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Hello and welcome to Noom conference hosted

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Learn and Grow.

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get access to hundreds of case-based microlearning courses

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across all key radiologies and Specialties today.

0:40

We are honored to welcome Dr. Giovanni Lorenz

0:43

and Dr. Emilio fentanas for a lecture

0:46

on one heart one Mission success of a

0:49

multidisciplinary cardiac imaging team approach.

0:52

Dr. Lorenz is the Deputy of an Imaging

0:55

services in the San Antonio military health system and

0:58

Dr. Defenses is a cardiologist at active dude

1:01

on active duty at Brook Army Medical Center and

1:04

director of cardiac imaging and cardiovascular research and

1:07

co-director of echo. Cardiac Rafi.

1:10

At the end of the lecture join our presenters in a Q&A session

1:13

where they will address questions you may have on today's topic.

1:17

Please remember to use the Q&A feature to submit those questions so we can

1:20

get to as many as we can before our time is up. And with

1:23

that. We're ready to begin today's lecture Dr. Lorenz and

1:26

Dr. Frendinist, please take it from here.

1:29

For that introduction. I know Dr. Fantas

1:32

and I are super excited to share this as

1:35

you may or may not know making any

1:38

change is difficult but making change

1:41

across departments across

1:44

compartments such as the Army and the air force that

1:47

takes a lot of skill and effort. So we're super excited

1:50

to share our brief journey through this

1:53

but also want to say that this is just the

1:56

beginning and hopefully we can learn from growth and

1:59

be able to support further.

2:04

For now, we're very excited about this opportunity and

2:07

the ability to to kind of share our story

2:10

before we begin Uncle Sam didn't

2:13

want to make sure that you guys were aware that we're

2:16

about to discuss is obviously our opinions. Nothing

2:19

to do with the military the location where we

2:22

work the department of the fence of the defense health agency.

2:25

So we also don't have any potential conflict of

2:28

interest as part of this presentation. So before

2:31

we started we wanted to

2:34

kind of give you guys a quick introduction to the type of

2:37

valuation of chest pain

2:40

in the in the department of the fence and our transcend

2:43

utilization. We had a request

2:46

from Congress to kind of evaluate how we

2:49

were evaluating coronary our disease for both our

2:52

service members as well as beneficiaries into trying

2:55

to on their stand as you can see from this data why

2:58

cardiac CT cardiac MRI and some of the more

3:01

newer Imaging modalities were being significantly on

3:04

their

3:04

Realized and you know the impact that covid had

3:07

on a lot of these Trends in utilization and

3:10

more importantly how these tests modalities were being

3:13

used initially once we had

3:16

this information, but we noticed was that while you

3:19

know, it was reflective of the guidelines at that time

3:22

functional non-invasive testing with it with exercise treadmill, testing

3:25

stressical cardiography or myocardial perfusion

3:29

spect Imaging then to be the, you know,

3:32

first line task for, you know, pretty large

3:35

significant majority of cases, but what

3:38

we found that even as a second line test, when did

3:41

that I was inconclusive or it needed

3:44

further validation or exploration functional testing was

3:47

always a second to modality whether

3:50

it's a repeat of the same modality or a secondary

3:53

functional modality.

3:56

So when all this information came out and

3:59

we were asked to kind of further explore the the

4:02

challenge came, you know from from Congress where

4:05

they they stated in their own words. They wanted

4:08

to see what would be a best way for us to come

4:11

up with an anatomy-guided pathway with the use of

4:14

cardiac CT as well as implementation of CTF of

4:17

far compared to the then guideline

4:20

recommended approach of mostly candidate ischemia

4:23

guided approach. They wanted to also receive an

4:26

outline of what were the necessary steps

4:29

moving forward in a plan of action to to

4:32

coming up with that but we reported to Congress

4:35

at that time was that you

4:38

know, as we had seen the the amount

4:41

of functional testing was quite prevalent

4:44

and it was marker of of a cultural

4:47

Trend and that time but we had seen an increase

4:50

although small, but an increase overall in the

4:53

utilization of cardiac CT.

4:56

Military health system. Our conclusion was

4:59

then that in order to increase this access to

5:02

coronary CT and then make Congress requests we needed

5:05

to do a better job training folks and ensuring

5:08

that the scanners were available the Technologies

5:11

for available and infrastructure was available for

5:14

our graduates from from our facilities would

5:17

be able to perform high quality CT. We

5:20

had the unique opportunities since we are the largest

5:23

training center for cardiologists and Radiologists in

5:26

the Department of Defense to really be able to provide this

5:29

service from two fronts and also kind

5:32

of make a pathway for for a collaboration

5:35

on doing this.

5:38

So our Legacy Approach at that time, you know,

5:41

what's kind of split into as you see the red line Radiology would

5:44

train their Radiology residents and fellows with

5:47

a separate. Gme Mission from Cardiology. They had

5:50

their own cardiac imaging research. They focus mostly in

5:53

the technical aspects and imaging findings at that time. And then

5:56

obviously the reports were mostly focused on anatomical findings

5:59

versus Cardiology with you

6:02

know, we had supper training from them.

6:05

We had cardiac imaging research eat from the same patients same

6:08

patient population same studies or the

6:11

focus more on clinical outcomes. And then the reports

6:14

read more of a clinical management recommendation rather than

6:17

a anatomical finding. So after we

6:20

reviewed this we decided and we were able to

6:23

have the opportunity to really create our first joint

6:26

radiology and Cardiology program where we

6:29

were able to blend The Best of Both Worlds, we had, you

6:32

know, collaboration and patient scheduling education and

6:35

access to care from both departments.

6:38

And that was something that allowed us to really help

6:41

improve access to care

6:44

as we were having contribution from our Cardiology clinic

6:47

schedulers as well as scheduler from the Department of

6:50

radiology the other important thing that came from

6:53

this course probably providing nurses and technologists from

6:56

each department kind of help improve access

6:59

and more importantly expedite the

7:02

workflows through education training.

7:05

Dating of protocols as well as ensuring that the quality

7:08

of the test and then the consistency of the

7:11

images were consistent across two sites because

7:14

we have two different sites in San Antonio the other thing that

7:17

also benefit we benefited from when this joint

7:20

program was the referrals we were able

7:23

to then tackle from both fronts, you know an education

7:26

approach from when a physician orders or

7:29

clinician orders cardiac CT. They didn't

7:32

just receive feedback on the appropriateness or the best

7:35

test for the patient from the cardiologists but also

7:38

their Radiologists or Radiology training Cardiology fellow

7:41

as well as the protocol and ensuring that

7:44

the appropriate test was done at the appropriate time for the

7:47

right patient as far as the other benefit of doing a

7:50

joint program we had

7:52

The training of fellows we were able to have now

7:55

increased taxes and more importantly better at

7:58

more rounded education to our fellows. So they

8:01

can focus on achieving a cool cats level 2 training based

8:04

on the Cardiology training guidelines, but also focus

8:07

on our Radiology residents fulfilling the ACR and

8:10

nasty training requirements for cardiovascular CT

8:14

and cardiac MRI, as far as the best benefit

8:17

from all of this is we were able to join a Cardiology

8:20

and Radiology faculty. So now we had expertise

8:23

from a really Radiology perspective but

8:26

also expertise from board certified as

8:29

well as Fellowship trained cardiologists in an

8:32

imaging department to combine their overall learning experience. So

8:35

we we often now,

8:38

you know, I get asked this. Well, how do we

8:41

do this? And how do we arrive to this? So

8:44

A lot of it had to do with you know our our

8:47

approach and the address

8:50

for collaboration and reaching out. I

8:53

think it's probably going to be the hardest part is not the most challenging

8:56

part at first, you know from A

8:59

cardiology perspective. I will tell you that you have

9:02

to have a radiology Champion it goes

9:05

without saying that without having

9:08

a radiology Champion to have you know,

9:11

an understanding for a vision share an

9:14

equal Vision more importantly but also provide the

9:17

ability to really communicate with

9:20

their Department in a way that you know

9:23

transitions division from a single

9:26

Department to a multi-departmental thing is key.

9:30

For us it became then what there

9:33

was an agreement for collaboration and what

9:36

division of that would be and you know going through

9:39

credentials ensuring that the standard operating

9:42

procedures memorandums for understanding educational

9:45

training agreements were

9:48

all in place. Then we could start focusing on the basic things.

9:51

And one of the things that we standardized was

9:54

the workflow across different sites based on the resources that

9:57

we had bamc. We have the ability of

10:00

having our patients prepared for our now patient

10:03

coronary CT with the use of a nurse and

10:06

an lbn that's provided by the department of Cardiology versus

10:09

our other side of wood for Hall. We have

10:12

the cardiology fellows and Radiology resident working

10:15

directly with their Radiology technologists to

10:18

be able to get the same workflow achieved

10:21

with the same amount of time spent preparing patients,

10:24

but also providing, you know,

10:27

the same workflow in the same approach to perform in

10:30

Sam based on the resources available. The other

10:34

thing that we also wanted to make sure is that the product with

10:37

the workload itself was simple and it was reproducible the idea

10:40

being when these graduates would

10:43

leave our sites and they go on to different places

10:46

that they would take the exact same protocol the

10:49

exact same approach the same workflow to

10:52

perform cardiac CT with two

10:55

examples of how to do it if you have a nursing support available,

10:58

but also how to do it if you don't have a

11:01

nursing support available for the administration of medications and

11:04

patient preparations.

11:06

the other part that was challenging was the cultural

11:09

change when we

11:13

Optimize patients heart rate for the type of scanners that we have available

11:16

in our Marketplace low heart rate is key. So from

11:19

A cardiology perspective, I have very little heartburn giving

11:22

somebody 200.

11:24

Milligrams of oral metoprolol and giving them

11:27

10 milligrams of IV metoprol the scanner if needed in

11:30

addition to 800 micrograms of nitroglycerin and

11:33

not be worried about hypotension or profound very

11:36

cardiacs a result the unique opportunity to

11:39

work with their Radiology residents with this is they get the same

11:42

level of comfort they get the same level of experience. They

11:45

get the same level of safety margin and

11:48

understanding and and really seeing how

11:51

this impacts the image quality but more importantly the

11:54

safety behind it which you know to this day

11:57

we have not had any Adverse Events related to medication administration

12:00

and patient preparation. The other

12:03

thing with days with standardize our protocols. We wanted to

12:06

ensure that the injection volume the injection rates

12:09

the type of dozing for kvp million

12:12

amps based on weight. All of

12:15

those things to have our planning cardiac CT

12:18

calcium score functional sentiments.

12:21

We're all done and the same

12:24

Workflow the same protocol regardless of of

12:27

the location the other thing

12:30

and probably one of the most challenging thing was the standardization of reports. We

12:33

felt that this was something that needed to occur and we had

12:36

the challenge of having the new CAD rats system come

12:39

out halfway through our Standard Station or reports

12:42

and we were able fortunate enough to have a early review

12:45

of this can't Grant document before so that

12:48

we were able to address any concerns and consistency reporting

12:51

but now our reports regardless of

12:54

who the reader is regardless of, you know, then their

12:57

style Etc intends to be unified in a standardized report

13:00

that has been agreed on by all members. The other

13:03

thing that we were able then focused on was educational curriculum whether

13:06

you know, it involved lectures

13:09

involved. Do you send team Microsoft teams to

13:12

use a channel where regardless of

13:15

the location the reality residents of the Cardiology fellow

13:18

is able to join the reading session have access to

13:21

reference cases for education.

13:24

Or experience but also has access to

13:27

resources for where to look up

13:30

certain things the protocols for refreshing a guide

13:33

on what are the expectations for the rotation, but

13:36

more importantly what are the things that we want them to

13:39

get out of during their time of their rotation?

13:42

So now Dr. Lawrence is

13:45

back. I'm gonna let him kind of talk to you guys through through the

13:48

next part of our face on how we did our second part

13:51

of the journey.

13:52

Yes, so just as a review this this is a long.

13:55

Journey, and a pathway that definitely requires the

13:58

champion on both ends. And as

14:01

Dr. Fontana said mentioned a collegial

14:04

respect for each other is at the heart of all of this

14:07

stuff and so we were lucky as you can tell

14:10

is that we've all sort of wear the same uniform and we were able to

14:13

then to work from that sort of Baseline of equality and

14:16

move forward. So our journey did not just

14:19

end there that was just the beginning of setting up appropriate Champions

14:22

on both

14:25

ends workflows and so forth.

14:28

It was now to the more difficult things and that's the day to day

14:31

and so here you can see laid out here was the patient

14:34

education and standardizing that essentially this was

14:37

ensuring that we had materials that made sense that we can

14:40

provide to our ordering providers as well as do

14:43

our patients following this examinations. And so we really try

14:46

to include what was important from the clinical standpoint as well

14:49

as opposed to Imaging and post workflow.

14:53

Yeah, we were also ran into our fair

14:56

share of challenges. Where as we

14:59

were moving on our journey. Literally we

15:03

cannot make this things up. We

15:06

had a new EMR implemented at our Marketplace that

15:09

affected our work orders our workflow orders.

15:12

They the entire

15:15

process of how to order how to perform on interpret how

15:18

to document things that change shortly after that.

15:21

We had a new packs and the training that came with the new packs

15:24

and the ensuring that images transferred over and right

15:27

after we had summarize that and overcome that

15:30

challenge we had country shortages a staff shortages

15:33

and shortly after that. Then you chest pain guidelines came

15:36

out and then we had Tysons through proponent implementation. So I

15:39

think that we've had our fair share of challenges. It's

15:42

dark forens will be able to kind of share with you

15:45

how we we face all of these

15:48

things. Well, so like many of you you either work

15:51

in large academic instit

15:56

And or even private act

15:59

groups that have imaging centers and service workflows

16:02

that just need to be efficiency based and

16:05

so sometimes items such as new emrs or

16:08

PAC systems or throwing at you without your service

16:11

line being part of that discussion. So we try

16:14

to do is ensure that individuals who made those decisions were

16:17

aware that cardiac imaging definitely need

16:20

to be part of that early on and and when we could or could not

16:23

then we just had to brace for the or the

16:26

answer. So as an example when we

16:29

overhauled a brand new electronic health

16:32

record for the entire department defense health

16:35

agency. We really try to determine

16:38

what is the best way to do this from a cardiac imaging standpoint.

16:41

So we sat on both committees there were

16:44

items in the Cardiology workflow in

16:47

those meetings that I had no idea what this talk to what

16:50

was going to be talked about but I sure I definitely

16:53

want to ensure that they knew that the Imaging

16:56

Point in my voice was being discussed and similarly when we

16:59

had meetings that were just Radiology specific that I

17:02

shared by notes or Dr. Fontana's came in on that.

17:05

Now similar to that was our

17:08

Pac system. We had probably about

17:11

two months of latency before we after

17:14

getting our new EMR on is that when

17:17

we started our packs integration and so this was

17:20

another challenge that we had to do which was moving from

17:23

something that we're used to to something that we weren't and

17:26

then being the test site for this. So we're now on an Enterprise

17:29

pack system. I think it's going to be really wonderful in the

17:32

future. But of course things didn't work correctly. And so

17:35

we immediately had to work together and have essentially pen

17:38

and paper just find out what worked on a

17:41

cardiac CT deployment what didn't and then

17:44

to make those changes with those engineers.

17:47

Like many of you contrast shortages last year were a big deal and so

17:50

we had to work together and although we're

17:53

probably five maybe ten miles apart

17:56

from each other. It was vastly different worlds as far as

17:59

ordering credit cards and and so

18:03

forth as far as getting contrast to our facilities it it

18:07

can sometimes be advantageous to

18:10

be Army in Air Force. We can apply those different

18:13

principles Air Force

18:16

tends to have Deep Pockets and army tends to

18:19

have a very loud voice. So between the two of us we were able to

18:22

really push for contrast from vendors that

18:25

we normally or individually would not be able to

18:28

get

18:29

With the chest pain guidelines, I think we've gone through these

18:32

and other workflows and webinars before is that

18:35

this really provided the the

18:38

push around the inertia to do

18:41

new things such as party xct and anatomy and

18:44

based evaluation and chest pain. So there was a lot

18:47

of Education that was required for our clinicians to order this

18:50

as a type of exam, but also was to ensure that

18:53

we had the technicians the time in the schedule and

18:56

to essentially just kind of push in and kind

18:59

of push out some of those other Radiology type of examination so

19:02

we can do the cardiac imaging.

19:04

And it it goes on and on

19:07

right? I mean there's plenty of these different types of challenges that we can continue to

19:10

talk about and we're gonna save a little bit of time at the end so we can get

19:13

some further Q&A on there, but I wanted to hit

19:16

on number 10, which is the growth area.

19:19

I have two years ago three years ago. I think when we started this we

19:22

had no idea what our endpoint was and I

19:25

think that was a good thing mainly because we really wanted to

19:28

push to see how far we can get with

19:31

this and I think the integration of

19:34

our reading programs being able

19:37

to have specific equipment for

19:40

the cardiac commission has been the first step. I

19:43

think our second step is our outline there and that's research

19:46

collaboration for instance.

19:48

I think two departments on the year IRB or

19:51

on your Z proposal has made

19:54

a huge difference in the amount of

19:57

I think at last count millions of dollars that have been

20:00

able to flow to us into our type of programs that

20:04

we want to do.

20:05

And I think that is because we can

20:08

come at it from both types of departments points of

20:11

views and imaging Innovation and in

20:14

the clinical directive. So I think that was extremely useful. We

20:17

didn't really set out with that in the beginning but that has really

20:20

been something that we both relied on.

20:22

Dedicated cardiac imaging equipment at last

20:25

count. I think we're looking at about five million dollars

20:28

worth of new equipment that could be coming through. So this

20:31

is really helped us kind of obviate some of

20:34

the new challenges such as technicians and

20:37

ensuring that we have growth even though we might

20:40

have technician shortages.

20:42

Academic opportunities abound everywhere both in

20:45

our facility and institutions as well as yours. And

20:48

so I think one of the big things has been is how do

20:51

we grow gross smart and strategically while ensure

20:54

growing with our fellows and our residents who will be

20:57

taking over our response. So at every step in the process we've been

21:00

trying to ensure that our gme is

21:03

aware of and recognizes these achievements that

21:06

we've done. We definitely a huge players in our

21:09

PI and qpi API projects. We've also

21:12

set out to ensure that our residents and

21:15

fellows are at the top of their game and

21:18

you might have seen us recently in the ACC cat and

21:22

nabbing first prize in our January challenge.

21:26

Yeah, so it's it's been a fantastic thing, but

21:29

we've learned a couple lessons and I'll tell

21:32

you this from A cardiology perspective and this kind of applies for

21:35

more just making friends and Radiology. We'll just making friends with

21:38

other places and I think the most important

21:41

characteristic as a person as a physician is to be

21:44

adaptable.

21:45

And what does it mean to be adaptable obviously becomes

21:48

teachable a lot of us are highly

21:51

trained. A lot of us have had a lot of experience bring different

21:54

things. But there's something to be said about having the humility

21:57

to to be teachable to understand your

22:00

limitations to understand that knowledge gaps

22:03

and more importantly to be appropriately, you

22:06

know, and and adequately emotionally secured to

22:09

to understand where your gaps are of the

22:12

deficiencies are and understand that, you know,

22:15

everything that's happening every every conversation that

22:18

you have every Gap that gets addressed every

22:21

deficiency or every area of growth. It's essentially made to

22:24

ultimately serve a purpose and that requires

22:27

you to be very service minded but more

22:30

importantly be intentional that everything that you're doing happens for

22:33

a reason every when you process every new

22:36

lesson every new finding every new skill

22:39

that is developed has a purpose and the purpose ultimately

22:42

becoming, you know a person that can be

22:45

collaborated on so that that's one of the key lessons

22:48

that we've learned with with collaboration the other

22:52

thing and you know that Dr. Loren Stark and this is more

22:55

like, you know bringing friends along so

22:58

Yeah, the dependability. We

23:01

really tried to

23:04

ensure that everybody had skin in the

23:07

game and what that meant is that I ensured that

23:11

our Cardiology readers managed our

23:14

imaging centers and for some

23:17

Radiologists that that's that

23:20

could be a big leap and I completely understand that because you

23:23

know, it's it's something that's new but

23:26

their clinicians their positions just like you and

23:29

so placing them in the center of a highly efficient

23:32

or fast-paced workflow

23:35

that that can sometimes be

23:38

it's scary. So I I thought that was a really wonderful

23:41

growth period for us where we're able to put some of our new

23:44

cardiologists who are cardiac images into that

23:47

space and they ran imaging centers very well this handling

23:50

all the different things that of course can hit you from,

23:53

you know on the CT side as well

23:56

as Mars time.

23:57

Another thing that I think was kind of useful is that

24:00

we really tried to ensure that everybody knew

24:03

what we were looking for as

24:06

far as threshold and Baseline expertise.

24:09

And so

24:12

that was something that if we ensured everybody knew about that

24:15

they can at least reach to that goal. There was no hidden agenda

24:18

because everybody knew that there was a certain level of readership there

24:22

was a certain level of peer review that was going to be done and all

24:25

the results from that were going to be shared equally and

24:28

openly so I think once you set that then everybody

24:31

could then rely on each other

24:34

depends on them and and be able to move forward.

24:37

We also did something which was

24:40

interesting which we did act team breeds.

24:43

That is everybody was to contributor on every read

24:46

that was done at a point of time. So we would do the Acquisitions

24:49

in the morning and then we would do a complete team-based

24:52

readout in the afternoon and for

24:55

some of our fellows and residents.

24:58

This was an opportunity for them to lead the discussion and

25:01

to go through the entire workflow. I thought that was

25:04

really interesting. I haven't seen too many places do that, but it

25:07

is something that was kind of exciting to see variable teaching

25:11

and variable interpretations based

25:14

on where you came from Cardiology and

25:17

Cardiology.

25:19

Yeah, and I think another important thing particularly

25:22

from from our transition is you know,

25:25

yes, there's education of opponent but there's obviously the

25:28

key players and nothing can be, you know,

25:31

not enough things can be said about our Technologies to nurses. But

25:34

when when we when we start engaging

25:37

with them, you know Radiology technologists Cardiology nurses

25:40

and vice versa. We've learned that in order to to really

25:43

bring that energy. You have to be enthusiastic. You know,

25:46

we we all love what we do. We are

25:49

skill that what we do and we want our technologist to

25:52

see that the reason why we go to work we work

25:55

with everybody while we focus so much and Excellence is because

25:58

we enjoy it. We're really want to get the best image

26:01

quality at the lowest possible those with the exact amount

26:04

of contrast that we need to get the best outcome for

26:07

the patient a lot of this especially

26:10

in the sense of shortages and and the

26:13

efficiency is is we've learned to do more things that

26:16

may not necessarily be seen as a role.

26:19

Physician to do but I'm willing to do you

26:22

know, I'm not very good at putting IVs. So

26:25

they told me to stop trying that but I can't give Ivy metoprolol.

26:28

I can't give IV nitroglycerin. I can't prepare the scanner

26:31

what diff is technologist is putting the EKG leads

26:34

on I can help putting the EKG leads on I can

26:37

help prepare the contrast I can help transport the

26:40

patient.

26:41

And a lot of nodes has to do with showing a source of

26:44

urgency when the technologist Pages me or calls me

26:47

because they have a question or something is concerning to

26:50

them. We have to demonstrate a sense of urgency to

26:53

be readily available because we want them to know that they

26:56

are a priority to us and how we approach them. How

26:59

do we talk to them how quickly we're respond to

27:02

things how readily available we are. You know, we move our

27:05

reading room to be literally 15 feet away from the scanner just

27:08

to ensure that we were readily available for

27:11

any potential issue and the scanner and that involved

27:14

the cardiologist moving from the third floor or officers

27:17

are located to moving to their location

27:20

in the new reading room. So we had room to be

27:23

available. And that was that was the main reason and that's, you

27:26

know, being there for the technologist to nurses and we

27:29

strive for Excellence our technologists take pride when they

27:32

come out without fantastic textbook quality CT scan

27:35

and they also have the sharing level of concern

27:38

and and you know, I don't want to say, you know,

27:41

Defeat but they really don't like having

27:44

non-diagnostic scans. So they will contact us

27:47

and be like, hey, this could be better. Can I do it again? Or I

27:50

think this patient needs more metoprolol or

27:53

perhaps we can do this better dkg leads in

27:56

there they take pride in that and it's very interesting to see

27:59

and very rewarding to see how the technologists and

28:02

the nurses really take pride when a CT scan comes out

28:05

perfect. But also how you know, they they

28:08

strive for doing better when the scam does not

28:11

turn out how it should be and there's always a conversation of making it

28:14

better and all has to do with the culture of change

28:17

and the culture of enthusiasm and and love

28:20

for what you do in in a scanning room.

28:24

I'll also add because we live in South Texas tacos.

28:28

and I don't think anybody

28:31

has ever turned down any of

28:34

our

28:36

Taco Tuesdays and stockers and

28:39

so forth and you know, it's

28:42

it's a hand placed out there

28:45

to help people and to just encourage the

28:48

friendship and the development of more than just a radiology

28:51

technician or a or Radiology nurse

28:54

or Cardiology nurse workload the team and

28:57

the team workflow. We we get through the exams together

29:00

we get through the workload together and we get to share

29:03

so I think that's also something that we've come have done

29:06

very well around here.

29:08

So education is kind of a big thing for us.

29:11

We're both geony professors and we have

29:14

a very large cohort of fellows and residents

29:17

probably the largest in the

29:20

Department of Defense. And so what we've been able to do is become process-oriented

29:23

and so we probably

29:26

plan out our cardiac imaging program

29:29

probably about a year in advance that is

29:32

to consider what kind of research we're going to attack

29:35

qipi papers and what

29:38

kind of things that we may need to do for our

29:41

individuals.

29:43

So this is something that we do together, we do set

29:46

up team meetings where we can discuss these

29:49

and in future plan out. What's going to be useful.

29:52

And we have also done a significant

29:55

amount of peer review of our prior exams. What

29:58

worked well what didn't work well workflow efficiencies and

30:01

as an example, I think

30:04

last week we actually sat through and kind of rolled up

30:07

about 10 different coronary CT cases and

30:11

we did notice that a few of

30:14

the calcium Springs had a higher dosage than

30:17

normal at one of our skin locations. And so

30:20

we reviewed that we got physics involved and we did identifying issue. There's only

30:23

because DR fintanus had noticed

30:26

noticed an issue. I then was able to confirm that

30:29

and then we were able to get Arkansas involved and

30:32

then come to an understanding of what was going on turns out

30:35

that it was a bit of technologist leaning forward.

30:38

And then also there was an issue with

30:41

the actual scanner that was immediately fixed when

30:44

we did that we were able to kind of find problems

30:47

very quickly and early and then move forward.

30:51

Planning our progress has been a big thing. Like many of you we've got

30:54

kpis and metrics that that we have to keep an eye

30:57

on as far as like turnaround time and and volumes

31:00

and RVs. And so we do try to

31:03

set minimum standards as what to we

31:06

want to exam for the month. And then what

31:09

those turnaround times are for those are those types of examinations. And

31:12

so periodically we do look at that.

31:15

I think it's kind of important to share that not just

31:18

with the staff and they interpretator interpreters but

31:21

also with your technicians and show them that this is

31:24

what ideal looks like and this is where some of the exams

31:27

that didn't quite meet that what we can do the fellows

31:30

and the residents have been immensely educated

31:33

by this and they're able

31:36

to see that they can also learn from this too. And I think

31:39

that's huge thing. I never got that as a resident fellow

31:42

that kind of service work well through evaluation. I thought

31:45

it was huge and extremely important values a

31:48

big thing. When you have a combined part department

31:51

that has ultrasound news VT Mr.

31:54

You're you have tools a

31:57

plenty. I mean you have more tools than probably

32:00

you know, or probably needed for most of your patients, but then

32:03

yeah, you have the opportunity to determine what's going to be value specific and

32:06

value or did it for your for that particular patient. But

32:09

as well as what's gonna grow the apartment

32:12

So we've noticed that we have a really great

32:15

tool in stress cardiac MRI for instance, but unfortunately, you don't

32:18

have the technicians to completely Run 10 cardiac

32:21

stress cardiac MRI, you know

32:25

per day so we have to still utilize what's sufficient

32:28

and then also what's effective for

32:31

the patient and be able to both of those needs.

32:35

Now all very important lessons and you

32:38

know with the changes come disagreements and

32:41

a lot of it has to do with how do

32:44

you approach those and you know what we

32:47

share very good relationship with everybody

32:50

in the department. We've learned that the key to this has

32:53

to do with being relational.

32:55

We have a tremendous amount of respect for each other

32:58

both professionally personally, but also as

33:01

Military Officers and I think that speaks volumes to the

33:04

type of Department that we run we trust each

33:07

other if there's a question or read if there's

33:10

a concern if there's something I can rest assured that

33:13

somebody has a question that the quality of the read

33:16

the quality of exam that was performed by Radiologists of

33:19

cardiologists is consistent because of the trust that

33:22

we've developed along the way and we've shared experiences, you

33:25

know, there's something I don't know or something. I'm not

33:28

clear with or something that clearly I need to sick

33:31

and die so, you know whether or not I'm on service or

33:34

not. I'm approachable people reach out and vice versa.

33:37

It's not uncommon for Dr. Laurence to be on

33:40

trauma calling me bothering him with the question or you know,

33:43

another one over radiologist who's on the

33:46

service with us and steps out for the minute or has another

33:49

obligation where where we have that so we

33:52

have the ability to really share a lot of the experiences.

33:55

Had but it goes beyond that working together in

33:58

research working together for presentations.

34:02

Having lunch together, you know going to Coffee. I

34:05

mean, I'm not saying go to each other's kids birthday parties.

34:08

I mean we do so, you know that helps but

34:11

you know, it's that type of like outside

34:14

of work experience. It's a really make the difference. We

34:17

enjoy going to conferences seeing our fellows and residents

34:20

perform, but also have the ability to go together as a

34:23

team and share those things to to kind

34:26

of celebrate the accomplishments for that more importantly. We're

34:29

really valued each other and this is not just like, oh we need

34:32

somebody for coverage. I think the value that each set and

34:35

member of the team has and and what they bring

34:38

to that team and and what their contribution is beyond

34:41

just an interpretation, but for patient care, I think

34:44

every one of our teammates is focused on

34:47

providing the best care for patient and that reflects on

34:50

their work their work ethic they're availability

34:53

in their availability to you know,

34:56

show value to each other it goes beyond just like

34:59

well, I'm happy to cover for you, but it's more of a

35:01

You know somebody's in need of something. We're there

35:04

for each other if somebody is sick or need something. We're

35:07

there, you know, it's not uncommon for us to have

35:10

days where there's a lot of MRIs that need to be read. But there's also

35:13

a lot of CTS if you know, I'm not busy with the

35:16

echo lab or I'm doing an administrative thing. We do go downstairs

35:19

and read together to try to help our our teammates.

35:22

Even if we're not on service and vice versa. It's not

35:25

uncommon for you know, those busy days to have one

35:28

of the actual Radiologists who was part of the team say I'm

35:31

gonna help out with this without asking so

35:34

we really show appreciation and value to each other

35:37

in many many different ways. And I think that comes with

35:40

selecting the right team what else so the teammates

35:43

thank you have even if there's disagreement. We always

35:46

have that mutual respect level trust insure experience

35:49

that allows to move, you know,

35:52

I disagreement and something academic or something, you know,

35:55

procedural turn understanding that our goals

35:58

our missions are perfectly aligned. We just sometimes

36:01

like

36:02

Deep Purple another people like to see Violet and it's the same

36:05

color but isn't.

36:06

so

36:11

challenges. Yeah, there's absolutely

36:14

no data occurs without

36:17

some sort of challenge occur.

36:20

Happening Here

36:21

I think the main thing that we

36:24

learned is that we take the emotion out of it. This is

36:27

service the service industry we try

36:30

to service our patients and we try to do that effectively and efficiently

36:33

so there is no

36:36

room for

36:38

a pain, you know and and letting that

36:41

ego get in the way there. So we take that opportunity

36:44

to learn from each other as room

36:47

for growth and I think that's really been the

36:50

start of all this.

36:52

so

36:55

I always update Forefront. In fact

36:58

just this morning. I had a patient of Dr. Fontana's

37:01

who came by for stress cardiac MRI finished

37:04

the exam late and because the images

37:07

weren't set because our internet went down so finished up

37:10

our early this morning.

37:12

And I called the patient.

37:13

Isn't any year old lady was very

37:16

concerned about the ischemia evaluation. And

37:19

so I called her and let her know the results and I told

37:22

her to follow up with Dr. Fantas as well as a further clinical concerns,

37:25

but I think when you have a good meeting a

37:28

good group at the individuals that you feel comfortable and then the

37:31

roles start to become clinical and then also become then

37:34

an exam oriented and you're able than to help the patient. And so

37:37

that was a nice thing. I felt comfortable doing that

37:40

and being able to support it within my limits of

37:43

their expertise, but then also to help the patient at the time

37:47

So that was kind of a big thing for us as I

37:50

mentioned before the right test for the right.

37:53

Page we're running into the point where we have so

37:56

many modalities available to our patients. You get to

37:59

choose you're almost like a kid in a candy store at this point. We have

38:02

beautiful equipment but not always great equipment at the same locations. So

38:05

we're able to find the right equipment for the right

38:08

patient for the right test and be able to do that. So I

38:11

think that's been really useful to know. What is the right clinical

38:14

scenario for the right exam for the right modality and

38:17

be able to do that and then be able to get that

38:20

information through protocol exam request

38:23

and then as well as interpretation,

38:28

And I think you know the next phase for us

38:31

is growth, you know, like Dr. Laurence mentioned then

38:34

the efforts of collaboration have, you

38:37

know yielded to the ability for us to start focusing more

38:40

on having dedicated cardiac imaging scanners. You

38:43

need a scanner for just cardiac.

38:46

CT you need a scanner just for cardiac MRI the clinical

38:49

expertise goes beyond

38:52

just one side, but we're focusing more now and offering

38:55

the same service.

38:57

for the entire Department of Defense Enterprise

39:00

Where if you know there's challenging cases or cases that

39:03

there's questions or concerns because of our use of

39:06

Microsoft teams in our environment. We're able to be at multiple

39:09

locations in the same time period and

39:12

assist our colleagues at remote sites that ask for

39:15

help. So that's an important aspect. We also

39:18

notice that there's been a significant increase in our volume

39:21

by simply improving access you build it. They

39:24

will come in the sense that we're getting more appropriate

39:27

test. I would go and say from a cardiologist

39:30

perspective and say that for all new hard failure

39:33

diagnosis. These are institution nearly 95 to

39:36

to 80% of patients and

39:39

our institution have a cardiac MRI at the

39:42

time of their diagnosis gonna help guide further management

39:45

further evaluation, but also importantly risk

39:48

trying to vacation. So getting that educational component

39:51

getting the access to the scanner time and

39:54

ensuring consistency quality have led

39:57

to that Improvement in there and more importantly we now have

40:00

Access to more technology for both clinical and research applications. We

40:03

have a new Vita scanner for cardiac

40:06

MRI with 3T that can do 4D flow. So

40:09

we're going to be utilizing this for our valvular patients. We

40:12

have myocardial blood flow quantification that we're getting

40:15

ready to deploy in our Marketplace for the evaluation of Anoka.

40:18

We you know, we have cardiac CT technology

40:21

that goes beyond just you know, coronary Anatomy

40:24

with you know, looking at the Avenues of black analysis

40:27

CTF a farm obviously tmdr. Appreciate

40:30

your planning as well as tab or valving

40:33

valve planning as our program continues to expand and

40:36

the demand for this pre procedural planning and

40:39

more complex cases exist. So we do that

40:42

from a research perspective.

40:44

You know machine learning algorithms Expediting

40:47

workflows clinical outcomes

40:50

research all of that opportunity to exist.

40:53

But you know, it's an opportunity for both Radiology residents

40:56

and fellows that they have to be able to do

40:59

to do things that go beyond just taking pictures

41:02

of the heart. So in summary,

41:05

you know, the best piece of advice that we can give you

41:08

this comes from coach John Wooden it would be you know

41:11

for us is being concerned more with

41:14

character than reputation because for

41:17

us, you know, our character is what matters your

41:20

character when you interact with folks your technologists

41:23

your nurses your dedication to Patient Care all of

41:26

that's really one one should matter in in

41:29

we emphasize that to our residents we have sides

41:32

into our fellows and more importantly is something that that

41:35

we see so we want to thank all of our teammates is

41:38

our cardiologists in our program. They're Radiologists and

41:41

our program, but more importantly our technologists who are the backbone of

41:44

Are Imaging Enterprise or nurses or lvns

41:47

or schedulers which we would have no scans

41:50

without them and our administrative staff of both facilities

41:53

who really allow us to to provide the care

41:56

that we provide for patients with our you know, challenging times

41:59

challenging resources and have been through all

42:02

of those obstacles along the way and and you

42:05

know allowed us to continue to collaborate and work

42:08

with them. So so we're very very grateful for that opportunities.

42:11

So now we kind of Segway into our what

42:14

can we do if you're interested in cardiac CT.

42:17

We are offering a ten week virtual course,

42:20

Dr. Lawrence and I wear, you know, we hope to have

42:23

the opportunity to kind of show you more details about our

42:26

workflows our challenging cases from our facility

42:29

and how we've approached them. We have standardized reports.

42:32

You'll have access to Tara Recon with its

42:35

full applications for detail plan analysis valve

42:38

in val simulation. We have templates reports

42:41

written so, you know if you're interested

42:44

Please reach out, you know, you can use our discount code

42:47

for 25% off as well as to.

42:50

Understand that these are cases that are hopefully

42:53

going to be able to teach you what we teach our residents and

42:56

fellows on how to approach cardiac CT and a systematic

42:59

approach and in there. So now we can transition

43:02

to questions. If anybody has any questions concerns, please

43:05

let me know. I'm gonna stop sharing this screen, but we

43:08

can we can discuss.

43:16

Feel free to put your questions in that Q&A box and

43:19

I've actually got a couple of questions for

43:22

you all. Um great. I'm curious

43:25

how you got approval to combine Imaging duties.

43:31

That's a wonderful question. So we

43:34

stirred out with our Hospital Administration determining

43:37

what is the way of

43:40

doing privileging and so we noticed that her

43:43

Imaging there are

43:46

a couple performance that take lead for this man. So Department of

43:49

radiology obviously handles most of the privileging for

43:52

Imaging interpretation, but we did notice the department of

43:55

Cardiology had Imaging interpretation responsibilities

43:58

as well. So we were able

44:01

to combine them find the right pathway and ensure

44:04

that that one or

44:07

two of us both ends were able to approve privileging

44:10

for both of for our

44:13

departments. And once we were able to review those

44:16

packets for privileging

44:19

we were able to see that we

44:22

had enormous amount of talent out there, but to

44:25

ensure quality we limited that amount of talent to

44:28

those who had met co-cats or

44:31

level two in three experiences.

44:36

familial

44:38

Yeah, you know it was one of those things where you know,

44:41

our departments were across way where we had to the way

44:44

forward was to join programs. And as you saw

44:47

from that report for congress did demand was there and you know,

44:50

I think they're really asking they were kind of making us

44:53

Find A Way Forward where we had

44:56

to train to radiologies and residents and fellows to

44:59

to do cardiac CT into

45:02

cardiacom Orion away. Then was reproducible in

45:05

the long term. So it became a solution that leadership

45:08

was able to support and understand what our

45:11

role was so that that helped.

45:15

And how did combining then in turn

45:18

help your research goals.

45:21

While funding is one of the easiest things than

45:24

you know, you've had it's when you have multidisciplinary funding

45:27

research opportunities and

45:30

projects. It adds a little certain level of certainty

45:33

and experience that comes with each, you know,

45:36

investigator and and pi and supporting staff

45:39

the ability also to

45:42

you know, having more different perspectives and

45:45

viewpoints to a research project having someone

45:48

else's expertise that expands Beyond just you know,

45:51

the clinical day to day but they, you know

45:54

daikons and their machine learning and a

45:57

lot of the additional expertise that are

46:00

Radiologists brings form like those reduction the physics

46:03

of things that are understanding of their modality that

46:06

adds certain level of of expertise

46:09

to each project that we didn't

46:12

have before and we're not able to to multiply

46:15

and reproduce but more importantly it allows

46:18

us to really apply for different.

46:21

instead are across different departments, you

46:24

know Radiology research opportunities cardiology-based research

46:27

opportunities that we otherwise wouldn't have access

46:30

to

46:32

Now add I think there's about 550 million

46:35

dollars in this last year's

46:38

worth of congressional mandated research available

46:42

to intramural and actor mural

46:45

parties when that's a ton of cash and there

46:48

are a lot of amazing technologies that in

46:51

the Imaging field I think would be perfect for

46:54

that. But if I don't have a clinical Champion to

46:57

help support, I'm never gonna get any of

47:00

that approval. It's just not going to happen. So we really

47:03

quickly notice that the only

47:06

way to

47:08

Be strategic about this was to combine

47:11

take a bind and direct towards common goals

47:14

and once we did that.

47:18

I'm gonna started to fall things started to get approved irbs

47:21

moved faster, you know things started

47:24

to really occur the way that they should and so I think at your

47:27

larger institutions, you know what I'm talking about these multidisciplinary

47:30

multi-departments sort of projects. They're

47:33

headed by individuals who are collaborators.

47:36

And so that's what we emulate

47:39

and that's what we even seeing that works very well.

47:43

Yeah, that's really interesting. And and I'm gonna pivot it

47:46

here a little bit to ask you about day to day.

47:49

A day-to-day question and how do

47:52

you handle cherry-picking with exam complexity?

47:57

So I don't think we Cherry Peak this is

48:00

we're reading all of it together, you know,

48:03

there are cases where they're simpler cases

48:06

where you know did the residents

48:09

and we're in cardiology fellows, you know,

48:12

obviously don't have a need for you know,

48:15

an extensive discussion on why this is a normal coronary CT.

48:18

So that allows us to focus more time on complex

48:21

cases, you know, when we get the valve in valves simulation

48:24

or the T and VR or Watchmen assessment

48:27

or or somebody with multivastal disease

48:30

or or unexpected findings that

48:33

then we are allowed to really collaborate on who

48:36

does this and the approach of having a

48:39

share reading session of both

48:42

experts being there. It kind of shares the low

48:45

if we if I start reading or helping

48:48

with the residents earlier and I see that it's gonna be a complex

48:51

case then we put those for for the team

48:54

to kind of discuss together so that there's an equal

48:57

And of that, so we don't we don't have a list of

49:00

15 cases. You know, somebody did the five

49:03

easiest ones and they're 10 of the hardest ones waiting for the next person to

49:06

read. It's 15 cases for everybody to to share

49:09

the load with for that afternoon and how

49:12

we get through those. How do we go through those is what

49:15

really makes our model a little

49:18

easier and more more. I completely

49:21

agree I think some and that's

49:24

a valid concern right? I mean the more quote unquote

49:27

complex cases are left for somebody with

49:30

a bit more experience or level three, you know

49:33

Fellowship training now, we don't do

49:36

that we go over all the cases together and we find that that

49:39

everybody does learn and everybody's able

49:42

to go through that. What is kind of fun and exciting

49:45

though is everybody knows.

49:46

Nobody's going home early. Unless all the cases are done.

49:49

So if we want to do them, we got to do them effectively and efficiently

49:52

and so that's a big motivator more than just

49:55

trying to find the the catarads one or two and try

49:58

to do all those first and leave everything else for for

50:01

somebody else.

50:04

What about addendums and over calling?

50:08

The tendons over calling when it comes

50:11

to a finding where there's discrepancies

50:14

in like the severity of disease or

50:17

concern of that, you know, we don't sign the report until you

50:20

know, all of those things have been addressed so that kind of

50:23

minimizes the issues if there is a let's say

50:26

that the report has been finalized somebody

50:29

won in a second opinion. They wanted to review the

50:32

case. Our default is actually address that with

50:35

the reader for that study kind of go over them with them

50:38

together see what they're findings were kind of

50:41

assess that and

50:43

If we deem as a group that this is

50:46

possible, you know that there's a discrepancy Central.

50:49

We let that reader for that report make the

50:52

addendum obviously if they find if they agree with that change,

50:55

but if we as a group say there's no change. This is the

50:58

this is what we find and we agree which often happens and

51:01

there's no need for us to kind of amend things or

51:04

change. Obviously. There's something like that got missed as part

51:07

of the peer review Etc. We do the same approach with again the

51:10

same concept that whoever read that study needs to put and get

51:13

them done for for that for that finding.

51:18

Once I think interesting is when I reviewed what was

51:21

requested for addendum, it actually

51:24

had a bit more to was more useful in determining a

51:27

better efficiency workflow. That is why we

51:30

didn't we address the clinical question. What was

51:33

missed in that clinical question and it turns out

51:36

it probably had a lot more to do with our EMR in transitioning

51:39

to a better EMR doing that. The

51:42

clinical information was presented in a

51:45

format.

51:46

Hl7 or otherwise that then populated certain

51:49

Fields. So I think that was actually

51:52

useful so I don't

51:55

see that as you know.

52:01

I think these are actually useful and we can see that so we handle them

52:04

all together. Everybody is feces on and on

52:07

the email for request for addendum. That was of course

52:10

part of it so that we can learn from it. And and I

52:13

think these are actually great opportunities for

52:16

learning and so again in our area we in our

52:19

institution, there's no worry about

52:23

an addendum. There's no concern for it. We handle

52:26

it and we evaluate it and we move on

52:31

Yeah, do you think this model could be replicated

52:34

in a private practice?

52:37

I think it depends on your organizational approach

52:40

in whose equipment and have the bill

52:43

is is made right who will charges that

52:46

depending on the insurance carrier depending

52:49

on the hospital policy the outpatient versus the inpatient

52:52

setting, you know Cardiology readers as

52:55

a whole that field of advanced cardiac imaging it's

52:58

a new field and with the new field come like, you know,

53:01

the challenges of like well, it's a cardiologists

53:04

coding as seven five five seven four for cardiac

53:07

CT gonna get reimbursed for that study by

53:10

this insurance and vice versa is you know cardiologist, you

53:14

know reading for cardiac MRI, you know

53:17

in a hospital setting where they're in an RV based model

53:20

is that time dedicated for accounted for

53:23

that RV you or is the RV you gonna

53:26

be, you know conducted by who interprets to report. I

53:29

think you kind of have to individualize to what the needs are for

53:32

your model and more importantly what the needs are for your institution

53:35

or your practice.

53:37

You know, if you own the equipment, which is something that's

53:40

happening cardiologists are starting to find some of the smaller cardiac CT

53:43

scanners and they they're able to interpret their

53:46

own images and higher, you know, that's your cardiac readings for

53:49

Radiologists and you know vice versa. There's cardio

53:52

radiologist centers and our, you know, having more

53:55

cardiologists getting involved in this because their Fellowship trained or

53:58

their poor sort of finding how the appropriate training that can

54:01

contribute to to the purpose. So I think from that perspective

54:04

that's you have to individualize at each

54:07

side.

54:08

I think the short answer is yes, and you have

54:11

advocacy groups that have laid out

54:14

very reasonable education standards in milestones.

54:18

I think you have interpretation guidelines that are

54:21

very sounds I think

54:24

there's a reality that we just don't have

54:27

enough individuals who are subject matter experts to

54:30

handle the current and the forecasted future

54:33

load of exams that I'm going to be coming through. I'm

54:36

sorry, but not all algorithms are gonna be able to handle all

54:39

that. We're still going to need, you know, flesh and blood and interpretation occurring

54:42

at the desk. So yeah with those in mind

54:45

they're absolutely will be models where private public

54:48

institutional academic and

54:51

then you know something at

54:54

the Imaging Center where this will occur and I

54:57

think it's useful to get ahead of it now and determine what

55:00

can be done in your potential environment in your

55:03

facility. To be honest. I think it's a great

55:06

model. I can along really well with cardiologists and

55:09

I think cardiologists get really well and get along really

55:12

well with Radiologists. We just think the same we act the

55:15

same. We're we're both interested in the same things, which is

55:18

Or fellow efficiencies Management's guideline based directed care

55:21

and development of cool new stuff. So it's a

55:24

win-win to be honest and I think those who

55:27

are being it as a win-win

55:30

currently will be taking probably larger market

55:33

share of that overall burden.

55:35

Yeah, we like the same toys it turns out.

55:39

Really? That's when it comes down to I'm shiny thing gets

55:42

as well. Same thing, maybe. Oh, that's nice.

55:45

Yeah, so so all that

55:48

said what what are the next areas for girlfriend?

55:53

Ending to network, you know that we're really Enterprise, you

55:56

know, if we for us really are conversation has

55:59

been you know, we have a larger volume. We have

56:02

more consistency. We want to reach Beyond just a

56:05

trainees and and you know the San Antonio Marketplace, there's

56:08

no reason why they're Radiology residents in Hawaii

56:11

or in San Diego or other sites

56:14

where they don't have access to cardio Imaging

56:17

with the shared EMR Enterprise white pack

56:20

system can contribute to to our efforts and

56:23

can be part of that educational opportunities. So

56:26

we're exploring that Avenue. It has a

56:29

lot to do more with credentials, you know, we're getting credentials. And yeah,

56:32

I think in the next two to five years will be scalability ensuring

56:35

scalability and continue operation

56:38

cardiac. Imaging care. We've got

56:41

some Mariners in San Diego. We've got you know

56:45

other

56:47

Shadowy groups and other locations of the Department of

56:50

Defense that need cardiac imaging and cardiac eval. How

56:53

do we do that? How do we Enterprise that and be able

56:56

to provide that remotely automatically be able

56:59

to give them the disposition they need to do the things

57:02

that they're wanting to do. That's one big

57:05

thing. I think the other thing area for growth is going to

57:08

be collaborative further collaboration. So

57:11

Radiology has a significant footprint

57:14

in imaging and what can

57:17

we do to support other missions that is the other holidays and

57:20

what can the other allergies neurology Cardiology opthamology

57:23

and so

57:26

forth that traditionally had been there areas of the expertise

57:29

and areas of Interest use the

57:32

Radiology departments to support Venice for instance cycle choreographed

57:35

and all the things so we're finding

57:38

that that's good new area of interest and concern we can

57:41

automate some of that stuff and so on innovating cardiac MRI

57:44

automating maybe all your sound echocardio.

57:47

Those are some really fun areas that we're looking at.

57:52

That's excellent. Yeah seems like the the name of

57:55

the game is collaboration here. So sky's the

57:58

limit.

57:59

Yep, I think that's all the questions

58:02

we have any final thoughts.

58:05

Make friends with Radiologists. If you're a cardiologist, if

58:08

you're a radiologist make friends with cardiologists and promise.

58:11

We we do get along you'll find out that

58:14

we like the same movies. Even we like

58:17

the same food. Same toys. I mean

58:20

You'll be careful. If you get too close to a radiologist

58:23

or cardiologist, you might go to each other's kids birthday party.

58:26

So and that can be a consequence in the

58:29

long term.

58:32

Just I would just add just

58:37

this optic value-based proposition and working

58:40

with somebody who's a clinician is usually going to

58:43

work in your favor.

58:47

It's it's a win-win for everybody for education and

58:50

all that that's been there.

58:53

That's how things are done in 2023. So

58:56

I would suggest looking it for nest endpoint and making sure that you come.

59:02

That's what we do it right now.

59:05

excellent

59:07

Well, thank you both for the lecture today and thanks to everybody

59:10

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59:24

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