Abstract
Background: Because rural providers may experience barriers in achieving the necessary components to successfully re-credential in cardiac computed tomography (Cardiac CT), we evaluated the current system for re-credentialing at our organization and implemented processes to facilitate Cardiac CT re-credentialing for our providers.
Methods: Institutional opportunities for Cardiac CT quality assurance (QA) conference attendance, Cardiac CT imaging evaluation, and Cardiac CT continuing medical education (CME) acquisition were assessed in 2009 and 2013. Process improvement strategies were implemented in 2014 including adding electronic media hosting sites, a “hands-on” image interpretation course, and more options for CME acquisition. Pre- and post-educational improvements were evaluated over a 10-year period. The number and type of events hosted, attendees, image review opportunities, and CME credits awarded were assessed and compared at the provider level.
Results: Attendance at Cardiac CT QA conferences increased substantially following implemented changes despite fewer certified Cardiac CT providers. Electronic attendance accounted for 26% of this increased attendance, while the “hands on” course provided 43 images for review per year. The number of Cardiac CT CME credits awarded increased substantially, paralleling increased QA and “hands-on” attendance.
Conclusion: In rural healthcare systems, institutional strategies can increase provider access to components necessary for Cardiac CT level II re-credentialing. In the COVID-19 era, rural and urban health organizations may find considerable provider benefit and engagement by using similar process improvement methods to help providers meet local and national requirements for certification.
- Cardiovascular Computed Tomography
- Coronary CTA
- Re-credentialing
- Continuing medical education
- CME
- Rural healthcare providers
Cardiac computed tomography angiography (Cardiac CT) as a form of cardiovascular imaging has become a part of the cardiologist’s toolbox over the last two decades.1–4 To ensure practitioners produce high-quality results, credentialing societies, and medical institutions have set forth requirements for providers to maintain competency in Cardiac CT. These include quotas for live studies performed, for non-live images reviewed, and for continuing medical education (CME) credits specifically targeted to Cardiac CT. However, maintaining specialized clinical skills and associated certification can be challenging for many rural providers and healthcare organizations.5 Due to their geographic isolation, rural Cardiac CT specialists may lack access to Cardiac CT cases and CME opportunities.6 This has recently become an urban problem as well with the arrival of the corona virus infectious disease 2019 (COVID-19) pandemic.7 With physical distancing and restricted travel combined with low patient volume and financial constraints, physicians may face many challenges in attending and attaining specialty related CME courses as well as maintaining credentials for technically demanding procedures.8 These barriers can lead to skills attrition and decreased provider confidence in performing advanced techniques. In this era of COVID-19, developing and implementing strategies to provide appropriate educational content to providers in both urban and rural areas in a convenient and meaningful way is necessary to maintain clinical skills and ensure high standards of patient care.
Marshfield Clinic Health System (MCHS) is an integrated organization of 63 facilities that provide care to a predominantly rural population spread across a region greater than one million square miles in northern, central, and western Wisconsin and in the Upper Peninsula of Michigan. The system employs a staff of over 10,000, supports 86 clinical specialties, and collaborates with numerous community organizations to care for medically underserved, low income, and underinsured/uninsured individuals. In 2009, our institution fully operationalized a Cardiac CT program. At the start of the Cardiac CT program, criteria for reading Cardiac CT images and requirements for initial credentialing and re-credentialing were defined as follows: all Cardiac CT images used for credentialing purposes required dual interpretation by both a cardiologist and a radiologist; initial provider privileges for Cardiac CT included proof of national level II Cardiac CT criteria; and each provider was expected to attend a monthly institutional Cardiac CT quality assurance (QA) conference.9 This conference provided one hour of Cardiac CT CME.
Every 3 years, each provider was expected to meet national criteria for level II re-accreditation including cumulative Cardiac CT image interpretation and Cardiac CT specific CME (Table 1). The criteria for Cardiac CT image interpretation mirrored recommendations by the American College of Cardiology Foundation and American Heart Association clinical competence statement on cardiac imaging with CT, which requires yearly interpretation of at least 150 cumulative contrast Cardiac CT studies. Of these studies, a minimum of 50 must be personally performed, interpreted, co-read, or supervised (“live” cases) with the remaining reviewed and interpreted through recorded means and completed anywhere within the 3-year renewal period.9 Our local institutional criteria for re-accreditation also required attendance of ≥50% at Cardiac CT QA conferences held. The re-credentialling process at this institution begins with notification to the appropriate provider along with the criteria for Cardiac CT study interpretation, Cardiac CT CME and Cardiac CT QA conference attendance along with an attestation form that the provider signs confirming that all the criteria had been fulfilled. A statement that random audits of attestation verification is also provided. In the case of a random audit, the provider is required to provide the credentialling committee proof of all Cardiac CT CME, Cardiac CT conference attendance and an anonymized logbook or other documentation of all procedures (live and recorded).
Provider Characteristics
After program initiation, plans were made to reassess the program to determine if any additional institutional educational processes might aid our providers in acquiring Cardiac CT case studies, attending Cardiac CT QA conferences, and obtaining Cardiac CT CME. This reassessment was done in 2013.
We describe our 10-year experience in identifying and addressing these barriers to providers seeking Cardiac CT re-credentialing at our large rural system. We also discuss the potential of employing such processes in other subspecialty areas during the COVID-19 era.
Methods
Program Review
In 2013, an interdisciplinary team comprising the Cardiac CT QA medical director, cardiologists, radiologists, medical residents, medical educators, and the informatics team was created to review the Cardiac CT program educational opportunities. The team identified several barriers and opportunities in the existing Cardiac CT educational program. This review prompted the development of processes to overcome these barriers and provide additional institutional opportunities to our Cardiac CT providers. Three broad categories were addressed based on national and local re-accreditation requirements for level II Cardiac CT re-accreditation. These included institutional Cardiac CT QA attendance, Cardiac CT case review, and Cardiac CT CME. The review and process improvement corresponding with each category is outlined in the following sections.
Cardiac CT QA Conferences
Cardiac CT QA conferences were offered at 7:00 am at the on-site central conference location with two other remote interactive video conference sites. Due to patient care and on-call responsibilities generally starting at 7:00 am and throughout the workday, well beyond 5:00 pm, the team decided it was not feasible to change the start time. Lack of informatics personnel and hardware capabilities at the time precluded adding more videoconference sites for 7:00 am meetings. Vacation, time away from practice for illness, or nationally sponsored educational opportunities and time required to travel (up to 1–2 hours in many instances) to satellite clinics were identified as barriers in attaining the ≥50% Cardiac CT CME meeting requirements to obtain credit.
Our solution was to use MediaSite technology (https://MediaSite.com/health/) to record the monthly Cardiac CT QA meetings with subsequent upload to the clinic intranet for physician review for up to one year following the meeting. When viewed, the digital fingerprint of the provider viewing MediaSite is recorded and can be used as a surrogate for attendance.
Cardiac CT Case Review and Image Manipulation Course
The team found all providers were able to meet the yearly “live” 50 case Cardiac CT requirement. However, the majority were not able to meet the prerequisite 150 cases/year by “live” case acquisition alone, and most found it necessary to complement the “live” cases with 100 additional recorded cases from review courses. Generally, these courses had to be obtained elsewhere through attendance at multi-day conferences typically held out of state.
A partial solution was to start a “hands-on” Cardiac CT case review and image manipulation course similar to the courses held out of state. This course, which was agreed to by our Medical Education Department and the Society of Cardiac Computed Tomography Angiography, would be held under the aegis of a level III board certified Cardiac CT instructor within our institution. Each participant would be given a separate work/review station to allow manipulation and interpretation of Cardiac CT images. Each session would last about 1.5 hours and consist of approximately 10 cases, with participants discussing findings, appropriateness of testing, image comparison with other imaging modalities, and references to published articles in the field. These meetings, by necessity, were held after routine work hours at 5:00 pm and would be confined to our central site, since in-person workstation review was required with oversight of the Cardiac CT director for this course. A maximum of seven attendees per session was allowed due to space and technology limitations. Upon completion, an email was sent to the attendees with a link to obtain 1.5 Cardiac CT CME credits through the Medical Education Department.
Cardiac CT CME
Our group found that the only Cardiac CT CME credits issued by our institution were at the monthly one-hour Cardiac CT QA conference. The barriers in attaining this one-hour CME credit were the same barriers preventing participants from attending ≥50% of all Cardiac CT QA conferences held.
To address this limitation, the group agreed Cardiac CT CME credits should be awarded for both the Cardiac CT QA meeting MediaSite viewing and “hands-on” Cardiac CT case review course. Since the “hands-on” course sessions were in person and met specific educational requirements for CME, up to 1.5 Cardiac CT CME credits per course could be awarded. Simply viewing the Cardiac CT QA meeting MediaSite recordings did not meet medical education CME requirements, however. To receive this credit, a 70% pass rate in a series of knowledge-based questions was required for that particular session. Thus, it was determined that a series of questions would be generated and linked to the MediaSite presentation. After viewing, the attendee could click another link leading to an on-line CME survey with the questions posted at the end of the recorded session. Upon successful completion of these knowledge-based questions, a notation indicating successful completion was displayed and one Cardiac CT CME credit awarded and recorded by personnel at the CME office. Only 1.0 Cardiac CT CME credit could be obtained for a Cardiac CT QA conference meeting regardless of the method of attendance.
Changes in the above processes occurred May 1, 2014. Because of the necessary national and institutional permissions, the Cardiac CT “hands-on” case review and image manipulation course was added to the institutional educational course offerings January 2015. These procedures were reviewed again in 2018 by the re-accreditation team to evaluate the impact of these improvements on Cardiac CT QA attendance, Cardiac CT case review, and Cardiac CT CME.
Data Collection and Analysis
Data were collected and compared from January 1, 2009 to April 30, 2015, (Pre-Cardiac CT educational improvements [EI]) and from May 1, 2014 to December 31, 2018 (Post-Cardiac CT EI). Information regarding course offerings (number of Cardiac CT QA conference offerings and case review and image manipulation courses scheduled), formats (live in person on-site central conference location/regional videoconference location/MediaSite), and attendees (number at Cardiac CT QA conferences and “hands-on” case review and image manipulation course, specialty, and location [ie, central versus regional facility]), was recorded. Similarly, the total number of cases reviewed at the “hands-on” course per session, yearly, and for the entire four years of course availability were counted and evaluated. The number of providers who re-certified and those who did not along with the reasons for non-re-certification were also collected. Total and average Cardiac CT CME acquired, CME acquisition type (live in person, videoconference, or MediaSite Cardiac CT QA conference and/or “hands-on” case review course) were recorded for each provider.
Using commercially available software descriptive statistics, percentage comparisons, Chi Square test, Fisher’s exact test, and two-sample t test with pooled variance were utilized to analyze the data for the Pre- and Post-Cardiac CT EI groups described above. A P value <0.05 was considered statistically significant.
Results
Provider Characteristics
The total duration of Cardiac CT credentialing evaluation was approximately 10 years: 5.33 years for Pre-Cardiac CT EI, and 4.67 years Post-Cardiac CT EI. During the evaluation period from 2009 to 2018, 24 Cardiac CT-certified providers reading Cardiac CT studies included 7 radiologists and 17 cardiologists. Half of those read Cardiac CT studies in both the Pre- and Post-Cardiac CT EI periods. Eight read studies in the Pre-Cardiac CT EI period only, and the remaining four read Cardiac CT images in the Post-Cardiac CT EI period only. There were 20 providers Pre-Cardiac CT EI compared to 16 Post-Cardiac CT EI. The number of cardiologists from the central and regional locations was similar Pre- and Post-Cardiac CT EI. However, there were fewer radiologists engaged in Post-Cardiac CT EI activities (Table 1).
Of the 24 providers initially credentialed to interpret Cardiac CT studies, only 14 providers re-applied for level II Cardiac CT privileges. All 14 were successful in their application. Based on a 3-year re-credentialing cycle, a total of three providers re-credentialed three times, seven re-certified twice, and four re-credentialed once. Two who joined the program during the last 2 years of this evaluation did not need to re-credential. By choice, 8 of 24 providers (33%) did not reapply due to retirement (n=2), work/life issues (n=3), or change in employment (n=3).
Cardiac CT QA Conference Participation
Prior to May 2014, two options for obtaining the required ≥50% QA meeting attendance were available either in person on-site or in real-time video conference the day of the conference. In the Post-Cardiac CT EI period, three options for participation were available with the addition of MediaSite recording and knowledge-based questions. During the evaluation period from 2009 to 2018, 97 Cardiac CT QA conferences were held. The number of conferences Pre- and Post-Cardiac CT EI were similar (54 versus 43, respectively, mean 27±15 versus 22±12, P >0.05). Pre-Cardiac CT EI, there were approximately 10 conferences per year (range: 7-12 per year) and approximately 9 conferences per year in the Post-Cardiac CT EI period (range: 7–11 per year).
Over the 10-year Cardiac CT program evaluation, total attendance at the Cardiac CT QA sessions was 603. Of these, the total QA conference attendance in the Pre-Cardiac CT EI period was 238, and Post-Cardiac CT EI QA conference attendance was 365 (mean 120±69 versus 184±105, respectively, P <0.01) (Table 2). Cardiac CT QA conference attendance was significantly higher in the later period (P <0.01) due to the combination of increased live attendance and additional MediaSite viewing. The combined in person and videoconference attendance at Cardiac CT QA conferences was significantly higher in the Post-Cardiac CT EI group compared to the Pre-Cardiac CT EI group (238 versus 298 for Pre- and Post-Cardiac CT educational course group, respectively; mean 120±69 versus 150±86, P <0.01). Live in-person attendance was also significantly higher in the Post-Cardiac CT EI period (218 versus 270 for Pre- and Post-Cardiac CT EI period, respectively; mean 110±62 versus 136±77, P <0.01). Although attendance via videoconference slightly increased in the Post-Cardiac CT EI period, it was not significantly different compared to Pre-Cardiac CT EI period attendance (20 versus 28, respectively; P =0.06). However, when videoconference attendees were grouped with the number of MediaSite visitors in the Post-Cardiac CT EI era, the combination of videoconference and MediaSite use accounted for 26% of Cardiac CT QA attendance. Of the 365 total count of Cardiac CT QA attendees in the post-Cardiac CT EI period, MediaSite use accounted for 18% (n=67) of all QA conference attendance. Of the 67 MediaSite visits, 27 were from the central location (40%) and 40 from regional centers (60%).
Cardiac CT QA Conference Participation Pre- and Post-Cardiac CT EI
Cardiac CT Case Review and Image Manipulation Course Participation
“Hands-On” course attendee records are presented in Table 3. During the 4 years, 16 sessions were held with an average of four sessions per year (range: 2–6 sessions) and about 11 cases per session (average: 43 cases per year). Attendance for participants averaged approximately three sessions per year (range: 1–4). Because some sessions were missed by participants, the number of cases reviewed averaged 32 cases per year for sessions attended (range: 15–43 cases). Excluding the provider who attended only one session in four years, the remaining six providers read an average of 39 studies for each year of session attendance (range: 24–43 cases). Depending on the number of sessions attended per year, within a one to three year period, if needed, attendance at the “Hands On” course could be used to obtain an additional 100 cases for level II Cardiac CT physician re-accreditation.
Cardiac CT “Hands-On” Case Review and Manipulation Participation
Cardiac CT CME Acquisition
Overall Cardiac CT CME activity paralleled the changes in Cardiac CT QA live conference attendance and “hands-on” course attendance described above. All individuals attested to participating for the entire duration of the conference or course. All those who viewed MediaSite recordings passed the knowledge-based questionnaires.
Approximately 10 CME credits/year (range: 7–12 CME/year) were potentially available to providers attending all Cardiac CT QA conferences Pre-Cardiac CT EI and was similar Post-Cardiac CT EI with 9 CME credits/year (range: 7–11 CME/year). Over 4 years, the “hands-on” course provided a potential 6 additional CME credits/year. If a participant attended both Cardiac CT QA conferences and “hands-on” courses, a potential of 15 Cardiac CT CME credits could be awarded a year.
A total of 704 Cardiac CT CME credits were awarded to all providers from 2009 to 2018, and a significant increase in total Cardiac CT CME credits were available in the Post-Cardiac CT EI period (466) compared to Pre-Cardiac CT EI (238, P <0.01). In the Post-Cardiac CT EI period, 298 credits were awarded for live conference attendance either on-site or videoconference, 67 for MediaSite, and 101 for the “Hands-On” course (Table 4).
Cardiac CT CME Credits Awarded Pre- and Post-Cardiac CT EI
For the seven providers who participated in both the QA and “hands-on” sessions, a total of 313 CME credits were awarded (212 and 101, respectively). The “hands-on” course was a rich source of yearly CME and accounted for approximately 36% (range: 14%–54%) of Cardiac CT CME credit earned annually when attending both events. On average, each provider participating in both the Cardiac CT QA conference and “hands-on” conference received 12 CME credits a year. Of these, four credits were from the “hands-on” conference and eight credits from the Cardiac CT QA conference.
Discussion
Achievement of level II Cardiac CT re-certification at the national level requires time and effort to satisfy the many components needed (Table 5). This includes, in many instances, time away from practice to attend national conferences with the expenses of course registration, travel, lodging, and meals. Our local institutional standard requiring ≥50% level II Cardiac CT QA conference attendance for level II Cardiac CT re-accreditation could be problematic for a provider traveling from a regional center, providers who are on-call and busy with clinical issues, or providers who fall ill or are on vacation. The processes we put in place addressed some of these issues and facilitated Cardiac CT level II re-certification for our providers at a national and local level. The new processes implemented were not meant to supplant other means already in place to achieve level II re-accreditation but rather supplement them by providing additional alternatives for providers to achieve the requisite number of cases reviewed and obtain Cardiac CT CME credit. Providing an asynchronous method for Cardiac CT QA conference attendance allowed providers to engage in the Cardiac CT QA material without having to be present on-site or available during a certain period of time during clinic hours.
Level II Renewal Requirements for Cardiac CT
We were not concerned with implementing additional processes for “live” Cardiac CT case acquisition since all of our providers met or exceeded the 50 case requirement through routine clinical practice at our facilities. Addition of the “hands-on” course allowed for supplementation of additional case review to the practitioner’s log for future level II Cardiac CT re-accreditation. Depending on the number of sessions attended per year, within a 1–3 year period, if needed, these cases could be used to obtain an additional 100 cases for level II Cardiac CT re-accreditation.
The addition of MediaSite technology significantly assisted our providers in attending the QA meetings at a later date and reduced missed opportunities in live attendance. MediaSite offered flexibility and increased access to CME credit for providers by allowing them to view meetings at any time up to one year post-event and answer post-event questions indicative of video completion.10,11 Despite the slightly lower number of conferences and a smaller number of reading providers in the Post-Cardiac CT EI period, attendance at the Cardiac CT QA conferences was significantly higher, presumably due to increased attendance for those opting to view the meeting via MediaSite at a later date and an increased number of live on-site attendees at our central campus.
Distance participation by providers at regional centers via electronic means increased in the Post-Cardiac CT EI period. In the Pre-Cardiac CT EI period, live videoconference accounted for 8% of participation while in the Post-Cardiac CT EI period, the combination of both videoconference and MediaSite accounted for 28%. In the current COVID-19 pandemic, when physical distancing is required, we showed that electronic participation is an effective method for maintaining clinical skills and acquiring CME credits for level II Cardiac CT re-certification for all providers.
Telemedicine and virtual conferencing are becoming the “new normal” in the COVID-19 era.12–14 All major medical societies are opting for virtual meetings in the coming year and possibly years to come. The number of workshops and hands-on experiences available will be limited with this new way of learning and practicing medicine. Our process improvement strategies have made us better equipped to face these challenging times of physical/social distancing and limited travel. We anticipate that with physical distancing practices in place, electronic participation will most likely increase and may become more appealing to participants both centrally and regionally at our facility.
Limitations
Since our distance learning and participation strategy relies heavily on the use of video conferencing technologies, rural or urban healthcare organizations with limited video conferencing equipment, training, or high-speed internet access may find implementation of these strategies challenging. This may improve as local governments implement programs to upgrade the quality and accessibility of internet service, and the option of secure cellular-based video streaming services may surmount this issue.15–16
The “hands-on” process, by necessity, restricts participation and is, therefore, not available for all credentialed readers in our system. Recently, the Society of Cardiovascular Computed Tomography began a weekly 1.5 hour virtual case review with a minimum of 15 cases and 1.5 CME credits for its members. This type of virtual case review format could potentially allow access to additional cases as needed for all providers in our system. We are exploring options for establishing an institutionally-sponsored meeting with a similar case review format and CME credit offering.
The requirements for level II Cardiac CT renewal nationally and at our institution remained consistent throughout the entire study period. As of January 1, 2021 it was anticipated that for level II re-certification with the Board of Cardiovascular Computed tomography (CBCCT) an increase in case mix would be required.17 However during the COVID-19 pandemic, these requirements were not implemented.17 Our institution is aware of the changes occurring in the national level II Cardiac CT renewal process and is ready to address these changes when they arise.
Conclusion
Institutional process improvement efforts reduced the burden of Cardiac CT re-certification efforts by offering more institutional programs including QA conferences, Cardiac CT image review, and CME. In the COVID-19 era, rural and urban healthcare organizations with providers seeking re-accreditation may find considerable provider benefit and engagement using similar methods where maintenance or enhancement of clinical skills is necessary to meet local and national requirements for Cardiac CT level II re-certification.
Acknowledgement
The authors wish to thank the Marshfield Clinic Research Institute’s Office of Scientific Writing for manuscript editing and submission.
Footnotes
Disclosure: The authors have no reported no conflicts of interest or financial support for this work.
- Received December 3, 2020.
- Accepted October 4, 2021.
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