Interpreting the Interpretation.

In this Editor’s opinion, one of the most important goals of cardiovascular imaging is the ability of the image to favorably impact clinical outcomes. I have spent more than 25 years hoping to match imaging with outcomes. This is not as easy to achieve as it may at first sound.

Since in the majority of cases, the requesting provider is not the interpreting physician, the only conceivable way that the echo would directly impact clinical outcomes is via the echocardiographic report (rather than the actual images). The report must be an accurate, true representation of the images and this is an area where your affiliation with the American Society of Echocardiography (ASE) offers great value. The ASE is dedicated to improving your skills at interpretation and has published recommendations for standardizing the adult transthoracic echo (TTE) report (Recommendations for a Standardized Report for Adult Transthoracic Echocardiography, JASE, February 2002).

However, the accurate reporting of a restrictive filling pattern or similar prognostic finding on TTE alone does little by itself to connect imaging with outcomes. Although the cardiovascular specialist managing the patient with this returned echo interpretation will likely know what this finding signifies and steps to modify care, many other providers may completely overlook that reported finding and focus on the LVEF or whether there is moderate or greater valve pathology.

There is a hole in our echo reporting process which is the assumption that the requesting provider knows what to do with the reported findings. As the imaging experts, it is contingent upon us to carefully communicate the prognostic implications of our reported findings. In a recent JASE Editorial we emphasized the importance of the need for greater communication standards in a Call-to-Action report. In that report, we recommended three levels of enhanced communication that included echo findings warranting immediate, urgent, and routine communication. We provided a list of pathologic findings that we determined would be best communicated via direct verbal notification.

Although I remain convinced that this is a best practice model, it is becoming increasingly rare that this occurs. Not only does the interpreting physician find limited time to ‘make the call’ (or send an EMR alert), the requesting physician has limited time to receive your call or respond to your alert. In our ever-increasingly fragmented healthcare delivery system, the requesting physician is frequently no longer the managing physician for the patient.

So, how do we move forward? How can we improve the likelihood that the actual managing physician who is going to use the echo report in the management of the patient, has what they need to fully ‘interpret the interpretation’? I believe it is time we re-think our historical approach to reporting and consider offering standardized recommendations to assist providers that are evidence-based, guideline-driven, and build upon our vast experience and insights. This could be similar to what the American College of Radiology (ACR) has recommended for years where radiology reports include comments specifically aimed at facilitating decision-making regarding further patient management. Certainly, the general medical community can’t keep up with the available evidence in the oncology literature regarding which lung nodule warrants further diagnostic investigations or what is the optimal timing for serial imaging. Another example of this approach that impacts cardiovascular imaging specialists, is the CAD-RADS (Coronary Artery Disease Reporting and Data System) standardized method for communicating findings and clinical follow up recommendations for cardiac computed tomography (just recently updated to CAD-RADS 2.0). Using this approach, the individual reading the interpretation is provided short management recommendations, such as “CAD-RADS 0: Consider non-atherosclerotic causes of chest pain” or “CADS-RADS 4: Consider symptom-guided anti-ischemic and preventive pharmacotherapy as well as risk factor modifications.” This effort was driven by the fact that it is how clinicians act on the test results that will ultimately impact patient care and clinical outcomes.

In this issue of CASE, you will see beautiful examples highlighting the complimentary role of magnets, x-rays and isotopes from Marzlin et al. and Arango et al; important insights into cardiac tumors and pseudotumors can be gained from reading Fujiwara et al. and Winkie et al., respectively; and we are reminded again that you are never too young or too old to be diagnosed with congenital heart disease in reports from Liebman et al. and Leighton et al. A newer category of maneuvers, waveforms, and pressure tracings can be found in our Hemodynamic Corner, with cases from Wang et al. and Morcos et al. as they tackle fixed serial and dynamic LV outflow obstructions, respectively.

So, I challenge you to consider how your clinical practice can improve the communication of the echo findings for your colleagues. Short of making direct verbal calls or sending text messages or adding an EMR alert, consider ways to provide messaging within your report. It’s time for the experts in imaging to assist in the interpretation of these potentially complex interpretations.

And remember, every echo you read today has a teaching point and every teaching point is a potential new CASE report.