: ACC’s Founders Plaque ***

Last night I officially turned over the gavel to David Holmes, MD, FACC, marking the end of my presidency of the ACC. This past year as president has been rewarding, but it’s also been incredibly challenging. When I first took over from Alfred Bove, MD, PhD, MACC, I identified the theme of my presidency as “professionalism,” knowing that the year would bring many changes that would require others in the health care arena to view us as true professionals, not just a guild.

Reflecting on the past year, I feel that we’ve accomplished a lot in proving ourselves as such. We are viewed by many as a forward-thinking, professional society, and as a trusted resource when it comes to cardiovascular science and education expertise. We are also increasingly the go-to organization for issues involving quality assessment, appropriateness of cardiovascular care, and new care delivery and payment models. Our efforts to date have been consistently recognized by the White House, Congress, Medicare, National Institutes of Health, the Agency for Healthcare Research and Quality, FDA, patient advocacy groups and our partners in the medical community.

This is not to say the year has been without struggle. Interventional cardiology has been accused on multiple occasions of overuse of coronary stenting procedures. Electrophysiologists received similar criticism when a JAMA article, based on NCDR ICD Registry data, reported the presence of inappropriate implantation of ICDs for primary prevention of sudden cardiac death in Medicare beneficiaries. Health care reform and other regulatory changes have placed cardiology in an uncertain position – where will the profession be 5, 10, 15 years from now? Will there be “private practice” as we know it today?

The ACC has worked to overcome these challenges by taking a leadership role, rising to the occasion of “knights of cardiology,” and proving to the world that we will not stand by and be simply knaves or pawns. We are quality in action.

Under Holmes’ leadership, we will continue this tradition of professionalism, with Holmes bringing additional focus on education and science. Whether it’s through education, science, quality programming, professionalism or advocacy, we are making a collective difference and saving the lives of countless patients in the process.

Thank you for the past year of my presidency, and for the opportunity to hear your concerns and questions through the ACC in Touch Blog. Although I’ll no longer be an author here, I hope to have frequent “guest blogs” where I can continue to hear your feedback. Thank you for all that you do.

*** Image from Flickr (walknboston). ***  

By W. Douglas Weaver, MD, MACC, chair of the CathPCI Registry Steering Committee and former ACC president

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Beginning in May, the NCDR CathPCI Registry reports will provide participating hospitals the ability to compare their performance against peer hospitals using ACC’s Coronary Revascularization Appropriate Use Criteria (AUC). These AUC are based on the Coronary Revascularization Guideline, and are intended to show whether PCI was appropriate, inappropriate or uncertain for each patient entered into the registry database.

This is important for a number of reasons. As can hardly be missed, the overuse of stenting has been suggested in several places and been the subject of state investigations both in Maryland and most recently, in Pennsylvania. Inclusion of AUC metrics in the CathPCI Registry is one step being taken by the ACC to enable well-intentioned cardiovascular professionals to determine whether their case mix of appropriate use is similar to other sites in the registry and enables them to benchmark performance. The data will be reported at the hospital level, but will also include a listing of the inappropriate cases, which will allow the hospital and interventionalists to review any such cases.

There are some important caveats. The metrics are currently considered “test metrics,” meaning that we’ll be modifying them if we determine from feedback that some of the data was either inaccurate or incomplete. To do this, we’ll be leaning heavily on CathPCI participants to make sure that they are vigilant in providing the highest quality of data possible. At this time, we believe that the metrics are not valid to be used in health plan payment programs or for public reporting purposes. The ACC will be using the experience gained during the metric testing phase to refine and enhance the value of AUC to aid professionals in improving quality of care and enhancing patient outcomes.

The ultimate goal is two-fold: offer a greater value to participating hospitals and physicians in the CathPCI Registry and to improve the quality of care provided to patients with cardiovascular disease. More information is available on the NCDR website.

If you’re interested in learning more of the topic, I encourage you to attend a session with Paul Chan, MD, FACC: “Appropriateness of PCI in the U.S.: Insights from the NCDR CathPCI Registry,” from 8-9:30 a.m. tomorrow in Room 238.

Yesterday we held a great spotlight session on health IT at ACC.11 & i2 Summit. The morning session featured Mike Mirro, MD, FACC, Health IT Committee co-chair, of Fort Wayne Cardiology, Jeff Westcott, MD, FACC, of Seattle Cardiology, and Lee Goldberg, MD, FACC, of the University of Pennsylvania, discussing their experiences implementing an electronic health record (EHR) in various practice settings. The session included a Q&A with the group, along with John Windle, MD, FACC, and Jay Alexander, MD, FACC, both of whom were panelists at last year’s Health IT Spotlight Session.

In the afternoon, John Harold, MD, MACC, Ralph Brindis, MD, MPH, FACC, and I attended the 2^nd part of the Health IT Spotlight Session, which discussed the Medicare EHR Incentive Program and what providers can do to qualify. Farzad Mostashari, MD, ScM, Deputy National Coordinator for Programs and Policy at the Office of the National Coordinator, gave the keynote address. Mostashari discussed the program, which has $17.2 billion in incentives to assist providers in adopting health IT. From 2011-2015, physicians who demonstrate “meaningful use (MU)” of EHR technology and performance will be eligible for positive payment incentives. Mostashari discussed at length what exactly “meaningful use” is and how providers can demonstrate that they’re doing it. (You can view the specifics of MU on CardioSource.) He also highlighted ACC’s opportunities to lead in leveraging MU to promote the triple aim, and encouraged us to act. Carpe diem.

Following Mostashari’s keynote, ACC Health IT Committee Co-Chair James Tcheng, MD, FACC, discussed which providers and hospitals are eligible and under which program (Medicare or Medicaid) they are able to participate. Understanding if you’re eligible to participate in the Medicaid program is critical, because there are greater financial incentives available under that program than the Medicare program.

Finally, Floyd Eisenberg, MD, MPH, senior vice president for health IT at the National Quality Forum, concluded the session with a discussion of electronic quality reporting. Under the program, electronic data collection is required for quality measures, and his discussion made it clearer about how providers and hospitals can submit this data.

If you missed these great sessions, you can still learn more about health IT. At 11:15 today, there will be a Health IT Gadgets & Gizmos "Show & Tell" in the ACC Central Theater (Booth #1947).

Earlier today, I co-chaired a panel with ACC President Ralph Brindis, MD, FACC, discussing what health care reform means to cardiovascular practice. A panel of ACC leaders – BOG Chair Dick Kovacs, MD, FACC, ACC SVP of Advocacy Jim Fasules, MD, FACC, and Brindis – spoke about their views on health care reform. I talked about the types of delivery system reform that we should expect to see in the near future, with or without the Affordable Care Act (ACA): more integration of hospitals, physicians, and insurers, possibly through accountable care organizations (ACOs), but also via medical homes, team practice models, major payment reforms and improved coordination of care at all levels. Fasules provided an overview of the College’s advocacy efforts, citing payment reform, self-referral, tort reform and health care reform implementation as the four “mountains” facing the practice of cardiovascular medicine from a health policy perspective.

Brindis said we need to overhaul the current care delivery and payment models and lead the profession toward systematic and measured reductions in cardiovascular morbidity and mortality, as well as toward ongoing improvements in personal and population-based prevention and health care outcomes. To do this the College needs to continue promoting its registries, as well as develop point-of-care decision support tools that put guidelines directly in the hands of cardiovascular professionals. Kovacs agreed, while also noting that health reform implementation will largely take place at the state level. He said its important for ACC members to build relationships with their state and federal lawmakers and mentioned potential opportunities to bring patients to the Hill with cardiologists.

Afterwards, there was a Q&A for session attendees. Not surprisingly, there were a lot of questions about what health care reform means for ACC members. Unfortunately, while we all had our opinions of what the answers were, there aren’t a lot of definitive responses that we could offer. We know what ACA requires, and what provisions have already been implemented, but it’s looking less and less clear how far the implementation of the ACA will proceed. Will it be funded, even it survives its legal challenges? This leaves ACC leaders and members in a tricky spot of trying to prepare for an uncertain future with thousands of moving parts. Despite the ever-increasing and miraculous abilities of health care to better diagnose,  treat, and prevent  medical problems, the economic imperatives related to the relationship between the national debt and rising health care costs, and the growing inabilities of families, businesses, and states to fund their own share of the costs, represents a growing fiscal emergency that cannot be ignored. This is going to be tough on physicians, unless we help find a way out of the mess.

What has your practice done to prepare for any of the changes in the ACA?

Tonight, Anthony DeMaria, M.D., M.A.C.C., JACC editor-in-chief, will deliver the 42nd Annual Louis F. Bishop Lecture from 4:45 – 6 p.m in Room 221 in the Convention Center. His lecture discusses a topic of utmost importance to cardiovascular professionals, and one that all ACC.11 & i2 Summit attendees will have to struggle with following the meeting – how do we take the latest clinical trials, with their narrow study populations and design limitations, and apply them to the specific and unique patient sitting before us in our office? It’s a tricky question, and one that I am sure will garner interesting discussion following the presentation. For more about the lecture, read this interview between DeMaria and Cardiology magazine editor Cherie Black in the ACC.11 & i2 Summit Community. I’ll be at the lecture tonight, and I hope you will join me!

Tomorrow night (April 3) the ACC is holding the All-Chapter reception from 6:30-8 p.m. in the Grand Ballroom of the New Orleans Marriott. ACC President Ralph Brindis, MD, MPH, FACC, Vice President Bill Zoghbi, MD, FACC, former ACC President Fred Bove, MD, PhD, MACC, former BOG Chair and incoming VP John Harold, MD, MACC, and ACC CEO Jack Lewin, MD, and I will all be there, and there will be food, drinks, and perhaps a little bit of dancing. Don’t miss this chance to catch up with other cardiovascular professionals in your state and meet new colleagues from across the globe. Hope to see you tomorrow!