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Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Cindy Stotts
Title	Lead Coordinator
Email	cindy.stotts@commonspirit.org
Phone	(602)-406-4551
User ID	Cindy Stotts
Facility ID	1019

Screen-eligible Rate	0
SDM Documentation Rate	0
Follow-up Rate %	0
Follow-up Rate %	0
Follow-up Rate %	0
Follow-up Rate %	0
Nonmalignant Resection Rate %	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
User ID	Angela Barry
Facility ID	1823

Patients with lung cancer (Stage IB and higher) who receive biomarker testing at the time of diagnosis in	0
Total patients diagnosed with lung cancer (Stage IB and higher) in	281
Biomarker Testing at Diagnosis Rate %	0
Results Documented	Yes
Testing Before Systemic Therapy	Yes
Patients with disease progression on targeted therapy or immunotherapy +/- chemo who receive biomarker testing in	0
Total patients with disease progression on targeted therapy or immunotherapy +/- chemo in	0
Progression Biomarker Testing Rate %	0
Clinical Trials Review	Yes
Referral Testing	Yes
Liquid Biopsy	Yes
Negative Liquid Biopsy Tissue	Yes
Score	6
Qualification Status	Qualified
Checkpoint Inhibitors	Yes
Comprehensive Testing	Yes
Name	Jennifer Finch
Title	VP of Supply Chain
Email	fincjl@mchealth.net
Phone	(270)-745-1224
User ID	Jennifer Finch
Facility ID	2029

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	No
Name	Patricia Spiser
Title	Senior Lung Nurse Navigator
Email	pattispiser@gmail.com
Phone	(432)-221-3415
User ID	Patricia Spiser
Facility ID	2276

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	3,952
Total number of people screened in	3,952
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	3,952
Total number of people who received baseline screening LDCT scans in (with and without SDM)	3,952
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	No
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	2,656
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	3,349
Follow-up Rate %	79
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	225
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	460
Follow-up Rate %	49
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	132
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	460
Follow-up Rate %	29
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	67
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	460
Follow-up Rate %	15
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	17
Stage II	4
Stage III	6
Stage IV	4
Stage I %	55
Stage II %	13
Stage III %	19
Stage IV %	13
Total screen-detected lung cancers	31
Name	Ashley Racette
Title	Physician Assistant
Email	racettea@southcoast.org
Phone	(508)-973-2204
User ID	Ashley Racette
Facility ID	1248

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
If Other, describe your screening eligibility criteria	I-elcap protocol
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	No
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Denise Holford, RN
Title	Oncology Services Nurse Navigator
Email	denise.holford@holycrosshealth.org
Phone	(301)-754-7278
User ID	Denise Holford
Facility ID	1101

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	114
Total number of people screened in	114
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, USPSTF
If Other, describe your screening eligibility criteria	I-ELCAP Study Protocol
Total number of people who received baseline screening LDCT scans in where SDM is documented	58
Total number of people who received baseline screening LDCT scans in (with and without SDM)	58
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	51
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	59
Follow-up Rate %	86
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	1
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	1
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	No
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Denise Holford, RN
Title	Oncology Services Nurse Navigator
Email	denise.holford@holycrosshealth.org
Phone	(301)-754-7278
User ID	Denise Holford
Facility ID	1102

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	718
Total number of people screened in	718
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	718
Total number of people who received baseline screening LDCT scans in (with and without SDM)	718
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Michelle Ottesrabch
Title	Nurse Consultant
Email	michelle_ottersbach@med.unc.edu
Phone	(919)-843-2277
User ID	Michelle Ottersbach
Facility ID	1877

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,151
Total number of people screened in	1,151
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Michelle Ottesrabch
Title	Nurse Consultant
Email	michelle_ottersbach@med.unc.edu
Phone	(919)-843-2277
User ID	Michelle Ottersbach
Facility ID	1875

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	399
Total number of people screened in	399
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	399
Total number of people who received baseline screening LDCT scans in (with and without SDM)	399
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Michelle Ottesrabch
Title	Nurse Consultant
Email	michelle_ottersbach@med.unc.edu
Phone	(919)-843-2277
User ID	Michelle Ottersbach
Facility ID	1878

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	26
Total number of people screened in	26
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	26
Total number of people who received baseline screening LDCT scans in (with and without SDM)	26
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Michelle Ottesrabch
Title	Nurse Consultant
Email	michelle_ottersbach@med.unc.edu
Phone	(919)-843-2277
User ID	Michelle Ottersbach
Facility ID	2042

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	627
Total number of people screened in	714
Screen-eligible Rate	88
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	606
Total number of people who received baseline screening LDCT scans in (with and without SDM)	622
SDM Documentation Rate	97
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	170
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	281
Follow-up Rate %	60
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	14
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	32
Follow-up Rate %	44
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	5
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	9
Follow-up Rate %	56
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	1
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	7
Follow-up Rate %	14
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	80
Total nonsurgical lung biopsies in	156
Nonmalignant/Nondiagnostic Biopsy Rate %	51
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Silvia Lopez
Title	Sr Director Accreditation, Clinical Certification & PI
Email	si.lopez@dhrhealth.com
Phone	(956)-362-7991
User ID	Silvia Lopez
Facility ID	2014

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	738
Total number of people screened in	738
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	145
Total number of people who received baseline screening LDCT scans in (with and without SDM)	145
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	803
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	803
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	62
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	62
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	42
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	42
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	25
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	25
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Leslie Sorenson
Title	Manager, Lung Screening Program
Email	lmsorens@lhs.org
Phone	(503)-413-8446
User ID	Leslie Sorenson
Facility ID	1716

Patient Discussion	Yes
Biomarker Testing	Yes
Comments	NCCN, ASCO, CAP
Medical Oncology	Yes
Select all that apply	NCCN, ASCO
Radiation Oncology	Yes
Select all that apply	ASTRO, NCCN
Thoracic Oncology	Yes
Comments	American Joint Commission on Cancer (AJCC)
Pathology	Yes
Select all that apply	ASCO, CAP, NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Comments	Texas Tumor Registry, National Cancer Databank
Select all that apply	Central or state cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Silvia Lopez
Title	Sr. Director Accreditation, Clinical Certification and PI
Email	si.lopez@dhrhealth.com
Phone	(956)-362-7991
User ID	Silvia Lopez
Facility ID	2014

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	238
Total number of people screened in	238
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	3
Total number of people who received baseline screening LDCT scans in (with and without SDM)	3
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	115
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	115
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	13
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	13
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	6
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	6
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	8
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	8
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Leslie Sorenson
Title	Manager, Lung Cancer Screening
Email	lmsorens@lhs.org
Phone	(503)-413-8446
User ID	Leslie Sorenson
Facility ID	2065

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Neel Chudgar, MD
Title	Assistant Professor - Thoracic Surgery
Email	nchudgar@montefiore.org
Phone	(718)-862-8840
User ID	Maria Serrano
Facility ID	1650

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN, ASCO
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, ASTRO, NCCN
Thoracic Oncology	Yes
Select all that apply	AATS, ACCP, NCCN, STS, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	ASCO, CAP, NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry, Central or state cancer registry, NCI, NPCR, SEER
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Maria Serrano, ANP-BC, AOCNP
Title	Nurse Practitioner - Clinical Coordinator
Email	mserrano@montefiore.org
Phone	(718)-862-8840
User ID	Maria Serrano
Facility ID	1650

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	3,132
Total number of people screened in	3,415
Screen-eligible Rate	92
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,054
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,054
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	2,049
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,715
Follow-up Rate %	75
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	151
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	155
Follow-up Rate %	97
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	54
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	55
Follow-up Rate %	98
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	50
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	50
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	3
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	13
Nonmalignant Resection Rate %	23
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	44
Total nonsurgical lung biopsies in	85
Nonmalignant/Nondiagnostic Biopsy Rate %	52
	Yes
	Yes
Stage I	32
Stage II	5
Stage III	4
Stage I %	78
Stage II %	12
Stage III %	10
Stage IV %	0
Total screen-detected lung cancers	41
Name	Maria Serrano, ANP-BC, AOCNP
Title	Nurse Practitioner - Clinical Coordinator
Email	mserrano@montefiore.org
Phone	(718)-862-8840
User ID	Maria Serrano
Facility ID	1650

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Arissa Munzo
Title	Clinical Programs Manager
Email	arissa.munoz@ascension.org
Phone	(850)-416-6993
User ID	Arissa Munoz
Facility ID	1647

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,820
Total number of people screened in	1,820
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	954
Total number of people who received baseline screening LDCT scans in (with and without SDM)	954
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	644
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,771
Follow-up Rate %	36
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	89
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	98
Follow-up Rate %	91
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	48
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	51
Follow-up Rate %	94
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	39
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	44
Follow-up Rate %	89
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	1
Total nonsurgical lung biopsies in	18
Nonmalignant/Nondiagnostic Biopsy Rate %	6
	Yes
	Yes
Stage I	10
Stage II	2
Stage III	1
Stage IV	5
Stage I %	56
Stage II %	11
Stage III %	6
Stage IV %	28
Total screen-detected lung cancers	18
Name	Arissa Munoz
Title	Clinical Programs Manager
Email	arissa.munoz@ascension.org
Phone	(850)-416-6993
User ID	Arissa Munoz
Facility ID	1644

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Arissa Munoz
Title	Clinical Programs Manager
Email	arissa.munoz@ascension.org
Phone	(850)-416-6993
User ID	Arissa Munoz
Facility ID	1646

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Arissa Munoz
Title	Clinical Programs Manager
Email	arissa.munoz@ascension.org
Phone	(850)-416-6993
User ID	Arissa Munoz
Facility ID	1645

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	757
Total number of people screened in	757
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	185
Total number of people who received baseline screening LDCT scans in (with and without SDM)	185
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	525
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	16
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	1
Follow-up Rate %	1,600
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	14
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	5
Follow-up Rate %	280
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	22
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	4
Follow-up Rate %	550
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	74
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	No
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Brenda Gibler
Title	CMA
Email	brenda.gibler@nmhs.org
Phone	(712)-396-7250
User ID	NatalieJean Ahrens
Facility ID	1813

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	468
Total number of people screened in	468
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	468
Total number of people who received baseline screening LDCT scans in (with and without SDM)	468
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	171
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	388
Follow-up Rate %	44
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	7
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	8
Follow-up Rate %	88
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	7
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	7
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	4
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	5
Follow-up Rate %	80
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	2
Total nonsurgical lung biopsies in	7
Nonmalignant/Nondiagnostic Biopsy Rate %	29
	Yes
	Yes
Stage I	20
Stage II	0
Stage III	20
Stage IV	60
Stage I %	20
Stage II %	0
Stage III %	20
Stage IV %	60
Total screen-detected lung cancers	100
Name	Gregory Donaldson
Title	AVP
Email	gdonalds@jhmc.org
Phone	(718)-206-6158
User ID	Gregory Donaldson
Facility ID	1968

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	6
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	291
LDCT Protocol Compliance Rate %	2
Tracking Adherence	Yes
Select all that apply	Tracking software, Manual tracking (Excel, etc.)
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	3
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	17
Nonmalignant Resection Rate %	18
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	175
Total nonsurgical lung biopsies in patients with IPN in	297
Nonmalignant/Nondiagnostic Biopsy Rate %	59
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Jennifer Finch
Title	VP of Supply Chain
Email	fincjl@mchealth.net
Phone	(270)-745-1224
User ID	Jennifer Finch
Facility ID	2029

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	3,698
Total number of people screened in	3,934
Screen-eligible Rate	94
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	980
Total number of people who received baseline screening LDCT scans in (with and without SDM)	980
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	3,573
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	3,573
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	176
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	176
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	240
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	262
Follow-up Rate %	92
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	66
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	66
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	No
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Michal Barszczewski
Title	Practice Manager
Email	michal.barszczewski@rochesterregional.org
Phone	(518)-256-2037
User ID	Michal Barszczewski
Facility ID	1821

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,058
Total number of people screened in	1,060
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	207
Total number of people who received baseline screening LDCT scans in (with and without SDM)	250
SDM Documentation Rate	83
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	864
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	971
Follow-up Rate %	89
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	34
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	37
Follow-up Rate %	92
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	23
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	24
Follow-up Rate %	96
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	15
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	16
Follow-up Rate %	94
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	6
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	7
Total nonsurgical lung biopsies in	8
Nonmalignant/Nondiagnostic Biopsy Rate %	88
	Yes
	Yes
Stage I	5
Stage II	2
Stage I %	71
Stage II %	29
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	7
Name	Sara Kraus DNP, FNP-BC
Title	Nurse Practitioner, Associate Director of Lung Cancer Screening
Email	sara-kraus@uiowa.edu
Phone	(319)-356-4331
User ID	Sara Kraus
Facility ID	2012

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,110
Total number of people screened in	1,110
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	313
Total number of people who received baseline screening LDCT scans in (with and without SDM)	313
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	981
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	981
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	71
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	71
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	27
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	27
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	21
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	21
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Crystal A Casey
Title	Nurse Navigator
Email	crystal.casey@bhsi.com
Phone	(859)-408-2022
User ID	Crystal Casey
Facility ID	1827

Access to guideline-directed testing for molecular and immune biomarkers with NGS technology in all patients with guideline eligible tumors (when clinically appropriate) to determine eligibility for targeted therapies or immunotherapies.	Yes
Biomarker and PD-L1 results are reviewed and discussed with patients once results are available. Discussion includes the clinical implications and therapeutic options based on these results.	Yes
When appropriate, guideline directed PD-L1 and biomarker testing are integrated into treatment decisions before systemic therapy is initiated.	Yes
In the setting of disease progression on FDA approved therapy, updated PD-L1 and biomarker testing is utilized to identify next therapeutic option.	Yes
In the setting of disease progression, updated PD-L1 and biomarker testing is utilized to confirm need for clinical trial referral when FDA approved therapeutics are not an option.	Yes
Calculated Section Total	5
Qualification Status	Qualified
Rapid on-site evaluation (ROSE), when available to increase diagnostic and molecular yield.	Yes
Utilization of liquid biopsy modalities in the setting of tissue insufficiency or unavailability and points of disease progression.	Yes
Name	Parker Harris
Title	CEO- Administrator
Email	Parker.Harris@BMHCC.org
Phone	(901)-475-5500
User ID	Jasmine Banks
Facility ID	2267

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Parker Harris
Title	CEO-Administrator
Email	Parker.Harris@BMHCC.org
Phone	(901)-475-5500
User ID	Jasmine Banks
Facility ID	2267

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer
Thoracic Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	CAP
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry, Central or state cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	No
Name	Jennifer Finch
Title	VP of Supply Chain
Email	fincjl@mchealth.net
Phone	(270)-745-1224
User ID	Jennifer Finch
Facility ID	2029

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,339
Total number of people screened in	1,352
Screen-eligible Rate	99
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,161
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,165
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	624
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,078
Follow-up Rate %	58
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	81
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	152
Follow-up Rate %	53
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	57
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	85
Follow-up Rate %	67
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	73
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	108
Follow-up Rate %	68
Surgical lung resections with benign (nonmalignant) pathology in	2
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	25
Nonmalignant Resection Rate %	8
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	21
Total nonsurgical lung biopsies in	34
Nonmalignant/Nondiagnostic Biopsy Rate %	62
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Jennifer Finch
Title	VP of Supply Chain
Email	fincjl@mchealth.net
Phone	(270)-745-1224
User ID	Jennifer Finch
Facility ID	2029

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Muhammad Saeed MD FACP
Title	Pulmonary and Critical Care Attending
Email	msaeed@beaconhealthsystem.org
Phone	(267)-283-8828
User ID	Muhammad Saeed
Facility ID	2274

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Muhammad Saeed MD FACP
Title	Pulmonary and Critical Care Attending
Email	msaeed@beoconhealthsystem.org
Phone	(267)-283-8828
User ID	Muhammad Saeed
Facility ID	2274

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	5,000
Total number of people screened in	5,500
Screen-eligible Rate	91
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	5,000
Total number of people who received baseline screening LDCT scans in (with and without SDM)	5,000
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	4,625
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	4,625
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	250
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	250
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	75
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	75
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	50
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	50
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	No
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Diane Horner/Dr. Catherine Sears
Title	NP/MD
Email	dianekhorner@comcast.net
Phone	(317)-997-6952
User ID	Diane Horner
Facility ID	1937

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	857
Total number of people screened in	857
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	857
Total number of people who received baseline screening LDCT scans in (with and without SDM)	857
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	857
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	857
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	11
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	11
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	9
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	9
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	3
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	3
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	5
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	5
Nonmalignant Resection Rate %	100
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	LABANI
Title	COORDINATING MANAGER
Email	DEYL@NYCHHC.ORG
Phone	(718)-918-4505
User ID	labani dey
Facility ID	1992

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	2,524
Total number of people screened in	3,011
Screen-eligible Rate	84
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	583
Total number of people who received baseline screening LDCT scans in (with and without SDM)	583
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	2,428
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,732
Follow-up Rate %	89
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	185
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	203
Follow-up Rate %	91
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	42
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	45
Follow-up Rate %	93
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	85
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	90
Follow-up Rate %	94
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	24
Nonmalignant Resection Rate %	4
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	26
Total nonsurgical lung biopsies in	60
Nonmalignant/Nondiagnostic Biopsy Rate %	43
	Yes
	Yes
Stage I	19
Stage II	3
Stage III	1
Stage IV	1
Stage I %	79
Stage II %	13
Stage III %	4
Stage IV %	4
Total screen-detected lung cancers	24
Name	Brandon Koehler
Title	Lung Cancer Program Manager
Email	brandon.koehler@nmhs.org
Phone	(402)-354-8337
User ID	Brandon Koehler
Facility ID	1029

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Brandon Koehler
Title	Lung Cancer Program Manager
Email	brandon.koehler@nmhs.org
Phone	(402)-354-8337
User ID	Brandon Koehler
Facility ID	1029

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Thoracic Oncology	Yes
Select all that apply	AATS, NCCN, STS, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	CAP, NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry, Central or state cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Brandon Koehler
Title	Lung Cancer Program Manager
Email	brandon.koehler@nmhs.org
Phone	(402)-354-8337
User ID	Brandon Koehler
Facility ID	1029

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Radiation Oncology	Yes
Thoracic Oncology	Yes
Pathology	Yes
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Nathaniel Moulton
Title	Director, Interventional Pulmonology
Email	nathan.moulton@integrishealth.org
Phone	(217)-577-1759
User ID	Nathaniel Moulton
Facility ID	2000

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Nikki Lawrence
Title	Imaging Manager
Email	nikki.lawrence@sutterhealth.org
Phone	(707)-521-4407
User ID	Nikki Lawrence
Facility ID	2271

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Nikki Lawrence
Title	Imaging Manager
Email	nikki.lawrence@sutterhealth.org
Phone	(707)-521-4407
User ID	Nikki Lawrence
Facility ID	2271

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Nikki Lawrence
Title	Imaging Manager
Email	nikki.lawrence@sutterhealth.org
Phone	(707)-521-4407
User ID	Nikki Lawrence
Facility ID	2268

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Nikki Lawrence
Title	Imaging Manager
Email	nikki.lawrence@sutterhealth.org
Phone	(707)-521-4407
User ID	Nikki Lawrence
Facility ID	2268

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	100
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	150
LDCT Protocol Compliance Rate %	67
Tracking Adherence	Yes
Select all that apply	Manual tracking (Excel, etc.), EHR appointment recall system
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	30
Total nonsurgical lung biopsies in patients with IPN in	100
Nonmalignant/Nondiagnostic Biopsy Rate %	30
Comments	Many Histoplasmosis, Carcinoid, Non TB MAI patients are included in the numerator
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Deepankar Sharma, MD
Title	Medical Director, Interventional Pulmonology and Lung Institute
Email	dsharma@crh.org
Phone	(443)-835-5863
User ID	Deepankar Sharma
Facility ID	2063

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,310
Total number of people screened in	1,310
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	300
Total number of people who received baseline screening LDCT scans in (with and without SDM)	300
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	1,010
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,227
Follow-up Rate %	82
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	203
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	213
Follow-up Rate %	95
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	203
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	213
Follow-up Rate %	95
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	203
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	213
Follow-up Rate %	95
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	60
Total nonsurgical lung biopsies in	200
Nonmalignant/Nondiagnostic Biopsy Rate %	30
	No
	Yes
Stage I	53
Stage II	11
Stage III	18
Stage IV	18
Stage I %	53
Stage II %	11
Stage III %	18
Stage IV %	18
Total screen-detected lung cancers	100
Name	Deepankar Sharma
Title	Medical Director, Interventional Pulmonology and Lung Institute
Email	dsharma@crh.org
Phone	(443)-835-5863
User ID	Deepankar Sharma
Facility ID	2063

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	No
Name	Suzanne Crotteau
Title	Director, Imaging
Email	Suzanne.Crotteau@sutterhealth.org
Phone	(510)-727-3008
User ID	Suzanne Crotteau
Facility ID	2272

A patient-centered discussion about the potential benefits and harms of lung cancer treatment occurs at each point of the patient’s cancer care journey.	Yes
Biomarker Testing: Access to and compliance with guideline-directed testing for molecular and immune biomarkers with NGS technology in all patients with guideline-eligible tumors (when clinically appropriate). Using NGS results, consistently identify actionable mutations and eligiblity for guideline-directed targeted therapies or immunotherapies.	Yes
Medical Oncology: Compliance with practice standards for the diagnostic workup, staging, and medical oncology (disease specific) treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Radiation Oncology: Compliance with practice standards for the diagnostic workup, staging, and radiation treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Thoracic Oncology: Compliance with practice standards for the diagnostic workup, staging, and surgical treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Pathology: Comply with practice standards based on evidence, expert consensus, and practice guidelines for pathologic evaluation of malignancies.	Yes
Actively engage or have access to multidisciplinary expert input by way of tumor board or other team-based mechanism, including virtual.	Yes
Commitment and care delivery mechanisms are in place that standardizes consistent communication with patients and their active care providers about test results, diagnostic workup, and management plan.	Yes
Contribute to aggregated collection of relevant data and report to a cancer registry. (hospital, central or state, or special purpose registry, NPCR, NCI, SEER)	Yes
Ask about current smoking status and, as appropriate, advise to quit. Provide or refer for cessation services.	Yes
Calculated Section Total	10
Qualification Status	Qualified
Internal clinical outcomes review and quality improvement process.	Yes
Thoracic Oncologist(s) are board certified thoracic or cardio-thoracic surgeons.	Yes
Name	Parker Harris
Title	CEO-Administrator
Email	Parker.Harris@BMHCC.org
Phone	(901)-475-5500
User ID	Jasmine Banks
Facility ID	2267

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Parker Harris
Title	CEO-Administrator
Email	Parker.Harris@BMHCC.org
Phone	(901)-475-5500
User ID	Jasmine Banks
Facility ID	2267

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	951
Total number of people screened in	973
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	287
Total number of people who received baseline screening LDCT scans in (with and without SDM)	288
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	594
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	915
Follow-up Rate %	65
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	30
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	39
Follow-up Rate %	77
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	50
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	51
Follow-up Rate %	98
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	40
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	41
Follow-up Rate %	98
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	100
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	18
Total nonsurgical lung biopsies in	39
Nonmalignant/Nondiagnostic Biopsy Rate %	46
	Yes
	Yes
Stage I	20
Stage II	0
Stage III	1
Stage IV	0
Stage I %	95
Stage II %	0
Stage III %	5
Stage IV %	0
Total screen-detected lung cancers	21
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1667

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1838

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	522
Total number of people screened in	533
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	142
Total number of people who received baseline screening LDCT scans in (with and without SDM)	143
SDM Documentation Rate	99
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	303
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	434
Follow-up Rate %	70
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	21
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	23
Follow-up Rate %	91
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	13
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	14
Follow-up Rate %	93
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	13
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	13
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	2
Total nonsurgical lung biopsies in	9
Nonmalignant/Nondiagnostic Biopsy Rate %	22
	Yes
	Yes
Stage I	5
Stage II	1
Stage III	0
Stage IV	0
Stage I %	83
Stage II %	17
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	6
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1670

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,140
Total number of people screened in	1,160
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	359
Total number of people who received baseline screening LDCT scans in (with and without SDM)	360
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	586
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	900
Follow-up Rate %	65
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	47
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	51
Follow-up Rate %	92
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	26
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	26
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	24
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	24
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	9
Total nonsurgical lung biopsies in	23
Nonmalignant/Nondiagnostic Biopsy Rate %	39
	Yes
	Yes
Stage I	10
Stage II	2
Stage III	1
Stage IV	1
Stage I %	71
Stage II %	14
Stage III %	7
Stage IV %	7
Total screen-detected lung cancers	14
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1675

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	832
Total number of people screened in	862
Screen-eligible Rate	97
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	227
Total number of people who received baseline screening LDCT scans in (with and without SDM)	229
SDM Documentation Rate	99
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	469
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	714
Follow-up Rate %	66
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	27
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	32
Follow-up Rate %	84
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	16
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	16
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	19
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	20
Follow-up Rate %	95
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	5
Total nonsurgical lung biopsies in	12
Nonmalignant/Nondiagnostic Biopsy Rate %	42
	Yes
	Yes
Stage I	6
Stage II	0
Stage III	1
Stage IV	0
Stage I %	86
Stage II %	0
Stage III %	14
Stage IV %	0
Total screen-detected lung cancers	7
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1672

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	675
Total number of people screened in	687
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	166
Total number of people who received baseline screening LDCT scans in (with and without SDM)	166
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	383
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	187
Follow-up Rate %	205
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	24
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	26
Follow-up Rate %	92
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	16
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	16
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	21
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	21
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	7
Total nonsurgical lung biopsies in	22
Nonmalignant/Nondiagnostic Biopsy Rate %	32
	Yes
	Yes
Stage I	12
Stage II	0
Stage III	1
Stage IV	2
Stage I %	80
Stage II %	0
Stage III %	7
Stage IV %	13
Total screen-detected lung cancers	15
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1673

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	685
Total number of people screened in	700
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	186
Total number of people who received baseline screening LDCT scans in (with and without SDM)	186
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	363
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	609
Follow-up Rate %	60
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	19
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	19
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	23
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	25
Follow-up Rate %	92
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	13
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	13
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	3
Total nonsurgical lung biopsies in	11
Nonmalignant/Nondiagnostic Biopsy Rate %	27
	Yes
	Yes
Stage I	6
Stage II	1
Stage III	1
Stage IV	0
Stage I %	75
Stage II %	13
Stage III %	13
Stage IV %	0
Total screen-detected lung cancers	8
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1668

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	536
Total number of people screened in	549
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	150
Total number of people who received baseline screening LDCT scans in (with and without SDM)	150
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	309
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	484
Follow-up Rate %	64
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	14
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	16
Follow-up Rate %	88
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	10
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	12
Follow-up Rate %	83
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	14
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	15
Follow-up Rate %	93
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	100
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	5
Total nonsurgical lung biopsies in	13
Nonmalignant/Nondiagnostic Biopsy Rate %	38
	Yes
	Yes
Stage I	7
Stage II	0
Stage III	0
Stage IV	1
Stage I %	88
Stage II %	0
Stage III %	0
Stage IV %	13
Total screen-detected lung cancers	8
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1671

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	717
Total number of people screened in	741
Screen-eligible Rate	97
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	197
Total number of people who received baseline screening LDCT scans in (with and without SDM)	205
SDM Documentation Rate	96
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	389
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	599
Follow-up Rate %	65
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	20
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	21
Follow-up Rate %	95
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	10
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	10
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	8
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	8
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	6
Total nonsurgical lung biopsies in	12
Nonmalignant/Nondiagnostic Biopsy Rate %	50
	Yes
	Yes
Stage I	4
Stage II	0
Stage III	2
Stage IV	0
Stage I %	67
Stage II %	0
Stage III %	33
Stage IV %	0
Total screen-detected lung cancers	6
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1837

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	613
Total number of people screened in	630
Screen-eligible Rate	97
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	162
Total number of people who received baseline screening LDCT scans in (with and without SDM)	162
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	363
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	585
Follow-up Rate %	62
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	24
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	24
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	10
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	12
Follow-up Rate %	83
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	12
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	13
Follow-up Rate %	92
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	7
Total nonsurgical lung biopsies in	18
Nonmalignant/Nondiagnostic Biopsy Rate %	39
	Yes
	Yes
Stage I	8
Stage II	0
Stage III	2
Stage IV	0
Stage I %	80
Stage II %	0
Stage III %	20
Stage IV %	0
Total screen-detected lung cancers	10
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1840

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	419
Total number of people screened in	433
Screen-eligible Rate	97
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	113
Total number of people who received baseline screening LDCT scans in (with and without SDM)	116
SDM Documentation Rate	97
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	260
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	404
Follow-up Rate %	64
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	12
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	13
Follow-up Rate %	92
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	12
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	12
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	6
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	6
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	4
Total nonsurgical lung biopsies in	4
Nonmalignant/Nondiagnostic Biopsy Rate %	100
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1669

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	342
Total number of people screened in	355
Screen-eligible Rate	96
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	89
Total number of people who received baseline screening LDCT scans in (with and without SDM)	94
SDM Documentation Rate	95
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	237
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	356
Follow-up Rate %	67
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	13
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	14
Follow-up Rate %	93
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	4
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	5
Follow-up Rate %	80
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	4
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	4
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	1
Total nonsurgical lung biopsies in	5
Nonmalignant/Nondiagnostic Biopsy Rate %	20
	Yes
	Yes
Stage I	3
Stage II	1
Stage III	0
Stage IV	0
Stage I %	75
Stage II %	25
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	4
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1749

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	196
Total number of people screened in	200
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	43
Total number of people who received baseline screening LDCT scans in (with and without SDM)	43
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	114
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	174
Follow-up Rate %	66
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	9
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	9
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	2
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	2
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	4
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	4
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	2
Total nonsurgical lung biopsies in	7
Nonmalignant/Nondiagnostic Biopsy Rate %	29
	Yes
	Yes
Stage I	4
Stage II	1
Stage III	0
Stage IV	0
Stage I %	80
Stage II %	20
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	5
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1800

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	495
Total number of people screened in	510
Screen-eligible Rate	97
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	146
Total number of people who received baseline screening LDCT scans in (with and without SDM)	146
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	280
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	462
Follow-up Rate %	61
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	15
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	19
Follow-up Rate %	79
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	20
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	21
Follow-up Rate %	95
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	14
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	14
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	6
Total nonsurgical lung biopsies in	9
Nonmalignant/Nondiagnostic Biopsy Rate %	67
	Yes
	Yes
Stage I	2
Stage II	0
Stage III	0
Stage IV	2
Stage I %	50
Stage II %	0
Stage III %	0
Stage IV %	50
Total screen-detected lung cancers	4
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1742

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	862
Total number of people screened in	880
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	257
Total number of people who received baseline screening LDCT scans in (with and without SDM)	257
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	511
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	751
Follow-up Rate %	68
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	23
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	28
Follow-up Rate %	82
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	18
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	21
Follow-up Rate %	86
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	20
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	20
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	13
Total nonsurgical lung biopsies in	26
Nonmalignant/Nondiagnostic Biopsy Rate %	50
	Yes
	Yes
Stage I	9
Stage II	1
Stage III	2
Stage IV	0
Stage I %	75
Stage II %	8
Stage III %	17
Stage IV %	0
Total screen-detected lung cancers	12
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1799

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	502
Total number of people screened in	512
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	148
Total number of people who received baseline screening LDCT scans in (with and without SDM)	148
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	279
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	424
Follow-up Rate %	66
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	13
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	16
Follow-up Rate %	81
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	14
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	16
Follow-up Rate %	88
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	13
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	13
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	8
Total nonsurgical lung biopsies in	23
Nonmalignant/Nondiagnostic Biopsy Rate %	35
	Yes
	Yes
Stage I	13
Stage II	0
Stage III	1
Stage IV	0
Stage I %	93
Stage II %	0
Stage III %	7
Stage IV %	0
Total screen-detected lung cancers	14
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1743

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	327
Total number of people screened in	335
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	87
Total number of people who received baseline screening LDCT scans in (with and without SDM)	87
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	194
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	305
Follow-up Rate %	64
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	9
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	10
Follow-up Rate %	90
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	9
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	9
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	2
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	2
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	3
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	3
Stage II	0
Stage III	0
Stage IV	0
Stage I %	100
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	3
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1839

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	432
Total number of people screened in	443
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	102
Total number of people who received baseline screening LDCT scans in (with and without SDM)	103
SDM Documentation Rate	99
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	295
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	434
Follow-up Rate %	68
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	19
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	20
Follow-up Rate %	95
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	10
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	10
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	8
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	8
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	5
Total nonsurgical lung biopsies in	14
Nonmalignant/Nondiagnostic Biopsy Rate %	36
	Yes
Stage I	6
Stage II	1
Stage III	0
Stage IV	1
Stage I %	75
Stage II %	13
Stage III %	0
Stage IV %	13
Total screen-detected lung cancers	8
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1797

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	NCCN, ACCP
Radiation Oncology	Yes
Select all that apply	NCCN
Thoracic Oncology	Yes
Select all that apply	ACCP, NCCN
Pathology	Yes
Select all that apply	ASCO, NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Sadie Davidson
Title	Executive Director of Operations
Email	sdavidson@iowaclinic.com
Phone	(712)-260-8104
User ID	Sadie Forey
Facility ID	1986

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	127
Total number of people screened in	133
Screen-eligible Rate	95
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	39
Total number of people who received baseline screening LDCT scans in (with and without SDM)	39
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	94
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	151
Follow-up Rate %	62
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	2
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	3
Follow-up Rate %	67
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	1
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	1
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	1
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	1
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	1
Total nonsurgical lung biopsies in	1
Nonmalignant/Nondiagnostic Biopsy Rate %	100
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1854

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	578
Total number of people screened in	594
Screen-eligible Rate	97
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	148
Total number of people who received baseline screening LDCT scans in (with and without SDM)	157
SDM Documentation Rate	94
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	330
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	499
Follow-up Rate %	66
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	24
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	27
Follow-up Rate %	89
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	20
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	22
Follow-up Rate %	91
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	12
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	13
Follow-up Rate %	92
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	2
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	5
Total nonsurgical lung biopsies in	14
Nonmalignant/Nondiagnostic Biopsy Rate %	36
	Yes
	Yes
Stage I	8
Stage II	0
Stage III	2
Stage IV	2
Stage I %	67
Stage II %	0
Stage III %	17
Stage IV %	17
Total screen-detected lung cancers	12
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1798

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	927
Total number of people screened in	945
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	213
Total number of people who received baseline screening LDCT scans in (with and without SDM)	213
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	563
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	801
Follow-up Rate %	70
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	33
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	36
Follow-up Rate %	92
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	24
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	25
Follow-up Rate %	96
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	22
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	23
Follow-up Rate %	96
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	8
Total nonsurgical lung biopsies in	24
Nonmalignant/Nondiagnostic Biopsy Rate %	33
	Yes
	Yes
Stage I	11
Stage II	0
Stage III	2
Stage IV	2
Stage I %	73
Stage II %	0
Stage III %	13
Stage IV %	13
Total screen-detected lung cancers	15
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1796

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,123
Total number of people screened in	1,155
Screen-eligible Rate	97
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	281
Total number of people who received baseline screening LDCT scans in (with and without SDM)	285
SDM Documentation Rate	99
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	670
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,025
Follow-up Rate %	65
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	54
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	62
Follow-up Rate %	87
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	34
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	35
Follow-up Rate %	97
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	22
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	22
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	2
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	15
Total nonsurgical lung biopsies in	39
Nonmalignant/Nondiagnostic Biopsy Rate %	38
	Yes
	Yes
Stage I	16
Stage II	3
Stage III	2
Stage IV	3
Stage I %	67
Stage II %	13
Stage III %	8
Stage IV %	13
Total screen-detected lung cancers	24
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1674

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	531
Total number of people screened in	685
Screen-eligible Rate	78
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	360
Total number of people who received baseline screening LDCT scans in (with and without SDM)	365
SDM Documentation Rate	99
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	248
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	549
Follow-up Rate %	45
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	31
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	46
Follow-up Rate %	67
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	22
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	27
Follow-up Rate %	81
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	18
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	18
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	5
Total nonsurgical lung biopsies in	14
Nonmalignant/Nondiagnostic Biopsy Rate %	36
	Yes
	Yes
Stage I	10
Stage II	0
Stage III	0
Stage IV	0
Stage I %	100
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	10
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1795

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	801
Total number of people screened in	911
Screen-eligible Rate	88
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	417
Total number of people who received baseline screening LDCT scans in (with and without SDM)	418
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	439
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	769
Follow-up Rate %	57
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	38
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	49
Follow-up Rate %	78
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	20
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	23
Follow-up Rate %	87
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	14
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	16
Follow-up Rate %	88
Surgical lung resections with benign (nonmalignant) pathology in	2
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	67
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	17
Total nonsurgical lung biopsies in	30
Nonmalignant/Nondiagnostic Biopsy Rate %	57
	Yes
	Yes
Stage I	6
Stage II	3
Stage III	3
Stage IV	2
Stage I %	43
Stage II %	21
Stage III %	21
Stage IV %	14
Total screen-detected lung cancers	14
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1768

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	976
Total number of people screened in	1,125
Screen-eligible Rate	87
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	432
Total number of people who received baseline screening LDCT scans in (with and without SDM)	435
SDM Documentation Rate	99
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	582
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,019
Follow-up Rate %	57
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	44
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	55
Follow-up Rate %	80
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	16
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	18
Follow-up Rate %	89
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	19
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	22
Follow-up Rate %	86
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	33
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	9
Total nonsurgical lung biopsies in	15
Nonmalignant/Nondiagnostic Biopsy Rate %	60
	Yes
	Yes
Stage I	2
Stage II	1
Stage III	2
Stage IV	2
Stage I %	29
Stage II %	14
Stage III %	29
Stage IV %	29
Total screen-detected lung cancers	7
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1767

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,670
Total number of people screened in	1,794
Screen-eligible Rate	93
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	632
Total number of people who received baseline screening LDCT scans in (with and without SDM)	638
SDM Documentation Rate	99
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	956
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,546
Follow-up Rate %	62
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	59
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	69
Follow-up Rate %	86
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	34
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	35
Follow-up Rate %	97
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	30
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	31
Follow-up Rate %	97
Surgical lung resections with benign (nonmalignant) pathology in	2
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	67
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	15
Total nonsurgical lung biopsies in	42
Nonmalignant/Nondiagnostic Biopsy Rate %	36
	Yes
	Yes
Stage I	14
Stage II	0
Stage III	7
Stage IV	4
Stage I %	56
Stage II %	0
Stage III %	28
Stage IV %	16
Total screen-detected lung cancers	25
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1691

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	700
Total number of people screened in	754
Screen-eligible Rate	93
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	282
Total number of people who received baseline screening LDCT scans in (with and without SDM)	282
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	379
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	714
Follow-up Rate %	53
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	27
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	34
Follow-up Rate %	79
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	16
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	20
Follow-up Rate %	80
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	10
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	11
Follow-up Rate %	91
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	11
Total nonsurgical lung biopsies in	21
Nonmalignant/Nondiagnostic Biopsy Rate %	52
	Yes
	Yes
Stage I	9
Stage II	0
Stage III	2
Stage IV	1
Stage I %	75
Stage II %	0
Stage III %	17
Stage IV %	8
Total screen-detected lung cancers	12
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1793

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,063
Total number of people screened in	1,183
Screen-eligible Rate	90
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	391
Total number of people who received baseline screening LDCT scans in (with and without SDM)	393
SDM Documentation Rate	99
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	647
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,088
Follow-up Rate %	59
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	53
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	65
Follow-up Rate %	82
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	28
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	32
Follow-up Rate %	88
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	10
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	12
Follow-up Rate %	83
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	2
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	10
Total nonsurgical lung biopsies in	33
Nonmalignant/Nondiagnostic Biopsy Rate %	30
	Yes
	Yes
Stage I	13
Stage II	2
Stage III	3
Stage IV	4
Stage I %	59
Stage II %	9
Stage III %	14
Stage IV %	18
Total screen-detected lung cancers	22
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1706

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,057
Total number of people screened in	1,148
Screen-eligible Rate	92
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	440
Total number of people who received baseline screening LDCT scans in (with and without SDM)	454
SDM Documentation Rate	97
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	545
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,027
Follow-up Rate %	53
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	88
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	114
Follow-up Rate %	77
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	33
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	37
Follow-up Rate %	89
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	21
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	21
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	17
Total nonsurgical lung biopsies in	25
Nonmalignant/Nondiagnostic Biopsy Rate %	68
	Yes
	Yes
Stage I	9
Stage II	0
Stage III	1
Stage IV	0
Stage I %	90
Stage II %	0
Stage III %	10
Stage IV %	0
Total screen-detected lung cancers	10
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1808

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	985
Total number of people screened in	1,127
Screen-eligible Rate	87
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	473
Total number of people who received baseline screening LDCT scans in (with and without SDM)	474
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	551
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	986
Follow-up Rate %	56
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	37
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	45
Follow-up Rate %	82
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	27
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	29
Follow-up Rate %	93
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	23
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	23
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	33
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	5
Total nonsurgical lung biopsies in	21
Nonmalignant/Nondiagnostic Biopsy Rate %	24
	Yes
	Yes
Stage I	9
Stage II	3
Stage III	3
Stage IV	0
Stage I %	60
Stage II %	20
Stage III %	20
Stage IV %	0
Total screen-detected lung cancers	15
Name	Meghan McHugh
Title	manager clinical cancer services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1693

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,949
Total number of people screened in	2,250
Screen-eligible Rate	87
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	8,814
Total number of people who received baseline screening LDCT scans in (with and without SDM)	8,886
SDM Documentation Rate	99
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	1,002
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,994
Follow-up Rate %	50
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	110
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	148
Follow-up Rate %	74
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	57
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	67
Follow-up Rate %	85
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	41
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	42
Follow-up Rate %	98
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	26
Total nonsurgical lung biopsies in	54
Nonmalignant/Nondiagnostic Biopsy Rate %	48
	Yes
	Yes
Stage I	18
Stage II	2
Stage III	5
Stage IV	1
Stage I %	69
Stage II %	8
Stage III %	19
Stage IV %	4
Total screen-detected lung cancers	26
Name	Meghan McHugh
Title	Manager Clinical Cancer Services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1658

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software, EHR appointment recall system
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	2
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	41
Total nonsurgical lung biopsies in patients with IPN in	90
Nonmalignant/Nondiagnostic Biopsy Rate %	46
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of Lung Cancer Screening and Incidental Lung Nodules
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1616

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Comments	Confirmed with physician leaders that we do abide by this protocol, but we do not track this information
Tracking Adherence	Yes
Select all that apply	Manual tracking (Excel, etc.)
Outcomes Review	No
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	0
Total nonsurgical lung biopsies in patients with IPN in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Comments	We do not actively track this information - not sure how to pull
Score	5
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Identification of IPNs on imaging by AI
Name	Brett Wilkosz
Title	Program Manager
Email	brett.wilkosz@adventhealth.com
Phone	(813)-416-4379
User ID	Brett Wilkosz
Facility ID	1935

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software, EHR appointment recall system
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	0
Total nonsurgical lung biopsies in patients with IPN in	2
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of Incidental Lung Nodule and Lung Cancer Screening Programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1606

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software, EHR appointment recall system
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	5
Total nonsurgical lung biopsies in patients with IPN in	13
Nonmalignant/Nondiagnostic Biopsy Rate %	38
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of Incidental Lung Nodules & Lung Cancer Screening
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1607

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software, EHR appointment recall system
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	4
Total nonsurgical lung biopsies in patients with IPN in	9
Nonmalignant/Nondiagnostic Biopsy Rate %	44
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of Incidental Lung Nodules & Lung Cancer Screening
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1605

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software, EHR appointment recall system
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	1
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	6
Nonmalignant Resection Rate %	17
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	23
Total nonsurgical lung biopsies in patients with IPN in	55
Nonmalignant/Nondiagnostic Biopsy Rate %	42
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of Incidental Lung Nodules and Lung Cancer Screening
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1604

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software, EHR appointment recall system
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	3
Total nonsurgical lung biopsies in patients with IPN in	9
Nonmalignant/Nondiagnostic Biopsy Rate %	33
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of Incidental Lung Nodules and Lung Cancer Screening Programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1617

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software, EHR appointment recall system
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	2
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	5
Nonmalignant Resection Rate %	40
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	23
Total nonsurgical lung biopsies in patients with IPN in	79
Nonmalignant/Nondiagnostic Biopsy Rate %	29
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of Incidental Lung Nodules & Lung Cancer Screening Programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1609

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software, EHR appointment recall system
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	21
Total nonsurgical lung biopsies in patients with IPN in	48
Nonmalignant/Nondiagnostic Biopsy Rate %	44
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of Incidental Lung Nodules & Lung Cancer Screening
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1610

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software, EHR appointment recall system
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	14
Total nonsurgical lung biopsies in patients with IPN in	44
Nonmalignant/Nondiagnostic Biopsy Rate %	32
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of Lung Cancer Screening and Incidental Lung Nodule Program
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1622

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN, ASCO
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, ASTRO, NCCN
Thoracic Oncology	Yes
Select all that apply	NCCN, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	ASCO, CAP, NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	kimberly pullen
Title	Lung Navigator
Email	kmbob1@yahoo.com
Phone	(571)-472-1423
User ID	Kimberly Pullen
Facility ID	1017

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	2,059
Total number of people screened in	2,392
Screen-eligible Rate	86
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	630
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,781
Follow-up Rate %	35
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	45
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	123
Follow-up Rate %	37
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	13
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	52
Follow-up Rate %	25
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	18
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	69
Follow-up Rate %	26
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	2
Stage II	1
Stage III	5
Stage IV	0
Stage I %	25
Stage II %	13
Stage III %	63
Stage IV %	0
Total screen-detected lung cancers	8
Name	Brett Wilkosz
Title	Program Manager
Email	brett.wilkosz@adventhealth.com
Phone	(813)-416-4379
User ID	Brett Wilkosz
Facility ID	1935

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	4
Total nonsurgical lung biopsies in patients with IPN in	17
Nonmalignant/Nondiagnostic Biopsy Rate %	24
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of Incidentals and Lung Cancer Screening Program
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1621

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software, EHR appointment recall system
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	14
Total nonsurgical lung biopsies in patients with IPN in	63
Nonmalignant/Nondiagnostic Biopsy Rate %	22
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of Incidental Lung Nodule Program and Lung Cancer Screening
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1614

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software, EHR appointment recall system
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	12
Total nonsurgical lung biopsies in patients with IPN in	22
Nonmalignant/Nondiagnostic Biopsy Rate %	55
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of Incidental Lung Nodules and Lung Cancer Screening
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1608

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software, EHR appointment recall system
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	24
Total nonsurgical lung biopsies in patients with IPN in	59
Nonmalignant/Nondiagnostic Biopsy Rate %	41
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of Incidiental Lung Nodules and Lung Cancer Screening
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1603

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software, EHR appointment recall system
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	5
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	27
Total nonsurgical lung biopsies in patients with IPN in	110
Nonmalignant/Nondiagnostic Biopsy Rate %	25
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of Incidental Lung Nodule Program and Lung Cancer Screening
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1618

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	759
Total number of people screened in	759
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	300
Total number of people who received baseline screening LDCT scans in (with and without SDM)	300
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	283
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	283
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	57
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	57
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	71
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	71
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	10
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	10
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	2
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	200
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	3
Total nonsurgical lung biopsies in	4
Nonmalignant/Nondiagnostic Biopsy Rate %	75
	No
	Yes
Stage I	1
Stage I %	100
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	1
Name	Nancy cerisier
Title	FNP Lung Cancer Screening Navigator
Email	CERISIEN@NYCHHC.ORG
Phone	(718)-963-8000
User ID	Nancy Cerisien
Facility ID	1997

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	652
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	250
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	342
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	29
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	38
Follow-up Rate %	76
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	31
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	33
Follow-up Rate %	94
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	10
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	10
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	15
Total nonsurgical lung biopsies in	14
Nonmalignant/Nondiagnostic Biopsy Rate %	107
	Yes
	No
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Erika Smith
Title	Lung Screen Navigator
Email	erika.smith@nychhc.org
Phone	(718)-245-8976
User ID	Erika Smith
Facility ID	1993

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Radiation Oncology	Yes
Thoracic Oncology	Yes
Pathology	Yes
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Special-purpose (internal or external) registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Diane Horner
Title	NP
Email	dianekhorner@comcast.net
Phone	(317)-997-6952
User ID	Diane Horner
Facility ID	1937

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	740
Total number of people screened in	740
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	253
Total number of people who received baseline screening LDCT scans in (with and without SDM)	253
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	442
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	647
Follow-up Rate %	68
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	22
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	28
Follow-up Rate %	79
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	18
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	25
Follow-up Rate %	72
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	6
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	10
Follow-up Rate %	60
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	14
Stage II	0
Stage III	0
Stage IV	2
Stage I %	88
Stage II %	0
Stage III %	0
Stage IV %	13
Total screen-detected lung cancers	16
Name	Janine Caswell
Title	Program Coordinator
Email	caswellj@upstate.edu
Phone	(315)-867-9036
User ID	Janine Caswell
Facility ID	1062

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,773
Total number of people screened in	1,773
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	331
Total number of people who received baseline screening LDCT scans in (with and without SDM)	331
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	1,150
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,402
Follow-up Rate %	82
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	115
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	152
Follow-up Rate %	76
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	65
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	80
Follow-up Rate %	81
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	40
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	63
Follow-up Rate %	63
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	21
Total nonsurgical lung biopsies in	21
Nonmalignant/Nondiagnostic Biopsy Rate %	100
	Yes
	Yes
Stage I	8
Stage II	3
Stage III	5
Stage IV	5
Stage I %	38
Stage II %	14
Stage III %	24
Stage IV %	24
Total screen-detected lung cancers	21
Name	Bridget Switzer
Title	RN
Email	bridget.switzer@bjc.org
Phone	(636)-578-4883
User ID	Bridget Switzer
Facility ID	2004

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	657
Total number of people screened in	657
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	82
Total number of people who received baseline screening LDCT scans in (with and without SDM)	82
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	476
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	503
Follow-up Rate %	95
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	128
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	156
Follow-up Rate %	82
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	56
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	60
Follow-up Rate %	93
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	20
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	28
Follow-up Rate %	71
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	4
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	4
Stage I %	100
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	4
Name	Bridget Switzer
Title	nurse Navigator
Email	bridget.switzer@bjc.org
Phone	(636)-578-4883
User ID	Bridget Switzer
Facility ID	2002

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	770
Total number of people screened in	770
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	103
Total number of people who received baseline screening LDCT scans in (with and without SDM)	103
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	576
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	770
Follow-up Rate %	75
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	29
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	66
Follow-up Rate %	44
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	55
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	56
Follow-up Rate %	98
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	36
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	40
Follow-up Rate %	90
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	12
Total nonsurgical lung biopsies in	12
Nonmalignant/Nondiagnostic Biopsy Rate %	100
	Yes
	Yes
Stage I	6
Stage II	4
Stage III	1
Stage IV	1
Stage I %	50
Stage II %	33
Stage III %	8
Stage IV %	8
Total screen-detected lung cancers	12
Name	Bridget Switzer
Title	Nurse Navigator
Email	bridget.switzer@bjc.org
Phone	(636)-578-4883
User ID	Bridget Switzer
Facility ID	2003

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,728
Total number of people screened in	1,728
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	203
Total number of people who received baseline screening LDCT scans in (with and without SDM)	203
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	1,100
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,330
Follow-up Rate %	83
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	120
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	140
Follow-up Rate %	86
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	90
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	112
Follow-up Rate %	80
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	12
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	15
Follow-up Rate %	80
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	7
Nonmalignant Resection Rate %	14
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	10
Total nonsurgical lung biopsies in	80
Nonmalignant/Nondiagnostic Biopsy Rate %	13
	Yes
	Yes
Stage I	10
Stage II	2
Stage III	4
Stage IV	2
Stage I %	56
Stage II %	11
Stage III %	22
Stage IV %	11
Total screen-detected lung cancers	18
Name	Bridget Switzer
Title	RN
Email	bridget.switzer@bjc.org
Phone	(636)-578-4883
User ID	Bridget Switzer
Facility ID	2001

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,681
Total number of people screened in	1,681
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	666
Total number of people who received baseline screening LDCT scans in (with and without SDM)	666
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	664
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,015
Follow-up Rate %	65
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	44
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	46
Follow-up Rate %	96
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	56
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	58
Follow-up Rate %	97
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	11
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	13
Follow-up Rate %	85
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	18
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	3
Total nonsurgical lung biopsies in	23
Nonmalignant/Nondiagnostic Biopsy Rate %	13
	Yes
	Yes
Stage I	17
Stage II	3
Stage III	1
Stage IV	2
Stage I %	74
Stage II %	13
Stage III %	4
Stage IV %	9
Total screen-detected lung cancers	23
Name	Denise Wojcik
Title	CT LCS Patient Care Coordinator
Email	Denise.wojcik@nm.org
Phone	(312)-926-9377
User ID	Denise Wojcik
Facility ID	1752

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN, ASCO
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Thoracic Oncology	Yes
Select all that apply	NCCN, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	ASCO, NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Central or state cancer registry, Special-purpose (internal or external) registry, SEER
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Ashley LeBlanc
Title	Regional Service Line Nurse Manager
Email	Ashley.LeBlanc@TrinityHealthOfNE.org
Phone	(413)-748-9629
User ID	Ashley LeBlanc
Facility ID	1382

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	671
Total number of people screened in	727
Screen-eligible Rate	92
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	502
Total number of people who received baseline screening LDCT scans in (with and without SDM)	502
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	474
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	596
Follow-up Rate %	80
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	14
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	16
Follow-up Rate %	88
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	7
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	8
Follow-up Rate %	88
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	4
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	4
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	4
Total nonsurgical lung biopsies in	10
Nonmalignant/Nondiagnostic Biopsy Rate %	40
	No
	Yes
Stage I	2
Stage II	2
Stage III	0
Stage IV	1
Stage I %	40
Stage II %	40
Stage III %	0
Stage IV %	20
Total screen-detected lung cancers	5
Name	Rinu
Title	NP
Email	joser5@nychhc.org
Phone	(718)-883-3717
User ID	Rinu Jose
Facility ID	1996

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	469
Total number of people screened in	469
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN
Total number of people who received baseline screening LDCT scans in where SDM is documented	221
Total number of people who received baseline screening LDCT scans in (with and without SDM)	221
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	405
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	405
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	18
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	18
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	12
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	12
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	22
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	22
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Ann Maddox
Title	NP Clinical Coordinator
Email	ann.maddox@northside.com
Phone	(706)-231-1929
User ID	Ann Maddox
Facility ID	1923

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	564
Total number of people screened in	564
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN
Total number of people who received baseline screening LDCT scans in where SDM is documented	286
Total number of people who received baseline screening LDCT scans in (with and without SDM)	286
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	507
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	507
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	25
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	25
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	12
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	12
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	10
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	10
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Ann Maddox
Title	NP Clinical Coordinator
Email	ann.maddox@northside.com
Phone	(706)-231-1929
User ID	Ann Maddox
Facility ID	1926

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	228
Total number of people screened in	228
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN
Total number of people who received baseline screening LDCT scans in where SDM is documented	61
Total number of people who received baseline screening LDCT scans in (with and without SDM)	61
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	266
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	266
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	7
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	7
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	11
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	11
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	3
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	3
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Ann Maddox
Title	NP Clinical Coordinator
Email	ann.maddox@northside.com
Phone	(706)-231-1929
User ID	Ann Maddox
Facility ID	1924

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,990
Total number of people screened in	1,990
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,990
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,990
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	1,774
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,774
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	79
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	79
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	49
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	49
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	66
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	66
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Ann Maddox
Title	NP Clinical Coordinator
Email	ann.maddox@northside.com
Phone	(706)-231-1929
User ID	Ann Maddox
Facility ID	1009

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	NCCN
Radiation Oncology	Yes
Select all that apply	NCCN
Thoracic Oncology	Yes
Select all that apply	NCCN
Pathology	Yes
Select all that apply	NCCN
Multidisciplinary Team	Yes
Comments	every Thursday morning
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Central or state cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Sarah F. Groce, AGAC-NP
Title	Chest Center Lead APP, AGAC NP
Email	sarah.groce@conehealth.com
Phone	(336)-555-8921
User ID	Sarah Groce
Facility ID	1713

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	3,740
Total number of people screened in	3,740
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, USPSTF
If Other, describe your screening eligibility criteria	CMS followed for age requirements
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,430
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,430
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Sarah F. Groce,
Title	AGAC-NP
Email	sarah.groce@conehealth.com
Phone	(336)-522-8921
User ID	Sarah Groce
Facility ID	1713

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	533
Total number of people screened in	570
Screen-eligible Rate	94
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	164
Total number of people who received baseline screening LDCT scans in (with and without SDM)	164
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	439
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	493
Follow-up Rate %	89
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	39
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	49
Follow-up Rate %	80
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	19
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	22
Follow-up Rate %	86
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	11
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	21
Follow-up Rate %	52
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	1
Total nonsurgical lung biopsies in	4
Nonmalignant/Nondiagnostic Biopsy Rate %	25
	Yes
	Yes
Stage I	1
Stage II	2
Stage IV	1
Stage I %	25
Stage II %	50
Stage III %	0
Stage IV %	25
Total screen-detected lung cancers	4
Name	Hillary Knowles
Title	Lung Screening Navigator
Email	hillary_knowles@rush.edu
Phone	(630)-978-4989
User ID	Hillary Knowles
Facility ID	1868

Access to guideline-directed testing for molecular and immune biomarkers with NGS technology in all patients with guideline eligible tumors (when clinically appropriate) to determine eligibility for targeted therapies or immunotherapies.	Yes
Comments	Yes, we are currently ordering Tempus xT tissue MGPT (multi gene panel testing) for all NSCLC stage IB thru IV. This includes 648 genes, all biomarkers that are guideline recommended for NSCLC adeno and squamous cell carcinoma, including: EGFR mutation (category 1), ALK (category 1), RET (category 1), KRAS, ROS1, BRAF, NTRK1/2/3, MET exon 14 skipping, ERBB2 (HER2), and NRG1  HER2 (by IHC) and HGF receptor (c-Met) by IHC — added if tissue allows, after prioritizing PD-L1 and MGPT  PD-L1 testing (category 1)  Testing methodology and principles: We use the large panel testing that identifies all NSCL-20 biomarkers in a single assay optimally also capturing emerging biomarkers; We do include RNA-based NGS to improve detection of fusions (e.g., NRG1, RET, ROS1).  We use a CLIA-accredited laboratory; Tempus is our preferred but we offer other options. Specimen and ctDNA considerations: When possible and clinically relevant for more advanced disease, we send concurrent tissue and plasma (ctDNA), All tumor tests with matched tumor normal are screened for incidental germline mutations and those are reviewed by a licensed and board -certified genetic counselor who contacts the patient to explain next steps including genetic counseling appt and validated testing. If EGFR T790M is found without prior EGFR TKI exposure, genetic counseling and possible germline testing are warranted. Consider genetic counseling referral for any pathogenic variant on somatic testing raising concern for a germline predisposition syndrome. Our rate of incidental germline finding is 7.3% over the last 6 years and we published this data. The following algorithm summarizes the NCCN biomarker testing pathway by histology, and the companion page maps each positive result to its treatment reference page. We follow these guidelines.
Biomarker and PD-L1 results are reviewed and discussed with patients once results are available. Discussion includes the clinical implications and therapeutic options based on these results.	Yes
Comments	Yes, our medical oncologists review the testing with patients and include patient in shared decision making based on biomarker testing. All of our tumor genomic profile testing (tissue and liquid) is Epic integrated thru Aura, so patients get the results in MyChart the same time that that oncology team does.
When appropriate, guideline directed PD-L1 and biomarker testing are integrated into treatment decisions before systemic therapy is initiated.	Yes
In the setting of disease progression on FDA approved therapy, updated PD-L1 and biomarker testing is utilized to identify next therapeutic option.	Yes
Comments	Yes, at time of progression we offer a new tissue test if tissue is available and also liquid biopsy Tempus xF+. We also have Guardant 360 Epic integrated as an option. Because our genomic results are Epic integrated, we can run reports in Reporting Workbench and identify patients with specific biomarkers from previous testing and compare those to newer FDA approvals. This helps us identify newly actionable biomarkers from previous tests.
In the setting of disease progression, updated PD-L1 and biomarker testing is utilized to confirm need for clinical trial referral when FDA approved therapeutics are not an option.	Yes
Comments	Yes, at time of progression liquid biopsy is considered to identify new drivers. We participate in the Tempus TIME trial program which offers rapid biomarker matching for clinical trials. The fact that we have discrete genomic variants in our Epic EMR also allows for more rapid trial matching. We have a robust research team with an in Epic referral for trial consideration.
Calculated Section Total	5
Qualification Status	Qualified
Rapid on-site evaluation (ROSE), when available to increase diagnostic and molecular yield.	No
Comments	No we do not have on site testing at TriHealth community cancer center.
Utilization of liquid biopsy modalities in the setting of tissue insufficiency or unavailability and points of disease progression.	Yes
Comments	Yes, we order by default in Epic a concurrent Tempus xT tissue test and a xF+ liquid biopsy. The xF+ includes 523 genes and the important biomarkers for lung cancer including relevant fusions and blood based TMB. If the solid xT has inadequate tissue we will consider alternate tissue or ensure the liquid biopsy is completed. When there are multiple metastatic sites, we do also consider tissue testing on each site due to tumor heterogeneity. Another best practice is that we use an AI-guided care gap identification program collaboratively with Tempus lab called Tempus Next. This surfaces biomarker care gaps. Our compliance data in 2023 was 70% for EGFR, ALK and PD-L1. We started a new workflow in Feb 2024 and within 12 weeks we reached 100% compliance. This program continues to go forward and now identifies patient tumors that had NGS but did not include newer biomarkers such as HER2 or c-MET IHC. We published our outcomes on this at the HOPE meeting. We also published an abstract at ASCO 2026 on the Tempus Next data.
Name	Karen Huelsman MS,LGC
Title	Precision Oncology Lead Board-Certified, Licensed Genetic Counselor TriHealth Precision Medicine Institute,
Email	Karen.Huelsman.LGC@gmail.com
Phone	(513)-706-5333
User ID	Tina Destefanis-Griffiths
Facility ID	1709

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	565
Total number of people screened in	650
Screen-eligible Rate	87
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	200
Total number of people who received baseline screening LDCT scans in (with and without SDM)	220
SDM Documentation Rate	91
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	300
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	350
Follow-up Rate %	86
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	70
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	90
Follow-up Rate %	78
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	40
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	50
Follow-up Rate %	80
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	43
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	55
Follow-up Rate %	78
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	5
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	1
Total nonsurgical lung biopsies in	4
Nonmalignant/Nondiagnostic Biopsy Rate %	25
	Yes
	Yes
Stage I	6
Stage II	1
Stage III	1
Stage I %	75
Stage II %	13
Stage III %	13
Stage IV %	0
Total screen-detected lung cancers	8
Name	hyewon shin
Title	NP
Email	Hyewon.Shin@nychhc.org
Phone	(212)-423-6574
User ID	Hyewon Shin
Facility ID	1995

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	475
Total number of people screened in	475
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	350
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	450
Follow-up Rate %	78
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	10
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	12
Follow-up Rate %	83
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	3
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	3
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	5
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	5
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	7
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	5
Total nonsurgical lung biopsies in	15
Nonmalignant/Nondiagnostic Biopsy Rate %	33
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Cindy Stotts
Title	Lead Coordinator
Email	cindy.stotts@commonspirit.org
Phone	(602)-406-4551
User ID	Cindy Stotts
Facility ID	1019

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Comments	LPOP
Monitor for lung cancer stage shift among screen-detected lung cancers.	No
Name	Katie Giardina
Title	Lung Cancer Screening Program Director
Email	kathryn.giardina@va.gov
Phone	(228)-523-4284
User ID	Casey Hutto
Facility ID	2264

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Sarah Groce, NP
Title	Nurse Practitioner
Email	sarah.groce@conehealth.com
Phone	(336)-522-8921
User ID	Denise phelps
Facility ID	2039

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Sarah Groce, NP
Title	Nurse Practitioner
Email	sarah.groce@conehealth.com
Phone	(336)-522-8921
User ID	Denise phelps
Facility ID	1374

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Sarah Groce, NP
Title	Nurse Practitioner
Email	sarah.groce@conehealth.com
Phone	(336)-522-8921
User ID	Denise phelps
Facility ID	2041

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Sarah Groce, NP
Title	Nurse Practitioner
Email	sarah.groce@conehealth.com
Phone	(336)-522-8921
User ID	Denise phelps
Facility ID	1371

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Sarah Groce, NP
Title	Nurse Practitioner
Email	sarah.groce@conehealth.com
Phone	(336)-522-8921
User ID	Denise phelps
Facility ID	1370

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Sarah Groce, NP
Title	Nurse Practitioner
Email	sarah.groce@conehealth.com
Phone	(336)-522-8921
User ID	Denise phelps
Facility ID	2036

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Sarah Groce, NP
Title	Nurse Practitioner
Email	sarah.groce@conehealth.com
Phone	(336)-522-8921
User ID	Denise phelps
Facility ID	2040

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Sarah Groce, NP
Title	Nurse Practitioner
Email	sarah.groce@conehealth.com
Phone	(336)-522-8921
User ID	Denise phelps
Facility ID	2037

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Sarah Groce, NP
Title	Nurse Practitioner
Email	sarah.groce@conehealth.com
Phone	(336)-522-8921
User ID	Denise phelps
Facility ID	2038

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Sarah Groce, NP
Title	Nurse Practitioner
Email	sarah.groce@conehealth.com
Phone	(336)-522-8921
User ID	Denise phelps
Facility ID	2030

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Sarah Groce, NP
Title	Nurse Practitioner
Email	sarah.groce@conehealth.com
Phone	(336)-522-8921
User ID	Denise phelps
Facility ID	1369

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	USPSTF
If Other, describe your screening eligibility criteria	I cannot release specific numerical data as this is protected information of the US Dept of Veterans Affairs. I have answered the program specific questions, but cannot release the remainder of the data. Thank you for understanding.
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	James Tarasuik
Title	Lung Cancer Screening Coordinator
Email	james.tarasuik@va.gov
Phone	(314)-652-4100
User ID	James Tarasuik
Facility ID	1984

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer
Thoracic Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	ASCO, CAP
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	James Tarasuik
Title	Lung Cancer Screening Coordinator
Email	james.tarasuik@va.gov
Phone	(314)-652-4100
User ID	James Tarasuik
Facility ID	1984

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software
Outcomes Review	Yes
Select all that apply	Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	0
Total nonsurgical lung biopsies in patients with IPN in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	IPNs identified by CPT codes
Name	James Tarasuik
Title	Lung Cancer Screening Coordinator
Email	james.tarasuik@va.gov
Phone	(314)-652-4100
User ID	James Tarasuik
Facility ID	1984

Patients with lung cancer (Stage IB and higher) who receive biomarker testing at the time of diagnosis in	0
Total patients diagnosed with lung cancer (Stage IB and higher) in	0
Biomarker Testing at Diagnosis Rate %	0
Results Documented	Yes
Testing Before Systemic Therapy	Yes
Patients with disease progression on targeted therapy or immunotherapy +/- chemo who receive biomarker testing in	0
Total patients with disease progression on targeted therapy or immunotherapy +/- chemo in	0
Progression Biomarker Testing Rate %	0
Clinical Trials Review	Yes
Referral Testing	Yes
Liquid Biopsy	Yes
Negative Liquid Biopsy Tissue	Yes
Score	6
Qualification Status	Qualified
Checkpoint Inhibitors	Yes
Comprehensive Testing	Yes
Name	James Tarasuik
Title	Lung Cancer Screening Coordinator
Email	james.tarasuik@va.gov
Phone	(314)-652-4100
User ID	James Tarasuik
Facility ID	1984

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	9,086
Total number of people screened in	9,086
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	No
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	No
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	No
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Kristi Crisafulli
Title	Lung Cancer Screening Coordinator, RN
Email	kristiroberts@tgh.org
Phone	(352)-406-7871
User ID	Kristi Crisafulli
Facility ID	1965

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	258
Total number of people screened in	258
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	157
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	No
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	108
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	214
Follow-up Rate %	50
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	8
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	15
Follow-up Rate %	53
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	14
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	15
Follow-up Rate %	93
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	18
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	18
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	2
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	4
Total nonsurgical lung biopsies in	9
Nonmalignant/Nondiagnostic Biopsy Rate %	44
	Yes
	Yes
Stage I	1
Stage II	0
Stage III	1
Stage IV	1
Stage I %	33
Stage II %	0
Stage III %	33
Stage IV %	33
Total screen-detected lung cancers	3
Name	Virginia Frantz
Title	RN, Lung Screening Navigator
Email	virginia.frantz@nortonhealthcare.org
Phone	(502)-636-7454
User ID	Jenny Frantz
Facility ID	1953

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	880
Total number of people screened in	880
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	315
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	No
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	340
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	679
Follow-up Rate %	50
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	26
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	47
Follow-up Rate %	55
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	44
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	47
Follow-up Rate %	94
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	57
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	57
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	6
Nonmalignant Resection Rate %	17
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	13
Total nonsurgical lung biopsies in	27
Nonmalignant/Nondiagnostic Biopsy Rate %	48
	Yes
	Yes
Stage I	6
Stage II	2
Stage III	0
Stage IV	2
Stage I %	60
Stage II %	20
Stage III %	0
Stage IV %	20
Total screen-detected lung cancers	10
Name	Virginia Frantz
Title	RN, Lung Screening Navigator
Email	virginia.frantz@nortonhealthcare.org
Phone	(502)-636-7454
User ID	Jenny Frantz
Facility ID	1946

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	249
Total number of people screened in	249
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	149
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	No
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	90
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	179
Follow-up Rate %	50
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	7
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	12
Follow-up Rate %	58
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	12
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	12
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	15
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	15
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	2
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	3
Total nonsurgical lung biopsies in	7
Nonmalignant/Nondiagnostic Biopsy Rate %	43
	Yes
	Yes
Stage I	0
Stage II	1
Stage III	2
Stage IV	1
Stage I %	0
Stage II %	25
Stage III %	50
Stage IV %	25
Total screen-detected lung cancers	4
Name	Virginia Frantz
Title	RN, Lung Screening Navigator
Email	virginia.frantz@nortonhealthcare.org
Phone	(502)-636-7454
User ID	Jenny Frantz
Facility ID	1949

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	996
Total number of people screened in	996
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	217
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	No
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	376
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	750
Follow-up Rate %	50
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	29
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	52
Follow-up Rate %	56
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	49
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	52
Follow-up Rate %	94
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	63
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	63
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	7
Nonmalignant Resection Rate %	14
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	14
Total nonsurgical lung biopsies in	30
Nonmalignant/Nondiagnostic Biopsy Rate %	47
	Yes
	Yes
Stage I	9
Stage II	0
Stage III	1
Stage IV	0
Stage I %	90
Stage II %	0
Stage III %	10
Stage IV %	0
Total screen-detected lung cancers	10
Name	Virginia Frantz
Title	RN, Lung Screening Navigator
Email	virginia.frantz@nortonhealthcare.org
Phone	(502)-636-7454
User ID	Jenny Frantz
Facility ID	1947

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,192
Total number of people screened in	1,192
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	289
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	No
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	448
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	893
Follow-up Rate %	50
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	35
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	62
Follow-up Rate %	56
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	59
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	62
Follow-up Rate %	95
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	75
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	75
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	9
Nonmalignant Resection Rate %	11
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	17
Total nonsurgical lung biopsies in	36
Nonmalignant/Nondiagnostic Biopsy Rate %	47
	Yes
Stage I	9
Stage II	3
Stage III	2
Stage IV	5
Stage I %	47
Stage II %	16
Stage III %	11
Stage IV %	26
Total screen-detected lung cancers	19
Name	Virginia Frantz
Title	RN, Lung Screening Navigator
Email	virginia.frantz@nortonhealthcare.org
Phone	(502)-636-7454
User ID	Jenny Frantz
Facility ID	1591

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,190
Total number of people screened in	1,190
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	429
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	No
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	448
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	893
Follow-up Rate %	50
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	35
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	62
Follow-up Rate %	56
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	59
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	62
Follow-up Rate %	95
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	75
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	75
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	9
Nonmalignant Resection Rate %	11
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	17
Total nonsurgical lung biopsies in	36
Nonmalignant/Nondiagnostic Biopsy Rate %	47
	Yes
	Yes
Stage I	12
Stage II	3
Stage III	2
Stage IV	3
Stage I %	60
Stage II %	15
Stage III %	10
Stage IV %	15
Total screen-detected lung cancers	20
Name	Virginia Frantz
Title	RN, Lung Screening Navigator
Email	virginia.frantz@nortonhealthcare.org
Phone	(502)-636-7454
User ID	Jenny Frantz
Facility ID	1948

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	2,649
Total number of people screened in	2,649
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	583
Total number of people who received baseline screening LDCT scans in (with and without SDM)	980
SDM Documentation Rate	59
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	1,291
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,340
Follow-up Rate %	55
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	82
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	104
Follow-up Rate %	79
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	43
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	53
Follow-up Rate %	81
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	52
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	53
Follow-up Rate %	98
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	4
Nonmalignant Resection Rate %	25
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	12
Total nonsurgical lung biopsies in	29
Nonmalignant/Nondiagnostic Biopsy Rate %	41
	Yes
	Yes
Stage I	15
Stage II	1
Stage III	4
Stage IV	4
Stage I %	63
Stage II %	4
Stage III %	17
Stage IV %	17
Total screen-detected lung cancers	24
Name	Beki Rhein
Title	Lung Cancer Screening Nurse Navigator
Email	rlrhein@saintfrancis.com
Phone	(918)-556-7088
User ID	Beki Rhein
Facility ID	1014

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,375
Total number of people screened in	1,405
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	CMS, USPSTF, Other
If Other, describe your screening eligibility criteria	VA, some private insurances approve up to age 80
Total number of people who received baseline screening LDCT scans in where SDM is documented	529
Total number of people who received baseline screening LDCT scans in (with and without SDM)	529
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	846
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,086
Follow-up Rate %	78
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	51
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	58
Follow-up Rate %	88
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	70
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	81
Follow-up Rate %	86
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	3
Stage II	4
Stage III	4
Stage IV	0
Stage I %	27
Stage II %	36
Stage III %	36
Stage IV %	0
Total screen-detected lung cancers	11
Name	Emily Groen
Title	Lung Cancer Screening Program Coordinator
Email	emily.groen@avera.org
Phone	(605)-322-1762
User ID	Emily Groen
Facility ID	1871

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Stephanie Terrell
Title	Lung Nurse Navigator
Email	slterrell@mercy.com
Phone	(513)-870-7738
User ID	Stephanie Terrell
Facility ID	1362

A patient-centered discussion about the potential benefits and harms of lung cancer treatment occurs at each point of the patient’s cancer care journey.	Yes
Biomarker Testing: Access to and compliance with guideline-directed testing for molecular and immune biomarkers with NGS technology in all patients with guideline-eligible tumors (when clinically appropriate). Using NGS results, consistently identify actionable mutations and eligiblity for guideline-directed targeted therapies or immunotherapies.	Yes
Medical Oncology: Compliance with practice standards for the diagnostic workup, staging, and medical oncology (disease specific) treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Radiation Oncology: Compliance with practice standards for the diagnostic workup, staging, and radiation treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Thoracic Oncology: Compliance with practice standards for the diagnostic workup, staging, and surgical treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Pathology: Comply with practice standards based on evidence, expert consensus, and practice guidelines for pathologic evaluation of malignancies.	Yes
Actively engage or have access to multidisciplinary expert input by way of tumor board or other team-based mechanism, including virtual.	Yes
Commitment and care delivery mechanisms are in place that standardizes consistent communication with patients and their active care providers about test results, diagnostic workup, and management plan.	Yes
Contribute to aggregated collection of relevant data and report to a cancer registry. (hospital, central or state, or special purpose registry, NPCR, NCI, SEER)	Yes
Ask about current smoking status and, as appropriate, advise to quit. Provide or refer for cessation services.	Yes
Calculated Section Total	10
Qualification Status	Qualified
Internal clinical outcomes review and quality improvement process.	Yes
Thoracic Oncologist(s) are board certified thoracic or cardio-thoracic surgeons.	Yes
Name	Stephanie Terrell
Title	Lung Nurse Navigator
Email	slterrell@mercy.com
Phone	(513)-870-7738
User ID	Stephanie Terrell
Facility ID	1362

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Rage Geringer
Title	Pulmonary and Critical Care Physician
Email	rage.geringer@crmcwy.org
Phone	(307)-638-7757
User ID	Rage Geringer
Facility ID	2255

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Comments	Currently revising our program, we no longer use ACS Fresh Start program. We are moving to ALA beginning of January 2027
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	1,263
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	1,263
LDCT Protocol Compliance Rate %	100
Comments	I am confused about the last question. I only included all CT CHEST FU after an IPN has been identified. I do not have the imaging radiation dose. The Radiologist informed they always try to do the lowest dose.
Tracking Adherence	Yes
Select all that apply	Tracking software
Outcomes Review	Yes
Select all that apply	Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	0
Total nonsurgical lung biopsies in patients with IPN in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Name	Tina DeStefanis-Griffiths MSN, BSN, RN , OCN
Title	Lung Program Administrator/Lung Naviagator
Email	tina_destefanis-griffiths@trihealth.com
Phone	(513)-853-1470
User ID	Tina Destefanis-Griffiths
Facility ID	1709

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	5,731
Total number of people screened in	5,731
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,780
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,780
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	4,808
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,509
Follow-up Rate %	192
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	296
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	220
Follow-up Rate %	135
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	122
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	105
Follow-up Rate %	116
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	115
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	103
Follow-up Rate %	112
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	68
Stage II	8
Stage III	10
Stage IV	17
Stage I %	66
Stage II %	8
Stage III %	10
Stage IV %	17
Total screen-detected lung cancers	103
Name	Tina DeStefanis-Griffiths MSN, BSN, RN, OCN
Title	Lung Program Administrator/Lung Navigator
Email	tina_destefanis-griffiths@trihealth.com
Phone	(513)-853-1470
User ID	Tina Destefanis-Griffiths
Facility ID	1709

Patient Discussion	Yes
Comments	A Lung Cancer Nurse Navigator assigned to newly dx lung cancer patients
Biomarker Testing	Yes
Comments	Workflow in place for Biomarker testing for Stage IB thru Stage IV
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN, ASCO, ACCP
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Thoracic Oncology	Yes
Select all that apply	AATS, ACCP, NCCN, STS, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	ASCO, CAP, NCCN
Multidisciplinary Team	Yes
Comments	Thoracic Multidisciplinary Tumor Board and clinic every Tuesday morning
Care Plan	Yes
Comments	Epic, Mychart, Snail mail, Fax, Phone call, Email
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry
Cessation Support	Yes
Comments	Temporarily restructuring the program to revamp on 1/1/2027 ; Electronic referral to
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Tina DeSTefanis-Griffiths
Title	Lung Program Administrator/Nurse Navigator
Email	tina_destefanis-griffiths@trihealth.com
Phone	(513)-853-1470
User ID	Tina Destefanis-Griffiths
Facility ID	1709

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Kim Dupuis
Title	Director
Email	kim.dupuis@hcahealthcare.com
Phone	(702)-807-8697
User ID	Kimberly Dupuis
Facility ID	1555

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Chelsea Cain
Title	Director of LCS & ILN
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	2261

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	226
Total number of people screened in	228
Screen-eligible Rate	99
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	173
Total number of people who received baseline screening LDCT scans in (with and without SDM)	187
SDM Documentation Rate	93
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	111
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	200
Follow-up Rate %	56
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	11
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	17
Follow-up Rate %	65
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	20
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	21
Follow-up Rate %	95
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	24
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	25
Follow-up Rate %	96
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	2
Total nonsurgical lung biopsies in	5
Nonmalignant/Nondiagnostic Biopsy Rate %	40
	Yes
	Yes
Stage I	1
Stage II	0
Stage III	0
Stage IV	0
Stage I %	100
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	1
Name	Chelsea Cain
Title	Director of LCS & ILN
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1617

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	685
Total number of people screened in	690
Screen-eligible Rate	99
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	495
Total number of people who received baseline screening LDCT scans in (with and without SDM)	534
SDM Documentation Rate	93
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	336
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	607
Follow-up Rate %	55
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	32
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	50
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	61
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	63
Follow-up Rate %	97
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	74
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	75
Follow-up Rate %	99
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	4
Nonmalignant Resection Rate %	25
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	7
Total nonsurgical lung biopsies in	15
Nonmalignant/Nondiagnostic Biopsy Rate %	47
	Yes
	Yes
Stage I	4
Stage II	1
Stage III	1
Stage IV	0
Stage I %	67
Stage II %	17
Stage III %	17
Stage IV %	0
Total screen-detected lung cancers	6
Name	Chelsea Cain
Title	Director of LCS & ILN Programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1610

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software, Manual tracking (Excel, etc.)
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	0
Total nonsurgical lung biopsies in patients with IPN in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of LCS & ILN Programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1612

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Chelsea Cain
Title	Director of LCS & ILN
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1612

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software, Manual tracking (Excel, etc.)
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	0
Total nonsurgical lung biopsies in patients with IPN in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of LCS & ILN
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1620

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software, Manual tracking (Excel, etc.)
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	0
Total nonsurgical lung biopsies in patients with IPN in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of LCS & ILN
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1619

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software, Manual tracking (Excel, etc.)
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	0
Total nonsurgical lung biopsies in patients with IPN in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of LCS & ILN
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1611

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software, Manual tracking (Excel, etc.)
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	0
Total nonsurgical lung biopsies in patients with IPN in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of LCS & ILN
Email	chelsea.cain@advocatehealth.or
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1613

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software, Manual tracking (Excel, etc.), EHR appointment recall system
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	0
Total nonsurgical lung biopsies in patients with IPN in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Chelsea Cain
Title	Director of LCS & ILN Programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1615

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Chelsea Cain
Title	Director of LCS & ILN
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1615

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	206
Total number of people screened in	207
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	152
Total number of people who received baseline screening LDCT scans in (with and without SDM)	162
SDM Documentation Rate	94
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	101
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	182
Follow-up Rate %	55
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	10
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	15
Follow-up Rate %	67
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	18
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	19
Follow-up Rate %	95
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	22
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	23
Follow-up Rate %	96
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	2
Total nonsurgical lung biopsies in	5
Nonmalignant/Nondiagnostic Biopsy Rate %	40
	Yes
	Yes
Stage I	1
Stage II	0
Stage III	0
Stage IV	0
Stage I %	100
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	1
Name	Chelsea Cain
Title	Director of LCS & ILN
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1608

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Chelsea Cain
Title	Director of LCS & ILN
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1611

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	809
Total number of people screened in	814
Screen-eligible Rate	99
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	469
Total number of people who received baseline screening LDCT scans in (with and without SDM)	508
SDM Documentation Rate	92
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	397
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	716
Follow-up Rate %	55
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	38
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	59
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	71
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	74
Follow-up Rate %	96
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	87
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	89
Follow-up Rate %	98
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	5
Nonmalignant Resection Rate %	20
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	8
Total nonsurgical lung biopsies in	18
Nonmalignant/Nondiagnostic Biopsy Rate %	44
	Yes
	Yes
Stage I	5
Stage II	1
Stage III	1
Stage IV	0
Stage I %	71
Stage II %	14
Stage III %	14
Stage IV %	0
Total screen-detected lung cancers	7
Name	Chelsea Cain
Title	Director of LCS & ILN
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1609

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,383
Total number of people screened in	1,392
Screen-eligible Rate	99
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,856
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,984
SDM Documentation Rate	94
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	679
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,225
Follow-up Rate %	55
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	64
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	101
Follow-up Rate %	63
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	122
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	127
Follow-up Rate %	96
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	150
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	152
Follow-up Rate %	99
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	8
Nonmalignant Resection Rate %	13
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	14
Total nonsurgical lung biopsies in	31
Nonmalignant/Nondiagnostic Biopsy Rate %	45
	Yes
	Yes
Stage I	9
Stage II	1
Stage III	2
Stage IV	1
Stage I %	69
Stage II %	8
Stage III %	15
Stage IV %	8
Total screen-detected lung cancers	13
Name	Chelsea Cain
Title	Director of LCS & ILN
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1614

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Chelsea Cain
Title	Director of LCS & ILN Programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1620

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	960
Total number of people screened in	965
Screen-eligible Rate	99
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	773
Total number of people who received baseline screening LDCT scans in (with and without SDM)	820
SDM Documentation Rate	94
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	471
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	850
Follow-up Rate %	55
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	45
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	70
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	85
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	88
Follow-up Rate %	97
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	104
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	106
Follow-up Rate %	98
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	6
Nonmalignant Resection Rate %	17
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	9
Total nonsurgical lung biopsies in	21
Nonmalignant/Nondiagnostic Biopsy Rate %	43
	Yes
	Yes
Stage I	6
Stage II	1
Stage III	1
Stage IV	0
Stage I %	75
Stage II %	13
Stage III %	13
Stage IV %	0
Total screen-detected lung cancers	8
Name	Chelsea Cain
Title	Director of LCS & ILN Programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1622

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,741
Total number of people screened in	1,752
Screen-eligible Rate	99
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,361
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,474
SDM Documentation Rate	92
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	854
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,542
Follow-up Rate %	55
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	81
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	128
Follow-up Rate %	63
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	154
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	160
Follow-up Rate %	96
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	188
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	192
Follow-up Rate %	98
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	10
Nonmalignant Resection Rate %	10
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	17
Total nonsurgical lung biopsies in	39
Nonmalignant/Nondiagnostic Biopsy Rate %	44
	Yes
	Yes
Stage I	11
Stage II	1
Stage III	2
Stage IV	1
Stage I %	73
Stage II %	7
Stage III %	13
Stage IV %	7
Total screen-detected lung cancers	15
Name	Chelsea Cain
Title	Director of LCS & ILN Programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1616

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Chelsea Cain
Title	Director of LCS & ILN
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1613

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Chelsea Cain
Title	Director of LCS & ILN
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1619

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	685
Total number of people screened in	690
Screen-eligible Rate	99
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	535
Total number of people who received baseline screening LDCT scans in (with and without SDM)	579
SDM Documentation Rate	92
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	336
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	607
Follow-up Rate %	55
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	32
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	50
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	61
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	63
Follow-up Rate %	97
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	74
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	75
Follow-up Rate %	99
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	4
Nonmalignant Resection Rate %	25
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	7
Total nonsurgical lung biopsies in	15
Nonmalignant/Nondiagnostic Biopsy Rate %	47
	Yes
	Yes
Stage I	4
Stage II	1
Stage III	1
Stage IV	0
Stage I %	67
Stage II %	17
Stage III %	17
Stage IV %	0
Total screen-detected lung cancers	6
Name	Chelsea Cain
Title	Director of LCS & ILN Programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1603

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,153
Total number of people screened in	1,160
Screen-eligible Rate	99
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	922
Total number of people who received baseline screening LDCT scans in (with and without SDM)	982
SDM Documentation Rate	94
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	556
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,021
Follow-up Rate %	54
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	54
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	85
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	102
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	106
Follow-up Rate %	96
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	125
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	127
Follow-up Rate %	98
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	7
Nonmalignant Resection Rate %	14
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	11
Total nonsurgical lung biopsies in	26
Nonmalignant/Nondiagnostic Biopsy Rate %	42
	Yes
	Yes
Stage I	7
Stage II	1
Stage III	1
Stage IV	1
Stage I %	70
Stage II %	10
Stage III %	10
Stage IV %	10
Total screen-detected lung cancers	10
Name	Chelsea Cain
Title	Director of ILN & LCS Programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1621

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	2,742
Total number of people screened in	2,759
Screen-eligible Rate	99
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,695
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,861
SDM Documentation Rate	91
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	1,345
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,428
Follow-up Rate %	55
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	128
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	201
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	242
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	252
Follow-up Rate %	96
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	296
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	302
Follow-up Rate %	98
Surgical lung resections with benign (nonmalignant) pathology in	2
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	16
Nonmalignant Resection Rate %	13
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	27
Total nonsurgical lung biopsies in	61
Nonmalignant/Nondiagnostic Biopsy Rate %	44
	Yes
	Yes
Stage I	18
Stage II	2
Stage III	3
Stage IV	1
Stage I %	75
Stage II %	8
Stage III %	13
Stage IV %	4
Total screen-detected lung cancers	24
Name	Chelsea Cain
Title	Director of ILN & LCS Programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1618

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Chelsea Cain
Title	Director of LCS & ILN Programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	2259

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Chelsea Cain
Title	Director of LCS & ILN Programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	2260

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Chelsea Cain
Title	Director of LCS and ILN Programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	2263

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Chelsea Cain
Title	Director of ILN & LCS Programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	2263

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Chelsea Cain
Title	Director of LCS and ILN programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	2258

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Chelsea Cain
Title	Director of LCS & ILN programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	2258

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Chelsea Cain
Title	Director of LCS & ILN Programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	2256

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Chelsea Cain
Title	Director of LCS & ILN programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	2256

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Chelsea Cain
Title	Director of LCS and ILN programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	2257

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Chelsea Cain
Title	Director of LCS and ILN
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	2257

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Chelsea Cain
Title	Director of lung cancer screening and incidental lung nodules
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	2262

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Chelsea Cain
Title	Director of lung cancer screening and incidental lung nodules
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	2254

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Chelsea Cain
Title	Director of lung cancer screening and incidental lung nodules
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	2254

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Chelsea Cain
Title	Director of Lung Cancer Screening and Incidental Lung Nodules
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	2253

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Chelsea Cain
Title	Director of Lung Cancer Screening and Incidental Lung Nodule Programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	2253

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	285
Total number of people screened in	287
Screen-eligible Rate	99
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	254
Total number of people who received baseline screening LDCT scans in (with and without SDM)	293
SDM Documentation Rate	87
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	140
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	252
Follow-up Rate %	56
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	13
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	21
Follow-up Rate %	62
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	25
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	26
Follow-up Rate %	96
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	31
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	31
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	2
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	3
Total nonsurgical lung biopsies in	6
Nonmalignant/Nondiagnostic Biopsy Rate %	50
	Yes
	Yes
Stage I	2
Stage II	0
Stage III	0
Stage IV	0
Stage I %	100
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	2
Name	Chelsea Cain
Title	Director of lung cancer screening and incidental lung nodule programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1606

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	498
Total number of people screened in	501
Screen-eligible Rate	99
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	339
Total number of people who received baseline screening LDCT scans in (with and without SDM)	424
SDM Documentation Rate	80
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	244
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	441
Follow-up Rate %	55
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	23
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	37
Follow-up Rate %	62
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	44
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	46
Follow-up Rate %	96
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	54
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	55
Follow-up Rate %	98
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	5
Total nonsurgical lung biopsies in	11
Nonmalignant/Nondiagnostic Biopsy Rate %	45
	Yes
	Yes
Stage I	3
Stage II	0
Stage III	1
Stage IV	0
Stage I %	75
Stage II %	0
Stage III %	25
Stage IV %	0
Total screen-detected lung cancers	4
Name	Chelsea Cain
Title	Director of lung screening and incidental lung nodule programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1607

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	629
Total number of people screened in	633
Screen-eligible Rate	99
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	438
Total number of people who received baseline screening LDCT scans in (with and without SDM)	501
SDM Documentation Rate	87
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	309
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	557
Follow-up Rate %	55
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	29
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	46
Follow-up Rate %	63
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	56
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	58
Follow-up Rate %	97
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	68
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	69
Follow-up Rate %	99
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	4
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	6
Total nonsurgical lung biopsies in	14
Nonmalignant/Nondiagnostic Biopsy Rate %	43
	Yes
	Yes
Stage I	4
Stage II	1
Stage III	1
Stage IV	0
Stage I %	67
Stage II %	17
Stage III %	17
Stage IV %	0
Total screen-detected lung cancers	6
Name	Chelsea Cain
Title	Director of Lung Cancer Screening and Incidental Lung Nodule Programs
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1605

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	279
Total number of people screened in	279
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	279
Total number of people who received baseline screening LDCT scans in (with and without SDM)	279
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	263
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	460
Follow-up Rate %	57
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	33
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	55
Follow-up Rate %	60
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	21
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	26
Follow-up Rate %	81
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	12
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	13
Follow-up Rate %	92
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	5
Total nonsurgical lung biopsies in	7
Nonmalignant/Nondiagnostic Biopsy Rate %	71
	No
	Yes
Stage I	1
Stage II	1
Stage III	0
Stage IV	0
Stage I %	50
Stage II %	50
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	2
Name	Odmene Sanon
Title	Nurse Practitioner
Email	sanond@nychhc.org
Phone	(718)-334-4051
User ID	alfredo astua
Facility ID	2052

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Rage Geringer
Title	Pulmonary and Critical Care Physician
Email	Rage.geringer@crmcwy.org
Phone	(307)-638-7757
User ID	Rage Geringer
Facility ID	2255

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	585
Total number of people screened in	589
Screen-eligible Rate	99
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	438
Total number of people who received baseline screening LDCT scans in (with and without SDM)	504
SDM Documentation Rate	87
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	287
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	518
Follow-up Rate %	55
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	27
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	43
Follow-up Rate %	63
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	52
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	54
Follow-up Rate %	96
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	63
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	64
Follow-up Rate %	98
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	4
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	6
Total nonsurgical lung biopsies in	13
Nonmalignant/Nondiagnostic Biopsy Rate %	46
	Yes
	Yes
Stage I	4
Stage II	0
Stage III	1
Stage IV	0
Stage I %	80
Stage II %	0
Stage III %	20
Stage IV %	0
Total screen-detected lung cancers	5
Name	Chelsea Cain
Title	Director of Lung Cancer Screening & Incidental Lung Nodule Program
Email	chelsea.cain@advocatehealth.org
Phone	(660)-221-3605
User ID	Chelsea Cain
Facility ID	1604

Patients with lung cancer (Stage IB and higher) who receive biomarker testing at the time of diagnosis in	0
Total patients diagnosed with lung cancer (Stage IB and higher) in	0
Biomarker Testing at Diagnosis Rate %	0
Comments	We do biomarker testing on all metastatic, and locally advanced lung cancer, as well as some early stage disease based on pre-established criteria.
Results Documented	Yes
Testing Before Systemic Therapy	Yes
Patients with disease progression on targeted therapy or immunotherapy +/- chemo who receive biomarker testing in	0
Total patients with disease progression on targeted therapy or immunotherapy +/- chemo in	0
Progression Biomarker Testing Rate %	0
Comments	Per provider, all metrics being asked can be calculated in retrospect but do not have data managers to do so. He does know non diagnostic rates are low but also many variables based on size, types of nodules, stable over time ect.
Clinical Trials Review	Yes
Comments	We do biomarker testing on all metastatic, and locally advanced lung cancer, as well as some early stage disease based on pre-established criteria.
Referral Testing	Yes
Liquid Biopsy	Yes
Negative Liquid Biopsy Tissue	Yes
Score	6
Qualification Status	Qualified
Checkpoint Inhibitors	Yes
Comprehensive Testing	Yes
Name	Ashley Nettles
Title	Lung Cancer Screening Coordinator
Email	ashgraff@med.umich.edu
Phone	(734)-998-6326
User ID	Ashley Nettles
Facility ID	1962

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Comments	IPN does not report or track like LCS does but best practice is to follow up IPN with a LDCT and ordered and completed within Radiology with LDCT.
Tracking Adherence	Yes
Comments	IPN tracks within EMR worklist not necessarily an EMR appointment recall system as well as excel.
Select all that apply	Manual tracking (Excel, etc.), EHR appointment recall system
Outcomes Review	Yes
Comments	Currently under review for QI and program development/improvement.
Select all that apply	Other (free text)
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	0
Total nonsurgical lung biopsies in patients with IPN in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Comments	Lung Cancer Care, IPN has been working within our quality department for development and improvement to develop a more robust nodule clinic.
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Comments	IPN's are identified by radiologist and flagged for review/management by IPN coordinator.
Select all that apply	Natural Language Processing program, Identification of IPNs on imaging by AI, IPNs identified by CPT codes, Other (free text)
Name	Ashley Nettles
Title	Lung Cancer Screening Coordinator
Email	ashgraff@med.umich.edu
Phone	(734)-998-6326
User ID	Ashley Nettles
Facility ID	1962

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Thoracic Oncology	Yes
Select all that apply	NCCN, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Comments	Reporting is done unsure which ones and do not have access to said registry post diagnosis.
Select all that apply	Hospital-based cancer registry, Central or state cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Ashley Nettles
Title	lung cancer screening coordinator
Email	ashgraff@med.umich.edu
Phone	(734)-998-6326
User ID	Ashley Nettles
Facility ID	1962

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Ashley Nettles
Title	Lung Cancer Screening Coordinator
Email	ashgraff@med.umich.edu
Phone	(734)-998-6326
User ID	Ashley Nettles
Facility ID	1962

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Ashley Nettles
Title	Lung Cancer Screening Coordinator
Email	ashgraff@med.umich.edu
Phone	(734)-998-6326
User ID	Ashley Nettles
Facility ID	1960

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Thoracic Oncology	Yes
Select all that apply	NCCN, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	CAP
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Central or state cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Virginia Frantz
Title	RN, Lung Screening Navigator
Email	virginia.frantz@nortonhealthcare.org
Phone	(812)-288-2268
User ID	Jenny Frantz
Facility ID	1592

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Thoracic Oncology	Yes
Select all that apply	NCCN, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	CAP
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Central or state cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Virginia Frantz
Title	RN, Lung Screening Navigator
Email	virginia.frantz@nortonhealthcare.org
Phone	(812)-288-2268
User ID	Jenny Frantz
Facility ID	1946

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Thoracic Oncology	Yes
Select all that apply	NCCN, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	CAP
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Central or state cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Virginia Frantz
Title	RN, Lung Screening Navigator
Email	virginia.frantz@nortonhealthcare.org
Phone	(812)-288-2268
User ID	Jenny Frantz
Facility ID	1593

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	2,169
Total number of people screened in	2,169
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	737
Total number of people who received baseline screening LDCT scans in (with and without SDM)	737
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	612
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,494
Follow-up Rate %	41
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	37
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	78
Follow-up Rate %	47
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	12
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	30
Follow-up Rate %	40
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	9
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	35
Follow-up Rate %	26
Surgical lung resections with benign (nonmalignant) pathology in	2
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	67
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	3
Total nonsurgical lung biopsies in	3
Nonmalignant/Nondiagnostic Biopsy Rate %	100
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Ashley Nettles
Title	Lung Cancer Screening Coordinator
Email	ashgraff@med.umich.edu
Phone	(734)-998-6326
User ID	Ashley Nettles
Facility ID	1961

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,247
Total number of people screened in	1,247
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, Other
If Other, describe your screening eligibility criteria	ACR
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,247
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,247
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	500
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	823
Follow-up Rate %	61
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	50
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	88
Follow-up Rate %	57
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	11
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	22
Follow-up Rate %	50
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	7
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	33
Follow-up Rate %	21
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	10
Total nonsurgical lung biopsies in	22
Nonmalignant/Nondiagnostic Biopsy Rate %	45
	Yes
	No
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Melissa Clark
Title	RN, Lung Program Coordinator
Email	melissa.jane.clark@gmail.com
Phone	(863)-386-6475
User ID	melissa Clark
Facility ID	1912

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	2,456
Total number of people screened in	9,535
Screen-eligible Rate	26
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	6,747
Total number of people who received baseline screening LDCT scans in (with and without SDM)	8,270
SDM Documentation Rate	82
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	3,924
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	6,240
Follow-up Rate %	63
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	392
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	499
Follow-up Rate %	79
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	221
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	246
Follow-up Rate %	90
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	211
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	246
Follow-up Rate %	86
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	No
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Andrew Munchel
Title	Quality Program Administrator
Email	amunchel3@wellspan.org
Phone	(717)-741-8100
User ID	Andrew Munchel
Facility ID	1889

A patient-centered discussion about the potential benefits and harms of lung cancer treatment occurs at each point of the patient’s cancer care journey.	Yes
Biomarker Testing: Access to and compliance with guideline-directed testing for molecular and immune biomarkers with NGS technology in all patients with guideline-eligible tumors (when clinically appropriate). Using NGS results, consistently identify actionable mutations and eligiblity for guideline-directed targeted therapies or immunotherapies.	Yes
Medical Oncology: Compliance with practice standards for the diagnostic workup, staging, and medical oncology (disease specific) treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Radiation Oncology: Compliance with practice standards for the diagnostic workup, staging, and radiation treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Thoracic Oncology: Compliance with practice standards for the diagnostic workup, staging, and surgical treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Pathology: Comply with practice standards based on evidence, expert consensus, and practice guidelines for pathologic evaluation of malignancies.	Yes
Actively engage or have access to multidisciplinary expert input by way of tumor board or other team-based mechanism, including virtual.	Yes
Commitment and care delivery mechanisms are in place that standardizes consistent communication with patients and their active care providers about test results, diagnostic workup, and management plan.	Yes
Contribute to aggregated collection of relevant data and report to a cancer registry. (hospital, central or state, or special purpose registry, NPCR, NCI, SEER)	Yes
Ask about current smoking status and, as appropriate, advise to quit. Provide or refer for cessation services.	Yes
Calculated Section Total	10
Qualification Status	Qualified
Internal clinical outcomes review and quality improvement process.	Yes
Thoracic Oncologist(s) are board certified thoracic or cardio-thoracic surgeons.	Yes
Name	Sherry OToole
Title	RN
Email	sotoole@mercy.com
Phone	(513)-215-5000
User ID	Sherry O'Toole
Facility ID	2230

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Sherry OToole
Title	RN
Email	sotoole@mercy.com
Phone	(513)-215-5000
User ID	Sherry O'Toole
Facility ID	2230

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	2,678
Total number of people screened in	2,678
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	485
Total number of people who received baseline screening LDCT scans in (with and without SDM)	485
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	2,016
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,348
Follow-up Rate %	86
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	86
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	108
Follow-up Rate %	80
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	66
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	70
Follow-up Rate %	94
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	61
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	63
Follow-up Rate %	97
Surgical lung resections with benign (nonmalignant) pathology in	4
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	34
Nonmalignant Resection Rate %	12
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	3
Total nonsurgical lung biopsies in	48
Nonmalignant/Nondiagnostic Biopsy Rate %	6
	Yes
	Yes
Stage I	89
Stage II	0
Stage III	7
Stage IV	4
Stage I %	89
Stage II %	0
Stage III %	7
Stage IV %	4
Total screen-detected lung cancers	100
Name	Ashley LeBlanc
Title	Regional Service Line Nurse Manager
Email	Ashley.LeBlanc@TrinityHealthOfNE.org
Phone	(413)-748-9629
User ID	Ashley LeBlanc
Facility ID	1382

Patients with lung cancer (Stage IB and higher) who receive biomarker testing at the time of diagnosis in	73
Total patients diagnosed with lung cancer (Stage IB and higher) in	81
Biomarker Testing at Diagnosis Rate %	90
Results Documented	Yes
Testing Before Systemic Therapy	Yes
Patients with disease progression on targeted therapy or immunotherapy +/- chemo who receive biomarker testing in	0
Total patients with disease progression on targeted therapy or immunotherapy +/- chemo in	0
Progression Biomarker Testing Rate %	0
Comments	We do not currently have a way to measure these metrics as described above. Will work on the development of reporting tools to identify this information for the future.
Clinical Trials Review	Yes
Referral Testing	Yes
Liquid Biopsy	Yes
Negative Liquid Biopsy Tissue	Yes
Score	6
Qualification Status	Qualified
Checkpoint Inhibitors	Yes
Comprehensive Testing	Yes
Name	Kristin Hurley, MSN, RN
Title	Director of Oncology Programs
Email	kristin.hurley@thechristhospital.com
Phone	(513)-585-1827
User ID	Kristin Hurley
Facility ID	1547

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	31
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	209
LDCT Protocol Compliance Rate %	15
Tracking Adherence	Yes
Select all that apply	Tracking software
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	8
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	26
Nonmalignant Resection Rate %	31
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	146
Total nonsurgical lung biopsies in patients with IPN in	282
Nonmalignant/Nondiagnostic Biopsy Rate %	52
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program, Identification of IPNs on imaging by AI
Name	Krystal Asher, BSN, RN
Title	Lung Cancer Nurse Navigator
Email	Krystal.Asher@thechristhospital.com
Phone	(513)-588-5908
User ID	Kristin Hurley
Facility ID	1547

Patient Discussion	Yes
Biomarker Testing	Yes
Comments	We routinely attempt biomarker testing and are successful in more than 90% of cases. Some cases are QNS.
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Thoracic Oncology	Yes
Select all that apply	NCCN, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	CAP
Multidisciplinary Team	Yes
Care Plan	Yes
Comments	We have standardized workflows but also recognize that there is always room for improvement. We utilize our multidisciplinary Clinical Performance Group as the avenue for such discussions when appropriate.
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry, Central or state cancer registry, SEER
Cessation Support	No
Comments	While we do consistently follow the Ask, Advise Refer process for our Lung Nodule Clinic patients, we are aware that there are opportunities for improvement with all newly diagnosed cancer patients. As we work toward compliance with the new CoC Standard 5.9 (Smoking Cessation for Patients with Cancer), we will complete a protocol and consistent pathway for smoking cessation referrals. We expect this to be in place by end of CY2026.
Score	9
Outcomes Review	Yes
Board Certified	Yes
Name	Kristin Hurley
Title	Director of Oncology Programs
Email	kristin.hurley@thechristhospital.com
Phone	(513)-585-1827
User ID	Kristin Hurley
Facility ID	1547

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	2,808
Total number of people screened in	3,155
Screen-eligible Rate	89
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	813
Total number of people who received baseline screening LDCT scans in (with and without SDM)	813
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	1,576
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,384
Follow-up Rate %	66
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	103
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	250
Follow-up Rate %	41
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	42
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	67
Follow-up Rate %	63
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	33
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	65
Follow-up Rate %	51
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	7
Nonmalignant Resection Rate %	14
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	14
Total nonsurgical lung biopsies in	37
Nonmalignant/Nondiagnostic Biopsy Rate %	38
	Yes
	Yes
Stage I	8
Stage II	6
Stage III	2
Stage IV	4
Stage I %	40
Stage II %	30
Stage III %	10
Stage IV %	20
Total screen-detected lung cancers	20
Name	Ashley Campbell, MSN, APRN, FNP-C
Title	Lung Program Nurse Practitioner
Email	Ashley.Campbell@thechristhospital.com
Phone	(513)-585-0690
User ID	Kristin Hurley
Facility ID	1547

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	730
Total number of people screened in	730
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	730
Total number of people who received baseline screening LDCT scans in (with and without SDM)	730
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	No
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Leung Yuet Tse Ho
Title	NP
Email	Leung-Yuet.Tse-Ho@nychhc.org
Phone	(929)-618-6228
User ID	Leung-Yuet Tse-Ho
Facility ID	1987

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Andrea Gresnick
Title	Regional Lung Health Coordinator
Email	agresnick@primehealthcare.com
Phone	(816)-943-7650
User ID	Andrea Gresnick
Facility ID	2239

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Andrea Gresnick
Title	Regional Lung Health Coordinator
Email	agresnick@primehealthcare.com
Phone	(816)-943-7650
User ID	Andrea Gresnick
Facility ID	2239

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Nicole Vogelsang
Title	Nurse Navigator
Email	nrvogelsang@mercy.com
Phone	(513)-686-5646
User ID	Nicole Vogelsang
Facility ID	2252

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN, ASCO
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, ASTRO, NCCN
Thoracic Oncology	Yes
Select all that apply	NCCN, STS, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	ASCO, CAP, NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Special-purpose (internal or external) registry, SEER
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Emily Hucker
Title	RN Manager
Email	EHucker@mercy.com
Phone	(513)-686-3000
User ID	Nicole Vogelsang
Facility ID	1358

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	No
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Samir Makani
Title	Director, Scripps Health Pulmonary Care Line
Email	Makani.Samir@Scrippshealth.org
Phone	(858)-554-5864
User ID	Nakiya Davis
Facility ID	2242

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	1,229
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	No
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	810
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	390
Follow-up Rate %	208
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	42
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	36
Follow-up Rate %	117
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	26
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	24
Follow-up Rate %	108
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	6
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	11
Follow-up Rate %	55
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	3
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	No
Stage III	2
Stage I %	0
Stage II %	0
Stage III %	100
Stage IV %	0
Total screen-detected lung cancers	2
Name	Deborah Woodstuff BSN, RN, OCN
Title	Lung Cancer Screening Program Coordinator
Email	deborah.woodstuff@wvumedicine.org
Phone	(304)-242-6461
User ID	Deborah Woodstuff
Facility ID	1936

Access to guideline-directed testing for molecular and immune biomarkers with NGS technology in all patients with guideline eligible tumors (when clinically appropriate) to determine eligibility for targeted therapies or immunotherapies.	Yes
Biomarker and PD-L1 results are reviewed and discussed with patients once results are available. Discussion includes the clinical implications and therapeutic options based on these results.	Yes
When appropriate, guideline directed PD-L1 and biomarker testing are integrated into treatment decisions before systemic therapy is initiated.	Yes
In the setting of disease progression on FDA approved therapy, updated PD-L1 and biomarker testing is utilized to identify next therapeutic option.	Yes
In the setting of disease progression, updated PD-L1 and biomarker testing is utilized to confirm need for clinical trial referral when FDA approved therapeutics are not an option.	Yes
Calculated Section Total	5
Qualification Status	Qualified
Rapid on-site evaluation (ROSE), when available to increase diagnostic and molecular yield.	No
Utilization of liquid biopsy modalities in the setting of tissue insufficiency or unavailability and points of disease progression.	Yes
Name	Ken Endo
Title	Cancer program director
Email	kenneth.endo@pihhealth.org
Phone	(714)-502-4295
User ID	Ken Endo
Facility ID	1205

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Ken Endo
Title	Cancer program director
Email	kenneth.endo@pihhealth.org
Phone	(714)-502-4295
User ID	Ken Endo
Facility ID	1205

A patient-centered discussion about the potential benefits and harms of lung cancer treatment occurs at each point of the patient’s cancer care journey.	Yes
Biomarker Testing: Access to and compliance with guideline-directed testing for molecular and immune biomarkers with NGS technology in all patients with guideline-eligible tumors (when clinically appropriate). Using NGS results, consistently identify actionable mutations and eligiblity for guideline-directed targeted therapies or immunotherapies.	Yes
Medical Oncology: Compliance with practice standards for the diagnostic workup, staging, and medical oncology (disease specific) treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Radiation Oncology: Compliance with practice standards for the diagnostic workup, staging, and radiation treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Thoracic Oncology: Compliance with practice standards for the diagnostic workup, staging, and surgical treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	No
Comments	we are working on coc standard 5.8 where lymph node sampling of the hilar and mediastinal lymph nodes need to be sampled during resection. This should be in compliance with our addition of an electronic bronchoscopy navigation system coming soon.
Pathology: Comply with practice standards based on evidence, expert consensus, and practice guidelines for pathologic evaluation of malignancies.	Yes
Actively engage or have access to multidisciplinary expert input by way of tumor board or other team-based mechanism, including virtual.	Yes
Commitment and care delivery mechanisms are in place that standardizes consistent communication with patients and their active care providers about test results, diagnostic workup, and management plan.	Yes
Contribute to aggregated collection of relevant data and report to a cancer registry. (hospital, central or state, or special purpose registry, NPCR, NCI, SEER)	Yes
Ask about current smoking status and, as appropriate, advise to quit. Provide or refer for cessation services.	Yes
Calculated Section Total	9
Internal clinical outcomes review and quality improvement process.	Yes
Comments	we use American College of Surgeons Commission on Cancer guidelines as well as NCDB data to be reviewed at cancer committee.
Thoracic Oncologist(s) are board certified thoracic or cardio-thoracic surgeons.	Yes
Name	Ken Endo
Title	Cancer program director
Email	kenneth.endo@pihhealth.org
Phone	(714)-502-4295
User ID	Ken Endo
Facility ID	1205

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
Comments	we screen per criteria
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Comments	We stopped when it became optional because of resource issues. Now we will transitioning to EPIC and will resume transmission in mid 2027
Monitor for lung cancer stage shift among screen-detected lung cancers.	No
Name	Ken Endo
Title	Cancer program director
Email	kenneth.endo@pihhealth.org
Phone	(714)-502-4295
User ID	Ken Endo
Facility ID	1205

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	NCCN
Radiation Oncology	Yes
Select all that apply	NCCN
Thoracic Oncology	Yes
Select all that apply	NCCN
Pathology	Yes
Select all that apply	NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Kimberly Turnbull
Title	Administrative Operations Coordinator
Email	KXTurnbull@KaleidaHealth.org
Phone	(716)-465-7801
User ID	Kimberly Turnbull
Facility ID	1941

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	457
Total number of people screened in	464
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	224
Total number of people who received baseline screening LDCT scans in (with and without SDM)	224
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	227
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	360
Follow-up Rate %	63
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	12
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	20
Follow-up Rate %	60
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	11
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	14
Follow-up Rate %	79
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	10
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	11
Follow-up Rate %	91
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	7
Nonmalignant Resection Rate %	14
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	7
Total nonsurgical lung biopsies in	66
Nonmalignant/Nondiagnostic Biopsy Rate %	11
	Yes
	Yes
Stage I	3
Stage II	0
Stage III	1
Stage IV	0
Stage I %	75
Stage II %	0
Stage III %	25
Stage IV %	0
Total screen-detected lung cancers	4
Name	Pam Worthy
Title	Program Director
Email	pam.worthy@mcleodhealth.org
Phone	(843)-777-5926
User ID	Noah Kleckner
Facility ID	1903

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	606
Total number of people screened in	615
Screen-eligible Rate	99
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	297
Total number of people who received baseline screening LDCT scans in (with and without SDM)	297
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	301
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	477
Follow-up Rate %	63
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	16
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	27
Follow-up Rate %	59
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	14
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	19
Follow-up Rate %	74
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	14
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	15
Follow-up Rate %	93
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	9
Nonmalignant Resection Rate %	11
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	9
Total nonsurgical lung biopsies in	87
Nonmalignant/Nondiagnostic Biopsy Rate %	10
	Yes
	Yes
Stage I	3
Stage II	1
Stage III	2
Stage IV	1
Stage I %	43
Stage II %	14
Stage III %	29
Stage IV %	14
Total screen-detected lung cancers	7
Name	Pam Worthy
Title	Program Director
Email	pam.worthy@mcleodhealth.org
Phone	(843)-777-5926
User ID	Noah Kleckner
Facility ID	1902

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,423
Total number of people screened in	1,445
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	697
Total number of people who received baseline screening LDCT scans in (with and without SDM)	697
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	706
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,121
Follow-up Rate %	63
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	38
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	63
Follow-up Rate %	60
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	34
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	44
Follow-up Rate %	77
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	32
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	35
Follow-up Rate %	91
Surgical lung resections with benign (nonmalignant) pathology in	2
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	21
Nonmalignant Resection Rate %	10
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	21
Total nonsurgical lung biopsies in	204
Nonmalignant/Nondiagnostic Biopsy Rate %	10
	Yes
	Yes
Stage I	9
Stage II	1
Stage III	1
Stage IV	3
Stage I %	64
Stage II %	7
Stage III %	7
Stage IV %	21
Total screen-detected lung cancers	14
Name	Pam Worthy
Title	Program Director
Email	pam.worthy@mcleodhealth.org
Phone	(843)-777-5926
User ID	Noah Kleckner
Facility ID	1909

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	307
Total number of people screened in	311
Screen-eligible Rate	99
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	150
Total number of people who received baseline screening LDCT scans in (with and without SDM)	150
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	152
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	242
Follow-up Rate %	63
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	8
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	14
Follow-up Rate %	57
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	7
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	10
Follow-up Rate %	70
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	7
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	7
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	5
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	5
Total nonsurgical lung biopsies in	44
Nonmalignant/Nondiagnostic Biopsy Rate %	11
	Yes
	Yes
Stage I	2
Stage II	0
Stage III	1
Stage IV	0
Stage I %	67
Stage II %	0
Stage III %	33
Stage IV %	0
Total screen-detected lung cancers	3
Name	Pam Worthy
Title	Program Director
Email	pam.worthy@mcleodhealth.org
Phone	(843)-777-5926
User ID	Noah Kleckner
Facility ID	1905

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	379
Total number of people screened in	385
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	186
Total number of people who received baseline screening LDCT scans in (with and without SDM)	186
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	188
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	299
Follow-up Rate %	63
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	10
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	17
Follow-up Rate %	59
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	9
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	12
Follow-up Rate %	75
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	9
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	9
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	6
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	6
Total nonsurgical lung biopsies in	54
Nonmalignant/Nondiagnostic Biopsy Rate %	11
	Yes
	Yes
Stage I	2
Stage II	1
Stage III	0
Stage IV	1
Stage I %	50
Stage II %	25
Stage III %	0
Stage IV %	25
Total screen-detected lung cancers	4
Name	Pam Worthy
Title	Program Director
Email	pam.worthy@mcleodhealth.org
Phone	(843)-777-5926
User ID	Noah Kleckner
Facility ID	1904

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	445
Total number of people screened in	452
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	218
Total number of people who received baseline screening LDCT scans in (with and without SDM)	218
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	221
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	351
Follow-up Rate %	63
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	12
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	20
Follow-up Rate %	60
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	11
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	14
Follow-up Rate %	79
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	10
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	11
Follow-up Rate %	91
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	7
Nonmalignant Resection Rate %	14
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	7
Total nonsurgical lung biopsies in	64
Nonmalignant/Nondiagnostic Biopsy Rate %	11
	Yes
	Yes
Stage I	7
Stage II	1
Stage III	0
Stage IV	0
Stage I %	88
Stage II %	13
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	8
Name	Pam Worthy
Title	Program Director
Email	pam.worthy@mcleodhealth.org
Phone	(843)-777-5926
User ID	Noah Kleckner
Facility ID	1906

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	2,151
Total number of people screened in	2,184
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,054
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,054
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	1,067
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,694
Follow-up Rate %	63
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	57
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	95
Follow-up Rate %	60
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	51
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	67
Follow-up Rate %	76
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	49
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	53
Follow-up Rate %	92
Surgical lung resections with benign (nonmalignant) pathology in	3
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	32
Nonmalignant Resection Rate %	9
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	32
Total nonsurgical lung biopsies in	309
Nonmalignant/Nondiagnostic Biopsy Rate %	10
	Yes
	Yes
Stage I	18
Stage II	5
Stage III	5
Stage IV	5
Stage I %	55
Stage II %	15
Stage III %	15
Stage IV %	15
Total screen-detected lung cancers	33
Name	Pam Worthy
Title	Program Director
Email	pam.worthy@mcleodhealth.org
Phone	(843)-777-5926
User ID	Noah Kleckner
Facility ID	1792

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Thoracic Oncology	Yes
Select all that apply	NCCN, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	CAP, NCCN
Multidisciplinary Team	Yes
Comments	Dedicated lung tumor board and brick and mortar clinic for multidisciplinary lung cancer clinic
Care Plan	Yes
Comments	At the multi-D setting, social work is assigned to each patient and any patient with stage 4 diagnosis has palliative care involvment.
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry, Central or state cancer registry, NCI
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Comments	Specifically worked on genetic and biomarker testing, now routine for surveillance (Natera)
Board Certified	Yes
Name	Maurice Smith, MD
Title	Thoracic Surgeon/Chief of Staff
Email	rmacellino@frederick.health
Phone	(301)-694-5864
User ID	Tammy Welch
Facility ID	2018

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Comments	unable to pull this report and we were in between navigators.
Tracking Adherence	Yes
Comments	epic patient lists
Select all that apply	Manual tracking (Excel, etc.), Other (free text)
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures, Established internal quality dashboard, Internal Morbidity and Mortality or risk management review policy and procedure
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	0
Total nonsurgical lung biopsies in patients with IPN in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Comments	unable to pull this report and we were in between navigators.
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Identification of IPNs on imaging by AI, IPNs identified by CPT codes
Name	Jacqueline Boyett
Title	Lung Navigator
Email	jacqueline.boyett@adventhealth.com
Phone	(813)-615-7398
User ID	Tiffany Taylor
Facility ID	1969

Access to guideline-directed testing for molecular and immune biomarkers with NGS technology in all patients with guideline eligible tumors (when clinically appropriate) to determine eligibility for targeted therapies or immunotherapies.	Yes
Biomarker and PD-L1 results are reviewed and discussed with patients once results are available. Discussion includes the clinical implications and therapeutic options based on these results.	Yes
When appropriate, guideline directed PD-L1 and biomarker testing are integrated into treatment decisions before systemic therapy is initiated.	Yes
In the setting of disease progression on FDA approved therapy, updated PD-L1 and biomarker testing is utilized to identify next therapeutic option.	Yes
In the setting of disease progression, updated PD-L1 and biomarker testing is utilized to confirm need for clinical trial referral when FDA approved therapeutics are not an option.	Yes
Calculated Section Total	5
Qualification Status	Qualified
Rapid on-site evaluation (ROSE), when available to increase diagnostic and molecular yield.	Yes
Utilization of liquid biopsy modalities in the setting of tissue insufficiency or unavailability and points of disease progression.	Yes
Name	Melissa Aune
Title	Health Program Coordinator
Email	melissa.aune@sanfordhealth.org
Phone	(701)-234-5308
User ID	Melissa Aune
Facility ID	1247

A patient-centered discussion about the potential benefits and harms of lung cancer treatment occurs at each point of the patient’s cancer care journey.	Yes
Biomarker Testing: Access to and compliance with guideline-directed testing for molecular and immune biomarkers with NGS technology in all patients with guideline-eligible tumors (when clinically appropriate). Using NGS results, consistently identify actionable mutations and eligiblity for guideline-directed targeted therapies or immunotherapies.	Yes
Medical Oncology: Compliance with practice standards for the diagnostic workup, staging, and medical oncology (disease specific) treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Radiation Oncology: Compliance with practice standards for the diagnostic workup, staging, and radiation treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Thoracic Oncology: Compliance with practice standards for the diagnostic workup, staging, and surgical treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Pathology: Comply with practice standards based on evidence, expert consensus, and practice guidelines for pathologic evaluation of malignancies.	Yes
Actively engage or have access to multidisciplinary expert input by way of tumor board or other team-based mechanism, including virtual.	Yes
Commitment and care delivery mechanisms are in place that standardizes consistent communication with patients and their active care providers about test results, diagnostic workup, and management plan.	Yes
Contribute to aggregated collection of relevant data and report to a cancer registry. (hospital, central or state, or special purpose registry, NPCR, NCI, SEER)	Yes
Ask about current smoking status and, as appropriate, advise to quit. Provide or refer for cessation services.	Yes
Calculated Section Total	10
Qualification Status	Qualified
Internal clinical outcomes review and quality improvement process.	Yes
Thoracic Oncologist(s) are board certified thoracic or cardio-thoracic surgeons.	Yes
Name	Melissa Aune
Title	Health Program Coordinator
Email	melissa.aune@sanfordhealth.org
Phone	(701)-234-5308
User ID	Melissa Aune
Facility ID	1247

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	989
Total number of people screened in	1,030
Screen-eligible Rate	96
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	563
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	884
Follow-up Rate %	64
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	48
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	64
Follow-up Rate %	75
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	22
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	26
Follow-up Rate %	85
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	29
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	34
Follow-up Rate %	85
Surgical lung resections with benign (nonmalignant) pathology in	1
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	33
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	2
Total nonsurgical lung biopsies in	16
Nonmalignant/Nondiagnostic Biopsy Rate %	13
	Yes
	Yes
Stage I	13
Stage II	1
Stage III	3
Stage IV	2
Stage I %	68
Stage II %	5
Stage III %	16
Stage IV %	11
Total screen-detected lung cancers	19
Name	Nicole Vogelsang
Title	Lung Nurse Navigator
Email	nrvogelsang@mercy.com
Phone	(513)-478-7706
User ID	Nicole Vogelsang
Facility ID	1358

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	482
Total number of people screened in	565
Screen-eligible Rate	85
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	565
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	268
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	324
Follow-up Rate %	83
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	27
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	30
Follow-up Rate %	90
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	13
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	13
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	16
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	16
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	40
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	641
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	No
	No
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Jacqueline Boyett
Title	Lung Navigator
Email	Jacqueline.boyett@adventhealth.com
Phone	(813)-615-7398
User ID	Tiffany Taylor
Facility ID	1969

Patients with lung cancer (Stage IB and higher) who receive biomarker testing at the time of diagnosis in	35
Total patients diagnosed with lung cancer (Stage IB and higher) in	38
Biomarker Testing at Diagnosis Rate %	92
Comments	the 3 patients who did not get testing within 30 days did get the testing one at 31 , 35 and 120 days after diagnosis
Results Documented	Yes
Testing Before Systemic Therapy	Yes
Patients with disease progression on targeted therapy or immunotherapy +/- chemo who receive biomarker testing in	14
Total patients with disease progression on targeted therapy or immunotherapy +/- chemo in	14
Progression Biomarker Testing Rate %	100
Clinical Trials Review	Yes
Referral Testing	Yes
Liquid Biopsy	Yes
Negative Liquid Biopsy Tissue	Yes
Score	6
Qualification Status	Qualified
Checkpoint Inhibitors	Yes
Comprehensive Testing	Yes
Comments	Tempus Next
Name	Kathryn Campuzano
Title	Thoracic Oncology / Screening Navigator
Email	KCampuzano@memorialcare.org
Phone	(562)-480-7747
User ID	KATHRYN CAMPUZANO
Facility ID	2089

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Andrea Gresnick
Title	Regional Lung Health Coordinator
Email	agresnick@primehealthcare.com
Phone	(816)-943-7650
User ID	Andrea Gresnick
Facility ID	2240

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Andrea Gresnick
Title	Regional Lung Health Coordinator
Email	agresnick@primehealthcare.com
Phone	(816)-943-7650
User ID	Andrea Gresnick
Facility ID	2240

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	No
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Blair Ford
Title	Thoracic Surgery Nurse Practitioner
Email	blair.ford@centrahealth.com
Phone	(434)-200-3100
User ID	Blair Ford
Facility ID	1569

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	No
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Blair Ford
Title	Thoracic Surgery Nurse Practitioner
Email	blair.ford@centrahealth.com
Phone	(434)-200-3100
User ID	Blair Ford
Facility ID	1336

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	No
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Blair Ford
Title	Thoracic Surgery Nurse Practitioner
Email	blair.ford@centrahealth.com
Phone	(434)-200-3100
User ID	Blair Ford
Facility ID	1571

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,230
Total number of people screened in	1,254
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,230
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,254
SDM Documentation Rate	98
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	510
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,206
Follow-up Rate %	42
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Stephonie Zwald
Title	Clinical Program Coordinator RN
Email	stephonie.zwald@providence.org
Phone	(707)-445-8121
User ID	Stephonie Zwald
Facility ID	1020

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Raymond Andreas
Title	Nurse Navigator Lung Oncology
Email	andrearr01@ah.org
Phone	(661)-863-2329
User ID	Raymond Andreas
Facility ID	2243

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	287
Total number of people screened in	289
Screen-eligible Rate	99
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	200
Total number of people who received baseline screening LDCT scans in (with and without SDM)	200
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	3
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	3
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	3
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	4
Follow-up Rate %	75
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	3
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	No
	No
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Jennifer Kummerfeldt
Title	Director of Population Health
Email	jkummerfeldt@masongeneral.com
Phone	(360)-426-2653
User ID	Jennifer Kummerfeldt
Facility ID	2077

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN, ASCO
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, ASTRO, NCCN
Thoracic Oncology	Yes
Select all that apply	NCCN, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Central or state cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Comments	We meet quarterly with our Cancer Committee
Board Certified	Yes
Name	Kathryn Campuzano
Title	Thoracic Oncology / Screening Navigator
Email	KCampuzano@memorialcare.org
Phone	(562)-480-7747
User ID	KATHRYN CAMPUZANO
Facility ID	2089

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	209
Total number of people screened in	225
Screen-eligible Rate	93
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	68
Total number of people who received baseline screening LDCT scans in (with and without SDM)	74
SDM Documentation Rate	92
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	No
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	104
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	151
Follow-up Rate %	69
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	8
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	13
Follow-up Rate %	62
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	4
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	6
Follow-up Rate %	67
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	2
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	3
Follow-up Rate %	67
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	1
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	No
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Kathryn Campuzano
Title	Thoracic Oncology / Screening Navigator
Email	KCampuzano@memorialcare.org
Phone	(562)-480-7747
User ID	KATHRYN CAMPUZANO
Facility ID	2089

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Andrea Gresnick
Title	Regional Lung Health Coordinator
Email	agresnick@primehealthcare.com
Phone	(816)-943-7650
User ID	Andrea Gresnick
Facility ID	2238

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Andrea Gresnick
Title	Regional Lung Health Coordinator
Email	agresnick@primehealthcare.com
Phone	(816)-943-7650
User ID	Andrea Gresnick
Facility ID	2238

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	4,094
Total number of people screened in	4,152
Screen-eligible Rate	99
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,302
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,447
SDM Documentation Rate	90
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	2,583
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	3,735
Follow-up Rate %	69
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	162
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	207
Follow-up Rate %	78
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	127
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	136
Follow-up Rate %	93
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	90
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	94
Follow-up Rate %	96
Surgical lung resections with benign (nonmalignant) pathology in	5
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	10
Nonmalignant Resection Rate %	50
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	53
Total nonsurgical lung biopsies in	107
Nonmalignant/Nondiagnostic Biopsy Rate %	50
	Yes
	Yes
Stage I	37
Stage II	3
Stage III	9
Stage IV	6
Stage I %	67
Stage II %	5
Stage III %	16
Stage IV %	11
Total screen-detected lung cancers	55
Name	Sandra
Title	Kohut
Email	kohuts@summahealth.org
Phone	(330)-375-6899
User ID	Sandy Kohut
Facility ID	1415

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	18
Total number of people screened in	18
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	5
Total number of people who received baseline screening LDCT scans in (with and without SDM)	5
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	23
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	29
Follow-up Rate %	79
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	1
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	1
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	1
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	1
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Sarah Valenti
Title	Nurse Practitioner
Email	sarah.debelak@vumc.org
Phone	(615)-322-0580
User ID	Sarah Valenti
Facility ID	1918

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Sarah Valenti
Title	Nurse Pracitioner
Email	sarah.debelak@vumc.org
Phone	(615)-322-0580
User ID	Sarah Valenti
Facility ID	1932

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	256
Total number of people screened in	270
Screen-eligible Rate	95
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	120
Total number of people who received baseline screening LDCT scans in (with and without SDM)	120
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	164
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	205
Follow-up Rate %	80
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	10
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	11
Follow-up Rate %	91
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	7
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	8
Follow-up Rate %	88
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	4
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	4
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	1
Total nonsurgical lung biopsies in	3
Nonmalignant/Nondiagnostic Biopsy Rate %	33
	Yes
	Yes
Stage I	2
Stage II	0
Stage III	0
Stage IV	2
Stage I %	50
Stage II %	0
Stage III %	0
Stage IV %	50
Total screen-detected lung cancers	4
Name	Sarah Valenti
Title	Nurse Practitioner
Email	sarah.debelak@vumc.org
Phone	(615)-322-0580
User ID	Sarah Valenti
Facility ID	1917

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,168
Total number of people screened in	1,230
Screen-eligible Rate	95
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	245
Total number of people who received baseline screening LDCT scans in (with and without SDM)	245
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	820
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,027
Follow-up Rate %	80
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	47
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	53
Follow-up Rate %	89
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	33
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	36
Follow-up Rate %	92
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	19
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	19
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	7
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	4
Total nonsurgical lung biopsies in	16
Nonmalignant/Nondiagnostic Biopsy Rate %	25
	Yes
	Yes
Stage I	8
Stage II	0
Stage III	1
Stage IV	2
Stage I %	73
Stage II %	0
Stage III %	9
Stage IV %	18
Total screen-detected lung cancers	11
Name	Sarah Valenti
Title	Nurse Practitioer
Email	sarah.debelak@vumc.org
Phone	(615)-322-0580
User ID	Sarah Valenti
Facility ID	1109

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	219
Total number of people screened in	227
Screen-eligible Rate	96
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	110
Total number of people who received baseline screening LDCT scans in (with and without SDM)	110
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	141
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	176
Follow-up Rate %	80
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	8
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	9
Follow-up Rate %	89
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	6
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	6
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	3
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	3
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	1
Total nonsurgical lung biopsies in	3
Nonmalignant/Nondiagnostic Biopsy Rate %	33
	Yes
	Yes
Stage I	1
Stage II	0
Stage III	0
Stage IV	2
Stage I %	33
Stage II %	0
Stage III %	0
Stage IV %	67
Total screen-detected lung cancers	3
Name	Sarah Valenti
Title	Nurse Pracitioner
Email	sarah.debelak@vumc.org
Phone	(615)-322-0580
User ID	Sarah Valenti
Facility ID	1916

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	252
Total number of people screened in	261
Screen-eligible Rate	97
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	75
Total number of people who received baseline screening LDCT scans in (with and without SDM)	75
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	164
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	205
Follow-up Rate %	80
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	9
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	10
Follow-up Rate %	90
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	7
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	8
Follow-up Rate %	88
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	4
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	4
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	1
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	1
Total nonsurgical lung biopsies in	3
Nonmalignant/Nondiagnostic Biopsy Rate %	33
	Yes
	Yes
Stage I	2
Stage II	0
Stage III	0
Stage IV	2
Stage I %	50
Stage II %	0
Stage III %	0
Stage IV %	50
Total screen-detected lung cancers	4
Name	Sarah Valenti
Title	Nurse Pracitioner
Email	sarah.debelak@vumc.org
Phone	(615)-322-0580
User ID	Sarah Valenti
Facility ID	1494

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	695
Total number of people screened in	743
Screen-eligible Rate	94
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	195
Total number of people who received baseline screening LDCT scans in (with and without SDM)	195
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	492
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	619
Follow-up Rate %	79
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	29
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	31
Follow-up Rate %	94
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	20
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	22
Follow-up Rate %	91
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	12
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	12
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	4
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	3
Total nonsurgical lung biopsies in	9
Nonmalignant/Nondiagnostic Biopsy Rate %	33
	Yes
	Yes
Stage I	5
Stage II	0
Stage III	1
Stage IV	1
Stage I %	71
Stage II %	0
Stage III %	14
Stage IV %	14
Total screen-detected lung cancers	7
Name	Sarah Valenti
Title	Nurse Practitoner
Email	sarah.debelak@vumc.org
Phone	(615)-322-0580
User ID	Sarah Valenti
Facility ID	1493

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	141
Total number of people screened in	170
Screen-eligible Rate	83
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	20
Total number of people who received baseline screening LDCT scans in (with and without SDM)	55
SDM Documentation Rate	36
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	84
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	106
Follow-up Rate %	79
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	7
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	8
Follow-up Rate %	88
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	1
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	2
Follow-up Rate %	50
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	No
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Kristi Crisafulli
Title	Lung Cancer Screening Coordinator, RN
Email	kristiroberts@tgh.org
Phone	(352)-406-7871
User ID	Kristi Crisafulli
Facility ID	1966

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Sarah Valenti
Title	Nurse Practitioner
Email	sarah.debelak@vumc.org
Phone	(615)-322-0580
User ID	Sarah Valenti
Facility ID	2227

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Sarah Valenti
Title	Nurse Practitioner
Email	sarah.debelak@vumc.org
Phone	(615)-322-0580
User ID	Sarah Valenti
Facility ID	1931

Patient Discussion	Yes
Comments	Patient-centered discussions about the potential benefits and harms of lung cancer treatment occur at each point of the patient's care journey, as evidenced by documentation from our Thoracic Medical Oncologist regarding a patient receiving treatment. "We discussed the possible benefits and side effects of chemoimmunotherapy in detail and informed consent was obtained-see below". In addition, our Patient Service Line Navigator, registered nurse, documents on all new oncology patients with referrals utilizing smart phrases such as “Provided counseling and emotional support to the Patient. Ensured autonomous decision making by the patient through personalized education and support. Coordinated patient specific plan of care by taking into consideration personal and cultural preferences to create a holistic cancer care plan with the patient”.
Biomarker Testing	Yes
Comments	Our Pathology Department completes all necessary testing to identify actionable mutations and determine eligibility for guideline-directed targeted therapies or immunotherapies.
Medical Oncology	Yes
Comments	The focus of Tampa General Hospital is to follow AJCC staging and NCCN guidelines. Utilizing our EMR system, EPIC, we document and focus on clinical staging as noted in the consultation note. In addition, we compare the clinical stage to the pathological stage to ensure accuracy. Per TGH policy, PD-L1 and NGS testing are performed on both blood and tissue specimens. Smart phrase templates are utilized throughout documentation to include all pertinent information. This includes smart phrases for chemotherapy education and tobacco cessation. We find that multidisciplinary care is key. Therefore, tumor board conferences, documentation in EPIC, and provider-to-provider discussions occur throughout the patient's care. This includes, but is not limited to, interventional radiologists, pulmonologists, thoracic surgeons, and nurse navigators.
Select all that apply	NCCN
Radiation Oncology	Yes
Comments	Our program adheres to the practice standards established by the relevant professional organizations, and we document discussions when individualized patient care results in deviation.
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Thoracic Oncology	Yes
Comments	As noted, the TGH Cancer Institute prides itself on a multidisciplinary approach to patient care by following practice guidelines and ensuring that TGH policies align with established practice standards.
Select all that apply	NCCN, STS, TNM Stage Classification for Lung Cancer
Pathology	Yes
Comments	Tampa General is a CAP-accredited hospital and follows the synoptic operative reporting with the Commission on Cancer. Additional testing is part of TGH policy based on guidelines and discussions with our Medical Oncologists.
Select all that apply	CAP
Multidisciplinary Team	Yes
Comments	TGH holds a Thoracic Tumor Board two to three times per month, every second, fourth, and fifth Thursday. We utilize the platform Oncolens to provide a detailed and concise outline of the patient's history, diagnosis, imaging, pathology, treatment, NCCN guidelines, and clinical trials. This information is documented and sent back to the patient's chart within EPIC, our EMR system. The tumor board includes medical oncologists, radiation oncologists, thoracic surgeons, interventional pulmonologists, radiologists, pathologists, and nurses to provide multidisciplinary care for the patient.
Care Plan	Yes
Comments	Our healthcare teams utilize smart phrases within our EMR, EPIC, to maintain consistency in discussion and documentation with and for patients. As previously mentioned, the Oncolens platform used for Thoracic Tumor Board has organized sections to ensure consistency and completeness in the discussions of each patient's case.
Cancer Registry	Yes
Comments	Yes, including the Florida Cancer Data System (FCDS), the National Cancer Database (NCDB), and the STS/ACC TVT Registry, a national clinical data collection system run jointly by the Society of Thoracic Surgeons and the American College of Cardiology.
Select all that apply	Central or state cancer registry, Special-purpose (internal or external) registry
Cessation Support	Yes
Comments	TGH Cancer Institute follows the standards set forth by the Commission on Cancer Standard 5.9: Smoking Cessation for Patients with Cancer Definitions and Requirements. Furthermore, this is evident from our Medical Oncologist's documentation, "3. Smoking Cessation -Counseled patient on importance of smoking cessation and gave community resources for cessation.".
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Comments	American Board of Thoracic Surgery
Name	Kristi Crisafulli
Title	Lung Cancer Screening Coordinator, RN
Email	kristiroberts@tgh.org
Phone	(813)-844-4278
User ID	Kristi Crisafulli
Facility ID	1965

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	786
Total number of people screened in	805
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	405
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	591
Follow-up Rate %	69
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	38
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	56
Follow-up Rate %	68
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	22
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	34
Follow-up Rate %	65
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	6
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	6
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	3
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	12
Nonmalignant Resection Rate %	25
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	1
Total nonsurgical lung biopsies in	3
Nonmalignant/Nondiagnostic Biopsy Rate %	33
	Yes
	Yes
Stage I	9
Stage II	0
Stage III	1
Stage IV	0
Stage I %	90
Stage II %	0
Stage III %	10
Stage IV %	0
Total screen-detected lung cancers	10
Name	Nicole Gay
Title	APRN
Email	nxg596@miami.edu
Phone	(305)-243-9134
User ID	Nicole Gay
Facility ID	1053

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	200
Total number of people screened in	207
Screen-eligible Rate	97
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	84
Total number of people who received baseline screening LDCT scans in (with and without SDM)	84
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	104
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	149
Follow-up Rate %	70
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	10
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	14
Follow-up Rate %	71
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	10
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	10
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	3
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	3
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	No
	Yes
Stage I	1
Stage II	1
Stage III	1
Stage I %	33
Stage II %	33
Stage III %	33
Stage IV %	0
Total screen-detected lung cancers	3
Name	Kimberly Pullen
Title	Lung Navigator
Email	kimberly.pullen@inova.org
Phone	(703)-307-0232
User ID	Kimberly Pullen
Facility ID	1015

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	835
Total number of people screened in	835
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	280
Total number of people who received baseline screening LDCT scans in (with and without SDM)	280
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	539
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	713
Follow-up Rate %	76
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	43
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	47
Follow-up Rate %	91
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	33
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	36
Follow-up Rate %	92
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	14
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	16
Follow-up Rate %	88
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	1
Total nonsurgical lung biopsies in	9
Nonmalignant/Nondiagnostic Biopsy Rate %	11
	Yes
	Yes
Stage I	2
Stage II	1
Stage III	2
Stage IV	3
Stage I %	25
Stage II %	13
Stage III %	25
Stage IV %	38
Total screen-detected lung cancers	8
Name	Katelyn Grados
Title	Lung Screening Program Coordinator
Email	kmg0322@mountnittany.org
Phone	(814)-231-6881
User ID	Katelyn Grados
Facility ID	1559

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Comments	LNT meets every Tuesday at 1145 typically review 10-18 patient per week- high risk nodules > 9 mm
Communication Process	Yes
Comments	Eon communication letters/calls
Cessation Support	No
Comments	not all IPN patients get counseling
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Comments	we do not collect data about radiation doses on IPN patients
Tracking Adherence	Yes
Comments	Eon with quarterly adherence reports
Select all that apply	Tracking software
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	1
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	17
Nonmalignant Resection Rate %	6
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	10
Total nonsurgical lung biopsies in patients with IPN in	33
Nonmalignant/Nondiagnostic Biopsy Rate %	30
Score	5
Institutional Workflows	Yes
Comments	AI picks up IPNs, not an actual referral
Institutional Tools	Yes
Comments	Eon
Select all that apply	Natural Language Processing program
Name	Amie J. Miller
Title	APRN
Email	amie-miller@smh.com
Phone	(941)-928-0223
User ID	Amie Miller
Facility ID	1400

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,577
Total number of people screened in	1,603
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	597
Total number of people who received baseline screening LDCT scans in (with and without SDM)	597
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	350
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	542
Follow-up Rate %	65
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	29
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	34
Follow-up Rate %	85
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	29
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	32
Follow-up Rate %	91
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	20
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	21
Follow-up Rate %	95
Surgical lung resections with benign (nonmalignant) pathology in	4
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	19
Nonmalignant Resection Rate %	21
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	13
Total nonsurgical lung biopsies in	31
Nonmalignant/Nondiagnostic Biopsy Rate %	42
	Yes
	Yes
Stage I	15
Stage II	3
Stage III	4
Stage IV	2
Stage I %	63
Stage II %	13
Stage III %	17
Stage IV %	8
Total screen-detected lung cancers	24
Name	Amie J. Miller APRN
Title	APRN
Email	amiemillerarnp@gmail.com
Phone	(941)-262-8242
User ID	Amie Miller
Facility ID	1400

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Comments	NCCN
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Thoracic Oncology	Yes
Select all that apply	AATS, NCCN, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Comments	•Florida Cancer Data System • and National Cancer Data Base
Select all that apply	Central or state cancer registry
Cessation Support	Yes
Comments	per CoC new standard
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Amie J. Miller
Title	APRN
Email	amie-miller@smh.com
Phone	(941)-928-0223
User ID	Amie Miller
Facility ID	1400

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,665
Total number of people screened in	1,665
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	471
Total number of people who received baseline screening LDCT scans in (with and without SDM)	471
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	1,194
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	88
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	34
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	54
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	2
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	16
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	No
Stage I	14
Stage II	0
Stage III	2
Stage IV	1
Stage I %	82
Stage II %	0
Stage III %	12
Stage IV %	6
Total screen-detected lung cancers	17
Name	Fatima Rocco-DiPietro
Title	Lung Cancer Screening Program Coordinator
Email	frocco@elliot-hs.org
Phone	(603)-663-1833
User ID	Fatima Rocco
Facility ID	1847

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN, ASCO
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, ASTRO, NCCN
Thoracic Oncology	Yes
Select all that apply	AATS, ACCP, NCCN, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Central or state cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Joanna Thompson
Title	Director, Multidisciplinary Programs
Email	jthompson@hogonc.com
Phone	(479)-587-1700
User ID	Joanna Thompson
Facility ID	1126

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	200
Total number of people screened in	207
Screen-eligible Rate	97
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	84
Total number of people who received baseline screening LDCT scans in (with and without SDM)	84
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	104
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	149
Follow-up Rate %	70
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	10
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	14
Follow-up Rate %	71
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	10
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	10
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	3
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	3
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	No
	Yes
Stage I	1
Stage II	1
Stage III	1
Stage I %	33
Stage II %	33
Stage III %	33
Stage IV %	0
Total screen-detected lung cancers	3
Name	Kimberly Pullen
Title	Lung Navigator
Email	kimberly.pullen@inova.org
Phone	(703)-307-0232
User ID	Kimberly Pullen
Facility ID	1017

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	497
Total number of people screened in	497
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	497
Total number of people who received baseline screening LDCT scans in (with and without SDM)	497
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	203
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	387
Follow-up Rate %	52
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	24
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	25
Follow-up Rate %	96
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	10
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	16
Follow-up Rate %	63
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	13
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	15
Follow-up Rate %	87
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Heather Anderson
Title	Clinical Registrar I
Email	heather.anderson@salemhealth.org
Phone	(503)-814-1466
User ID	Sarah McCall
Facility ID	1928

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,226
Total number of people screened in	1,226
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,226
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,226
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	584
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,213
Follow-up Rate %	48
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	46
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	46
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	33
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	38
Follow-up Rate %	87
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	21
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	24
Follow-up Rate %	88
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Heather Anderson
Title	Clinical Registrar I
Email	heather.anderson@salemhealth.org
Phone	(503)-814-1466
User ID	Sarah McCall
Facility ID	1085

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Comments	not tracked
Tracking Adherence	Yes
Select all that apply	EHR appointment recall system
Outcomes Review	Yes
Select all that apply	Established internal quality dashboard
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	0
Total nonsurgical lung biopsies in patients with IPN in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Comments	not tracked
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program, Identification of IPNs on imaging by AI
Name	Kimberly Pullen
Title	Lung Navigator
Email	kimberly.pullen@inova.org
Phone	(703)-307-0232
User ID	Kimberly Pullen
Facility ID	1017

Patients with lung cancer (Stage IB and higher) who receive biomarker testing at the time of diagnosis in	100
Total patients diagnosed with lung cancer (Stage IB and higher) in	100
Biomarker Testing at Diagnosis Rate %	100
Results Documented	Yes
Testing Before Systemic Therapy	Yes
Patients with disease progression on targeted therapy or immunotherapy +/- chemo who receive biomarker testing in	0
Total patients with disease progression on targeted therapy or immunotherapy +/- chemo in	0
Progression Biomarker Testing Rate %	0
Comments	NA
Clinical Trials Review	Yes
Referral Testing	Yes
Liquid Biopsy	Yes
Negative Liquid Biopsy Tissue	Yes
Score	6
Qualification Status	Qualified
Checkpoint Inhibitors	Yes
Comprehensive Testing	Yes
Name	Kimberly Pullen
Title	Lung Navigator
Email	kimberly.pullen@inova.org
Phone	(703)-307-0232
User ID	Kimberly Pullen
Facility ID	1017

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,934
Total number of people screened in	1,934
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	734
Total number of people who received baseline screening LDCT scans in (with and without SDM)	734
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	1,135
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,985
Follow-up Rate %	57
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	53
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	82
Follow-up Rate %	65
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	46
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	55
Follow-up Rate %	84
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	17
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	32
Follow-up Rate %	53
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	3
Stage II	2
Stage III	4
Stage IV	4
Stage I %	23
Stage II %	15
Stage III %	31
Stage IV %	31
Total screen-detected lung cancers	13
Name	Coreena Sowa
Title	RN, Program Coordinator
Email	csowa@kh.org
Phone	(208)-625-5864
User ID	Coreena (Cori) Sowa
Facility ID	1822

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	418
Total number of people screened in	418
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	91
Total number of people who received baseline screening LDCT scans in (with and without SDM)	91
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	245
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	245
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	35
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	35
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	20
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	20
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	13
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	13
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	1
Stage III	1
Stage IV	4
Stage I %	0
Stage II %	17
Stage III %	17
Stage IV %	67
Total screen-detected lung cancers	6
Name	Emily May
Title	Director-Screening and Outreach
Email	emily.may@commonspirit.org
Phone	(859)-967-5673
User ID	Emily May
Facility ID	1469

A patient-centered discussion about the potential benefits and harms of lung cancer treatment occurs at each point of the patient’s cancer care journey.	Yes
Biomarker Testing: Access to and compliance with guideline-directed testing for molecular and immune biomarkers with NGS technology in all patients with guideline-eligible tumors (when clinically appropriate). Using NGS results, consistently identify actionable mutations and eligiblity for guideline-directed targeted therapies or immunotherapies.	Yes
Medical Oncology: Compliance with practice standards for the diagnostic workup, staging, and medical oncology (disease specific) treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Radiation Oncology: Compliance with practice standards for the diagnostic workup, staging, and radiation treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Thoracic Oncology: Compliance with practice standards for the diagnostic workup, staging, and surgical treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Pathology: Comply with practice standards based on evidence, expert consensus, and practice guidelines for pathologic evaluation of malignancies.	Yes
Actively engage or have access to multidisciplinary expert input by way of tumor board or other team-based mechanism, including virtual.	Yes
Commitment and care delivery mechanisms are in place that standardizes consistent communication with patients and their active care providers about test results, diagnostic workup, and management plan.	Yes
Contribute to aggregated collection of relevant data and report to a cancer registry. (hospital, central or state, or special purpose registry, NPCR, NCI, SEER)	Yes
Ask about current smoking status and, as appropriate, advise to quit. Provide or refer for cessation services.	Yes
Calculated Section Total	10
Qualification Status	Qualified
Internal clinical outcomes review and quality improvement process.	Yes
Thoracic Oncologist(s) are board certified thoracic or cardio-thoracic surgeons.	Yes
Name	Joan Lafranchise
Title	Director Clinical Programs, Oncology Service Line
Email	joan.lafranchise@ascension.org
Phone	(912)-713-4966
User ID	Becky Bonds
Facility ID	2134

A patient-centered discussion about the potential benefits and harms of lung cancer treatment occurs at each point of the patient’s cancer care journey.	Yes
Biomarker Testing: Access to and compliance with guideline-directed testing for molecular and immune biomarkers with NGS technology in all patients with guideline-eligible tumors (when clinically appropriate). Using NGS results, consistently identify actionable mutations and eligiblity for guideline-directed targeted therapies or immunotherapies.	Yes
Medical Oncology: Compliance with practice standards for the diagnostic workup, staging, and medical oncology (disease specific) treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Radiation Oncology: Compliance with practice standards for the diagnostic workup, staging, and radiation treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Thoracic Oncology: Compliance with practice standards for the diagnostic workup, staging, and surgical treatment of all lung cancer types based on evidence, expert consensus, and practice guidelines for cancer care and treatment.	Yes
Pathology: Comply with practice standards based on evidence, expert consensus, and practice guidelines for pathologic evaluation of malignancies.	Yes
Actively engage or have access to multidisciplinary expert input by way of tumor board or other team-based mechanism, including virtual.	Yes
Commitment and care delivery mechanisms are in place that standardizes consistent communication with patients and their active care providers about test results, diagnostic workup, and management plan.	Yes
Contribute to aggregated collection of relevant data and report to a cancer registry. (hospital, central or state, or special purpose registry, NPCR, NCI, SEER)	Yes
Ask about current smoking status and, as appropriate, advise to quit. Provide or refer for cessation services.	Yes
Calculated Section Total	10
Qualification Status	Qualified
Internal clinical outcomes review and quality improvement process.	Yes
Thoracic Oncologist(s) are board certified thoracic or cardio-thoracic surgeons.	Yes
Name	Joan LaFranchise
Title	Director Clinical Programs, Oncology Service Line
Email	joan.lafranchise@ascension.org
Phone	(912)-713-4966
User ID	Becky Bonds
Facility ID	2234

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	302
Total number of people screened in	302
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	119
Total number of people who received baseline screening LDCT scans in (with and without SDM)	119
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	137
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	137
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	15
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	15
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	5
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	5
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	4
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	4
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	1
Stage II	1
Stage III	2
Stage IV	10
Stage I %	7
Stage II %	7
Stage III %	14
Stage IV %	71
Total screen-detected lung cancers	14
Name	Emily May
Title	Director-Screening and Outreach
Email	emily.may@commonspirit.org
Phone	(859)-967-5673
User ID	Emily May
Facility ID	1468

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	226
Total number of people screened in	226
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	48
Total number of people who received baseline screening LDCT scans in (with and without SDM)	48
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	134
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	134
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	30
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	30
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	8
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	8
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	6
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	6
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	9
Total nonsurgical lung biopsies in	25
Nonmalignant/Nondiagnostic Biopsy Rate %	36
	Yes
	Yes
Stage I	4
Stage II	1
Stage III	9
Stage IV	2
Stage I %	25
Stage II %	6
Stage III %	56
Stage IV %	13
Total screen-detected lung cancers	16
Name	Emily May
Title	Director-Screening and Outreach
Email	emily.may@commonspirit.org
Phone	(859)-967-5673
User ID	Emily May
Facility ID	1249

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	724
Total number of people screened in	724
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	161
Total number of people who received baseline screening LDCT scans in (with and without SDM)	161
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	422
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	422
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	101
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	101
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	15
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	15
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	5
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	5
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	79
Total nonsurgical lung biopsies in	168
Nonmalignant/Nondiagnostic Biopsy Rate %	47
	Yes
	Yes
Stage I	16
Stage II	6
Stage III	24
Stage IV	44
Stage I %	18
Stage II %	7
Stage III %	27
Stage IV %	49
Total screen-detected lung cancers	90
Name	Emily May
Title	Director-Screening and Outreach
Email	emily.may@commonspirit.org
Phone	(859)-967-5673
User ID	Emily May
Facility ID	1255

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	724
Total number of people screened in	724
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	161
Total number of people who received baseline screening LDCT scans in (with and without SDM)	161
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	422
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	422
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	101
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	101
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	15
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	15
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	5
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	5
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	79
Total nonsurgical lung biopsies in	168
Nonmalignant/Nondiagnostic Biopsy Rate %	47
	Yes
	Yes
Stage I	16
Stage II	6
Stage III	24
Stage IV	44
Stage I %	18
Stage II %	7
Stage III %	27
Stage IV %	49
Total screen-detected lung cancers	90
Name	Emily May
Title	Director-Screening and Outreach
Email	emily.may@commonspirit.org
Phone	(859)-967-5673
User ID	Emily May
Facility ID	1251

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, ASTRO, NCCN
Thoracic Oncology	Yes
Select all that apply	NCCN, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	ASCO, CAP, NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry, Central or state cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Emily May
Title	Director-Screening and Outreach
Email	emily.may@commonspirit.org
Phone	(859)-967-5673
User ID	Emily May
Facility ID	1255

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, ASTRO, NCCN
Thoracic Oncology	Yes
Select all that apply	NCCN, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	ASCO, CAP, NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry, Central or state cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Emily May
Title	Director-Screening and Outreach
Email	emily.may@commonspirit.org
Phone	(859)-967-5673
User ID	Emily May
Facility ID	1468

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN, ASCO
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, ASTRO, NCCN
Thoracic Oncology	Yes
Select all that apply	NCCN, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	ASCO, CAP, NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry, Central or state cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Emily May
Title	Director-Screening and Outreach
Email	emily.may@commonspirit.org
Phone	(859)-967-5673
User ID	Emily May
Facility ID	1251

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, ASTRO, NCCN
Thoracic Oncology	Yes
Select all that apply	NCCN, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	ASCO, CAP, NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry, Central or state cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Emily May
Title	Director-Screening and Outreach
Email	emily.may@commonspirit.org
Phone	(859)-967-5673
User ID	Emily May
Facility ID	1249

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	405
Total number of people screened in	405
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	100
Total number of people who received baseline screening LDCT scans in (with and without SDM)	100
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	228
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	228
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	45
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	45
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	20
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	20
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	10
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	10
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	2
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	67
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	326
Total nonsurgical lung biopsies in	499
Nonmalignant/Nondiagnostic Biopsy Rate %	65
	Yes
	Yes
Stage I	40
Stage II	17
Stage III	11
Stage IV	49
Stage I %	34
Stage II %	15
Stage III %	9
Stage IV %	42
Total screen-detected lung cancers	117
Name	Emily May
Title	Director-Screening and Outreach
Email	emily.may@commonspirit.org
Phone	(859)-967-5673
User ID	Emily May
Facility ID	1254

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	405
Total number of people screened in	405
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	100
Total number of people who received baseline screening LDCT scans in (with and without SDM)	100
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	228
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	228
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	45
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	45
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	20
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	20
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	10
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	10
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	2
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	67
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	326
Total nonsurgical lung biopsies in	499
Nonmalignant/Nondiagnostic Biopsy Rate %	65
	Yes
	Yes
Stage I	40
Stage II	17
Stage III	11
Stage IV	49
Stage I %	34
Stage II %	15
Stage III %	9
Stage IV %	42
Total screen-detected lung cancers	117
Name	Emily May
Title	Director-Screening and Outreach
Email	emilymay@commonspirit.org
Phone	(859)-967-5673
User ID	Emily May
Facility ID	1252

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	405
Total number of people screened in	405
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	100
Total number of people who received baseline screening LDCT scans in (with and without SDM)	100
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	228
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	228
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	45
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	45
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	20
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	20
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	10
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	10
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	2
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	67
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	326
Total nonsurgical lung biopsies in	499
Nonmalignant/Nondiagnostic Biopsy Rate %	65
	Yes
	Yes
Stage I	40
Stage II	17
Stage III	11
Stage IV	49
Stage I %	34
Stage II %	15
Stage III %	9
Stage IV %	42
Total screen-detected lung cancers	117
Name	Emily May
Title	Director-Screening and Outreach
Email	emily.may@commonspirit.org
Phone	(859)-967-5673
User ID	Emily May
Facility ID	1256

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, ASTRO, NCCN
Thoracic Oncology	Yes
Select all that apply	NCCN, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	ASCO, NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry, Central or state cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Emily May
Title	Director-Breast Center
Email	emily.may@commonspirit.prg
Phone	(859)-967-5673
User ID	Emily May
Facility ID	1893

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	405
Total number of people screened in	405
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	100
Total number of people who received baseline screening LDCT scans in (with and without SDM)	100
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	228
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	228
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	45
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	45
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	20
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	20
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	10
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	10
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	2
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	67
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	326
Total nonsurgical lung biopsies in	499
Nonmalignant/Nondiagnostic Biopsy Rate %	65
	Yes
	Yes
Stage I	40
Stage II	17
Stage III	11
Stage IV	49
Stage I %	34
Stage II %	15
Stage III %	9
Stage IV %	42
Total screen-detected lung cancers	117
Name	Emily May
Title	Director-Screening and Outrech
Email	emily.may@commonspirit.org
Phone	(859)-967-5673
User ID	Emily May
Facility ID	1893

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	405
Total number of people screened in	405
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	100
Total number of people who received baseline screening LDCT scans in (with and without SDM)	100
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	228
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	228
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	45
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	45
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	20
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	20
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	10
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	10
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	2
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	67
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	326
Total nonsurgical lung biopsies in	499
Nonmalignant/Nondiagnostic Biopsy Rate %	65
	Yes
	Yes
Stage I	40
Stage II	17
Stage III	11
Stage IV	49
Stage I %	34
Stage II %	15
Stage III %	9
Stage IV %	42
Total screen-detected lung cancers	117
Name	Emily May
Title	Director-Screening and Outreach
Email	emily.may@commonspirit.org
Phone	(859)-492-7419
User ID	Emily May
Facility ID	1467

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	405
Total number of people screened in	405
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	100
Total number of people who received baseline screening LDCT scans in (with and without SDM)	100
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	228
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	228
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	45
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	45
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	20
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	20
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	10
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	10
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	2
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	67
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	326
Total nonsurgical lung biopsies in	499
Nonmalignant/Nondiagnostic Biopsy Rate %	65
	Yes
	Yes
Stage I	44
Stage II	17
Stage III	20
Stage IV	65
Stage I %	30
Stage II %	12
Stage III %	14
Stage IV %	45
Total screen-detected lung cancers	146
Name	Emily May
Title	Director Screening and Outreach
Email	emily.may@commonspirit.org
Phone	(859)-967-5673
User ID	Emily May
Facility ID	1253

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	162
Total number of people screened in	162
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	162
Total number of people who received baseline screening LDCT scans in (with and without SDM)	162
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	No
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	146
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	163
Follow-up Rate %	90
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	4
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	5
Follow-up Rate %	80
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	8
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	8
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	6
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	7
Follow-up Rate %	86
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Jenn Bainey
Title	RN-Lung Health navigator
Email	jbainey@conemaugh.org
Phone	(814)-534-5212
User ID	Jenn Bainey
Facility ID	1835

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	151
Total number of people screened in	151
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	151
Total number of people who received baseline screening LDCT scans in (with and without SDM)	151
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	No
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	156
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	160
Follow-up Rate %	98
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	14
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	16
Follow-up Rate %	88
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	5
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	5
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	10
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	12
Follow-up Rate %	83
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Jenn Bainey
Title	RN- Lung Health Navgiator
Email	jbainey@conemaugh.org
Phone	(814)-534-5212
User ID	Jenn Bainey
Facility ID	1910

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	No
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Sophia Yeung
Title	Administrative Program Manager
Email	syeung@coh.org
Phone	(626)-218-9114
User ID	Sophia Yeung
Facility ID	1087

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	2
Total number of people screened in	2
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	2
Total number of people who received baseline screening LDCT scans in (with and without SDM)	2
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Lisa McGuire
Title	Director of Oncology
Email	Lisa.Mcguire@hcahealthcare.com
Phone	(352)-361-1174
User ID	Lisa McGuire
Facility ID	1036

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Thoracic Oncology	Yes
Comments	STS database participation expected early 2027 with addition of new cardiothoracic surgeon.
Select all that apply	NCCN
Pathology	Yes
Select all that apply	CAP
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry, Central or state cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Lisa McGuire
Title	Director of Oncology
Email	Lisa.Mcguire@hcahealthcare.com
Phone	(352)-496-2175
User ID	Lisa McGuire
Facility ID	1036

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Comments	If an incidental nodule is reported, the patient no longer meets criteria for a LDCT screening. LDCT patients have to be asymptomatic of lung cancer characteristics. Incidental nodules would likely have repeat follow-up CT Chest or PET scans.
Tracking Adherence	Yes
Comments	Yes to tracking all IPN patients. Unable to provide reconciliation metrics on interval follow-up adherence.
Select all that apply	Tracking software, Manual tracking (Excel, etc.)
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	174
Total nonsurgical lung biopsies in patients with IPN in	249
Nonmalignant/Nondiagnostic Biopsy Rate %	70
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Lisa McGuire
Title	Director of Oncology
Email	Lisa.Mcguire@hcahealthcare.com
Phone	(352)-496-2175
User ID	Lisa McGuire
Facility ID	1036

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Thoracic Oncology	Yes
Comments	STS database participation expected early 2027 with addition of new cardiothoracic surgeon.
Select all that apply	NCCN, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	CAP
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry, Central or state cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Lisa McGuire
Title	Director of Oncology
Email	Lisa.Mcguire@hcahealthcare.com
Phone	(352)-496-2175
User ID	Lisa McGuire
Facility ID	1035

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Comments	Yes to screen all smoking status; cannot attest to referrals for smoking cessation for all patients
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Comments	If an incidental nodule is reported, the patient no longer meets criteria for a LDCT screening. LDCT patients have to be asymptomatic of lung cancer characteristics. Incidental nodules would likely have repeat follow-up CT Chest or PET scans.
Tracking Adherence	Yes
Comments	Yes to tracking all IPN patients. Unable to provide reconciliation metrics on interval follow-up adherence.
Select all that apply	Tracking software, Manual tracking (Excel, etc.)
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	174
Total nonsurgical lung biopsies in patients with IPN in	249
Nonmalignant/Nondiagnostic Biopsy Rate %	70
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Lisa McGuire
Title	Director of Oncology
Email	Lisa.Mcguire@hcahealthcare.com
Phone	(352)-496-2175
User ID	Lisa McGuire
Facility ID	1035

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,280
Total number of people screened in	1,280
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,280
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,280
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	10
Total nonsurgical lung biopsies in	16
Nonmalignant/Nondiagnostic Biopsy Rate %	63
	Yes
	Yes
Stage I	2
Stage II	3
Stage III	1
Stage IV	0
Stage I %	33
Stage II %	50
Stage III %	17
Stage IV %	0
Total screen-detected lung cancers	6
Name	Lisa McGuire
Title	Director of Oncology
Email	Lisa.Mcguire@hcahealthcare.com
Phone	(352)-361-1174
User ID	Lisa McGuire
Facility ID	1034

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	No
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Jiami Wu
Title	Director of Clinics
Email	jiamiw@chasf.org
Phone	(415)-677-2475
User ID	Jiami Wu
Facility ID	1954

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	189
Total number of people screened in	189
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	189
Total number of people who received baseline screening LDCT scans in (with and without SDM)	189
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	83
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	85
Follow-up Rate %	98
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	6
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	7
Follow-up Rate %	86
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	6
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	7
Follow-up Rate %	86
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	1
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	2
Follow-up Rate %	50
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	No
	No
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Jenn Bainey
Title	RN-Lung Health Navigator
Email	jbainey@conemaugh.org
Phone	(814)-534-5212
User ID	Jenn Bainey
Facility ID	1627

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,571
Total number of people screened in	1,571
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,571
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,571
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	84
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	100
Follow-up Rate %	84
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	111
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	136
Follow-up Rate %	82
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	66
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	88
Follow-up Rate %	75
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	47
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	75
Follow-up Rate %	63
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Jenn Bainey
Title	RN Lung Health Navigator
Email	jbainey@conemaugh.org
Phone	(814)-534-5212
User ID	Jenn Bainey
Facility ID	1243

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	No
Comments	Do not do within our team but referring providers handle
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Comments	We currently do not have volumes of scans that are repeated
Tracking Adherence	Yes
Select all that apply	Tracking software
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	0
Total nonsurgical lung biopsies in patients with IPN in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Comments	Do not collect data per site but rather in entire system
Score	5
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	1543

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,065
Total number of people screened in	1,121
Screen-eligible Rate	95
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	460
Total number of people who received baseline screening LDCT scans in (with and without SDM)	460
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	419
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	800
Follow-up Rate %	52
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	97
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	142
Follow-up Rate %	68
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	29
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	46
Follow-up Rate %	63
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	4
Stage II	5
Stage III	2
Stage IV	1
Stage I %	33
Stage II %	42
Stage III %	17
Stage IV %	8
Total screen-detected lung cancers	12
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	1543

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,718
Total number of people screened in	1,775
Screen-eligible Rate	97
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	589
Total number of people who received baseline screening LDCT scans in (with and without SDM)	589
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	764
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,457
Follow-up Rate %	52
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	99
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	128
Follow-up Rate %	77
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	46
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	60
Follow-up Rate %	77
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	11
Stage II	0
Stage III	3
Stage IV	0
Stage I %	79
Stage II %	0
Stage III %	21
Stage IV %	0
Total screen-detected lung cancers	14
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	2085

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	2085

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	467
Total number of people screened in	477
Screen-eligible Rate	98
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	199
Total number of people who received baseline screening LDCT scans in (with and without SDM)	199
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	209
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	367
Follow-up Rate %	57
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	21
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	26
Follow-up Rate %	81
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	8
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	13
Follow-up Rate %	62
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	3
Stage II	1
Stage III	1
Stage IV	1
Stage I %	50
Stage II %	17
Stage III %	17
Stage IV %	17
Total screen-detected lung cancers	6
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	2086

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	2086

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	No
Comments	Do not do within our team but referring providers handle
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Comments	We currently do not have volumes of scans that are repeated
Tracking Adherence	Yes
Select all that apply	Tracking software
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	0
Total nonsurgical lung biopsies in patients with IPN in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Comments	Do not collect data per site but rather in entire system
Score	5
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	1194

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	281
Total number of people screened in	293
Screen-eligible Rate	96
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	175
Total number of people who received baseline screening LDCT scans in (with and without SDM)	175
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	76
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	149
Follow-up Rate %	51
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	12
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	17
Follow-up Rate %	71
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	7
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	9
Follow-up Rate %	78
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	2
Stage II	2
Stage III	1
Stage IV	0
Stage I %	40
Stage II %	40
Stage III %	20
Stage IV %	0
Total screen-detected lung cancers	5
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	1194

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	1544

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,347
Total number of people screened in	1,422
Screen-eligible Rate	95
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	530
Total number of people who received baseline screening LDCT scans in (with and without SDM)	530
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	601
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	985
Follow-up Rate %	61
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	75
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	89
Follow-up Rate %	84
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	30
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	38
Follow-up Rate %	79
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	5
Stage II	2
Stage III	2
Stage IV	1
Stage I %	50
Stage II %	20
Stage III %	20
Stage IV %	10
Total screen-detected lung cancers	10
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	1544

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	2087

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	235
Total number of people screened in	242
Screen-eligible Rate	97
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	170
Total number of people who received baseline screening LDCT scans in (with and without SDM)	170
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	18
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	27
Follow-up Rate %	67
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	4
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	8
Follow-up Rate %	50
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	4
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	6
Follow-up Rate %	67
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	1
Stage II	0
Stage III	1
Stage IV	0
Stage I %	50
Stage II %	0
Stage III %	50
Stage IV %	0
Total screen-detected lung cancers	2
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	2087

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	No
Comments	Do not do within our team but referring providers handle
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Comments	We currently do not have volumes of scans that are repeated
Tracking Adherence	Yes
Select all that apply	Tracking software
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	0
Total nonsurgical lung biopsies in patients with IPN in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Comments	Do not collect data per site but rather in entire system
Score	5
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	2081

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	758
Total number of people screened in	835
Screen-eligible Rate	91
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	339
Total number of people who received baseline screening LDCT scans in (with and without SDM)	339
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	273
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	584
Follow-up Rate %	47
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	21
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	34
Follow-up Rate %	62
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	26
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	35
Follow-up Rate %	74
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	3
Stage II	0
Stage III	2
Stage IV	1
Stage I %	50
Stage II %	0
Stage III %	33
Stage IV %	17
Total screen-detected lung cancers	6
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	2081

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	292
Total number of people screened in	7,669
Screen-eligible Rate	4
Screen by which criteria (select all that apply)	CMS, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	292
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	No
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	No
If no, what is the estimated percentage of LDCT lung cancer screening exams in that were reported using a classification system other than LungRADS?	2
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	No
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	98
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	200
Follow-up Rate %	49
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	5
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	5
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	3
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	3
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	3
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	3
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	1
Total nonsurgical lung biopsies in	3
Nonmalignant/Nondiagnostic Biopsy Rate %	33
	Yes
	No
Stage I	2
Stage I %	100
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	2
Name	Jillian Eastman
Title	Nurse Practitioner
Email	jeastman@hoacny.com
Phone	(315)-657-1769
User ID	Jillian Eastman
Facility ID	2064

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	3,742
Total number of people screened in	3,742
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	3,259
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	171
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Janet Cady, DNP, CRNP
Title	Program Manager
Email	jcady@pennstatehealth.psu.edu
Phone	(717)-531-0003
User ID	Janet Cady
Facility ID	1769

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Comments	we aren't routinely using LDCT for IPN unless patients are enrolled specifically in the lung screening program (in which case nodules identified are not classified as "incidental" but rather "screen-detected"), so this may be a matter of definitions. But specifically LDCT is not utilized outside of lung cancer screening.
Tracking Adherence	Yes
Comments	Currently in EMR, however dedicated tracking with a recall system is being implemented 9/2026
Select all that apply	Other (free text)
Outcomes Review	Yes
Select all that apply	Internal Morbidity and Mortality or risk management review policy and procedure
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	2
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	50
Nonmalignant Resection Rate %	4
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	22
Total nonsurgical lung biopsies in patients with IPN in	101
Nonmalignant/Nondiagnostic Biopsy Rate %	22
Comments	Primarily Robot-assisted bronchoscopic biopsies
Score	6
Qualification Status	Qualified
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Vivek Murthy
Title	Director, Interventional Pulmonology, Bellevue Hospital
Email	murthyv@nychhc.org
Phone	(212)-562-7819
User ID	Vivek Murthy
Facility ID	1999

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,249
Total number of people screened in	1,254
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,001
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,001
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	341
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	369
Follow-up Rate %	92
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	31
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	34
Follow-up Rate %	91
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	24
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	28
Follow-up Rate %	86
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	13
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	15
Follow-up Rate %	87
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	5
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	5
Total nonsurgical lung biopsies in	19
Nonmalignant/Nondiagnostic Biopsy Rate %	26
	No
	Yes
Stage I	43
Stage II	29
Stage III	14
Stage IV	14
Stage I %	43
Stage II %	29
Stage III %	14
Stage IV %	14
Total screen-detected lung cancers	100
Name	Vivek Murthy
Title	Director, Bellevue LCSP
Email	murthyv@nychhc.org
Phone	(212)-562-7819
User ID	Vivek Murthy
Facility ID	1999

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Amy Heiny
Title	Screening Manager
Email	amy.heiny@franciscanalliance.org
Phone	(317)-528-8402
User ID	Amy Heiny
Facility ID	1528

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Amy Heiny
Title	Screening Manager
Email	amy.heiny@franciscanalliance.org
Phone	(317)-528-8402
User ID	Amy Heiny
Facility ID	2013

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,203
Total number of people screened in	1,203
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	485
Total number of people who received baseline screening LDCT scans in (with and without SDM)	718
SDM Documentation Rate	68
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	928
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	43
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	32
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	30
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Amy Heiny
Title	Screening Manager
Email	amy.heiny@franciscanalliance.org
Phone	(317)-528-8402
User ID	Amy Heiny
Facility ID	1059

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Amy Heiny
Title	Screening Manager
Email	amy.heiny@franciscanalliance.org
Phone	(317)-528-8402
User ID	Amy Heiny
Facility ID	1527

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	2083

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	713
Total number of people screened in	771
Screen-eligible Rate	92
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	320
Total number of people who received baseline screening LDCT scans in (with and without SDM)	320
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	339
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	556
Follow-up Rate %	61
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	37
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	49
Follow-up Rate %	76
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	24
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	31
Follow-up Rate %	77
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	4
Stage II	2
Stage III	1
Stage IV	1
Stage I %	50
Stage II %	25
Stage III %	13
Stage IV %	13
Total screen-detected lung cancers	8
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	2083

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager Lung Screening and Incidentals
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	2084

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	713
Total number of people screened in	771
Screen-eligible Rate	92
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	320
Total number of people who received baseline screening LDCT scans in (with and without SDM)	320
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	339
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	556
Follow-up Rate %	61
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	37
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	49
Follow-up Rate %	76
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	24
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	31
Follow-up Rate %	77
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	4
Stage II	2
Stage III	1
Stage IV	1
Stage I %	50
Stage II %	25
Stage III %	13
Stage IV %	13
Total screen-detected lung cancers	8
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	2084

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	No
Comments	Do not do within our team but referring providers handle
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Comments	We currently do not have volumes of scans that are repeated
Tracking Adherence	Yes
Select all that apply	Tracking software
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	0
Total nonsurgical lung biopsies in patients with IPN in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Comments	Do not collect data per site but rather in entire system
Score	5
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	2082

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	758
Total number of people screened in	835
Screen-eligible Rate	91
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	339
Total number of people who received baseline screening LDCT scans in (with and without SDM)	339
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	273
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	584
Follow-up Rate %	47
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	21
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	34
Follow-up Rate %	62
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	26
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	35
Follow-up Rate %	74
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	3
Stage II	0
Stage III	2
Stage IV	1
Stage I %	50
Stage II %	0
Stage III %	33
Stage IV %	17
Total screen-detected lung cancers	6
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	2082

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	834
Total number of people screened in	834
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	384
Total number of people who received baseline screening LDCT scans in (with and without SDM)	450
SDM Documentation Rate	85
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	775
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	57
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	34
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	17
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Amy Heiny
Title	Screening Manager
Email	amy.heiny@franciscanalliance.org
Phone	(317)-528-8402
User ID	Amy Heiny
Facility ID	1491

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	No
Comments	Do not do within our team but referring providers handle
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Comments	We currently do not have volumes of scans that are repeated
Tracking Adherence	Yes
Select all that apply	Tracking software
Outcomes Review	Yes
Select all that apply	Internal quality outcomes data and metrics capturing policies and procedures
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	0
Total nonsurgical lung biopsies in patients with IPN in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Comments	Do not collect data per site but rather in entire system
Score	5
Institutional Workflows	Yes
Institutional Tools	Yes
Select all that apply	Natural Language Processing program
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	1542

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	307
Total number of people screened in	340
Screen-eligible Rate	90
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	170
Total number of people who received baseline screening LDCT scans in (with and without SDM)	170
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	102
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	180
Follow-up Rate %	57
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	6
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	13
Follow-up Rate %	46
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	6
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	9
Follow-up Rate %	67
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	2
Stage II	0
Stage III	3
Stage IV	0
Stage I %	40
Stage II %	0
Stage III %	60
Stage IV %	0
Total screen-detected lung cancers	5
Name	Tia Cantrell, BS RTR.M.CT
Title	Program Manager
Email	tia.cantrell@advocatehealth.org
Phone	(828)-455-0107
User ID	Tia cantrell
Facility ID	1542

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	40
Total number of people screened in	40
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	12
Total number of people who received baseline screening LDCT scans in (with and without SDM)	28
SDM Documentation Rate	43
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	39
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	1
Follow-up Rate %	3,900
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Amy Heiny
Title	Screening Manager
Email	amy.heiny@franciscanalliance.org
Phone	(317)-528-8402
User ID	Amy Heiny
Facility ID	1490

Structured nodule reporting in place for standardized follow-up and management decisions based on appropriate and established nodule classification systems and management guidelines.	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning findings.	Yes
Commitment to a standardized process for communication with patients and their active care providers about test results and management plan.	Yes
Ask about current smoking status and advise to quit. Provide or refer for cessation services.	Yes
Adherence to standards based on published best practices for controlling image quality, as low as reasonably achievable radiation dose, and diagnostic procedures as outlined by the American College of Radiology.	Yes
Tracking, measuring, and reconciliation process for interval follow-up adherence for incidentally detected lung nodules based on patient risk for lung cancer and surveillance guidelines.	Yes
Internal clinical outcomes review and quality improvement process.	Yes
Calculated Section Total	7
Qualification Status	Qualified
Institutional workflows that capture (at all entry points into the health system) and refer incidental pulmonary nodules for management.	Yes
Institutional tools are engaged to ensure all IPNs are identifed and managed.	Yes
Name	Alexis Paulson
Title	Nurse Practitioner, Lung Screening Program Coordinator
Email	alexis.paulson@commonspirit.org
Phone	(615)-506-5080
User ID	Alexis Paulson
Facility ID	1301

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	1,151
Total number of people screened in	1,197
Screen-eligible Rate	96
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
If Other, describe your screening eligibility criteria	if referred from PCP from screening and patient would like LDCT after risk-benefit and SDM consultation with NP, self-pay option is offered.
Total number of people who received baseline screening LDCT scans in where SDM is documented	296
Total number of people who received baseline screening LDCT scans in (with and without SDM)	296
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	688
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	917
Follow-up Rate %	75
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	59
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	67
Follow-up Rate %	88
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	38
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	40
Follow-up Rate %	95
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	45
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	49
Follow-up Rate %	92
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	4
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	6
Total nonsurgical lung biopsies in	17
Nonmalignant/Nondiagnostic Biopsy Rate %	35
	No
	Yes
Stage I	8
Stage II	4
Stage III	1
Stage IV	2
Stage I %	53
Stage II %	27
Stage III %	7
Stage IV %	13
Total screen-detected lung cancers	15
Name	Alexis Paulson
Title	Nurse Practitioner, Lung Screening Program Coordinator
Email	alexis.paulson@commonspirit.org
Phone	(615)-506-5080
User ID	Alexis Paulson
Facility ID	1301

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	Yes
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Name	Suzanne Blanchard
Title	Lung Program Coordinator
Email	suzanne.blanchard@adventhealth.com
Phone	(706)-368-8880
User ID	Suzanne Blanchard
Facility ID	1223

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, ASTRO, NCCN
Thoracic Oncology	Yes
Select all that apply	NCCN, STS, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	ASCO, NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	Meghan McHugh
Title	Manager Clinical Cancer Services
Email	meghan.mchugh@aah.org
Phone	(920)-461-4043
User ID	Meghan McHugh
Facility ID	1674

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	3,846
Total number of people screened in	3,846
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,701
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,701
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	2,145
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,806
Follow-up Rate %	76
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	86
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	202
Follow-up Rate %	43
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	70
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	110
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	40
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	55
Follow-up Rate %	73
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	14
Total nonsurgical lung biopsies in	45
Nonmalignant/Nondiagnostic Biopsy Rate %	31
	Yes
	Yes
Stage I	2
Stage II	3
Stage III	2
Stage IV	5
Stage I %	17
Stage II %	25
Stage III %	17
Stage IV %	42
Total screen-detected lung cancers	12
Name	Rochelle Waddell
Title	Service Line Coordinator for Lung Cancer Screening
Email	rwaddell@arh.org
Phone	(606)-435-7209
User ID	Rochelle Waddell
Facility ID	1885

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	3,846
Total number of people screened in	3,846
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,701
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,701
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	2,145
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,806
Follow-up Rate %	76
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	86
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	202
Follow-up Rate %	43
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	70
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	110
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	40
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	55
Follow-up Rate %	73
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	14
Total nonsurgical lung biopsies in	45
Nonmalignant/Nondiagnostic Biopsy Rate %	31
	Yes
	Yes
Stage I	2
Stage II	3
Stage III	2
Stage IV	5
Stage I %	17
Stage II %	25
Stage III %	17
Stage IV %	42
Total screen-detected lung cancers	12
Name	Rochelle Waddell
Title	Service Line Coordinator for Lung Cancer Screening
Email	rwaddell@arh.org
Phone	(606)-435-7209
User ID	Rochelle Waddell
Facility ID	1897

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	3,846
Total number of people screened in	3,846
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,701
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,701
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	2,145
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,806
Follow-up Rate %	76
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	86
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	202
Follow-up Rate %	43
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	70
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	110
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	40
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	55
Follow-up Rate %	73
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	14
Total nonsurgical lung biopsies in	45
Nonmalignant/Nondiagnostic Biopsy Rate %	31
	Yes
	Yes
Stage I	2
Stage II	3
Stage III	2
Stage IV	5
Stage I %	17
Stage II %	25
Stage III %	17
Stage IV %	42
Total screen-detected lung cancers	12
Name	Rochelle Waddell
Title	Service Line Coordinator for Lung Cancer Screening
Email	rwaddell@arh.org
Phone	(606)-435-7209
User ID	Rochelle Waddell
Facility ID	1907

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	3,846
Total number of people screened in	3,846
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,701
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,701
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	2,145
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,806
Follow-up Rate %	76
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	86
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	202
Follow-up Rate %	43
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	70
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	110
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	40
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	55
Follow-up Rate %	73
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	14
Total nonsurgical lung biopsies in	45
Nonmalignant/Nondiagnostic Biopsy Rate %	31
	Yes
	Yes
Stage I	2
Stage II	3
Stage III	2
Stage IV	5
Stage I %	17
Stage II %	25
Stage III %	17
Stage IV %	42
Total screen-detected lung cancers	12
Name	Rochelle Waddell
Title	Service Line Coordinator for Lung Cancer Screening
Email	rwaddell@arh.org
Phone	(606)-435-7209
User ID	Rochelle Waddell
Facility ID	1901

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	3,846
Total number of people screened in	3,846
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,701
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,701
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	2,145
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,806
Follow-up Rate %	76
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	86
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	202
Follow-up Rate %	43
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	70
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	110
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	40
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	55
Follow-up Rate %	73
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	14
Total nonsurgical lung biopsies in	45
Nonmalignant/Nondiagnostic Biopsy Rate %	31
	Yes
	Yes
Stage I	2
Stage II	3
Stage III	2
Stage IV	5
Stage I %	17
Stage II %	25
Stage III %	17
Stage IV %	42
Total screen-detected lung cancers	12
Name	Rochelle Waddell
Title	Service Line Coordinator for Lung Cancer Screening
Email	rwaddell@arh.org
Phone	(606)-435-7209
User ID	Rochelle Waddell
Facility ID	1900

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	3,846
Total number of people screened in	3,846
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,701
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,701
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	2,145
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,806
Follow-up Rate %	76
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	86
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	202
Follow-up Rate %	43
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	70
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	110
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	40
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	55
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	14
Total nonsurgical lung biopsies in	45
Nonmalignant/Nondiagnostic Biopsy Rate %	31
	Yes
	Yes
Stage I	2
Stage II	3
Stage III	2
Stage IV	5
Stage I %	17
Stage II %	25
Stage III %	17
Stage IV %	42
Total screen-detected lung cancers	12
Name	Rochelle Waddell
Title	Service Line Coordinator for Lung Cancer Screening
Email	rwaddell@arh.org
Phone	(606)-435-7209
User ID	Rochelle Waddell
Facility ID	1886

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	3,846
Total number of people screened in	3,846
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,701
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,701
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	2,145
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,806
Follow-up Rate %	76
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	86
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	202
Follow-up Rate %	43
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	70
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	110
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	40
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	55
Follow-up Rate %	73
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	14
Total nonsurgical lung biopsies in	45
Nonmalignant/Nondiagnostic Biopsy Rate %	31
	Yes
	Yes
Stage I	2
Stage II	3
Stage III	2
Stage IV	5
Stage I %	17
Stage II %	25
Stage III %	17
Stage IV %	42
Total screen-detected lung cancers	12
Name	Rochelle Waddell
Title	Service Line Coordinator for Lung Cancer Screening
Email	rwaddell@arh.org
Phone	(606)-435-7209
User ID	Rochelle Waddell
Facility ID	1898

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	3,846
Total number of people screened in	3,846
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,701
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,701
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	2,145
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,806
Follow-up Rate %	76
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	86
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	202
Follow-up Rate %	43
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	70
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	110
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	40
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	55
Follow-up Rate %	73
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	14
Total nonsurgical lung biopsies in	45
Nonmalignant/Nondiagnostic Biopsy Rate %	31
	Yes
	Yes
Stage I	2
Stage II	3
Stage III	2
Stage IV	5
Stage I %	17
Stage II %	25
Stage III %	17
Stage IV %	42
Total screen-detected lung cancers	12
Name	Rochelle Waddell
Title	Service Line Coordinator for Lung Cancer Screening
Email	rwaddell@arh.org
Phone	(606)-435-7209
User ID	Rochelle Waddell
Facility ID	1899

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	3,846
Total number of people screened in	3,846
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,701
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,701
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	2,145
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,806
Follow-up Rate %	76
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	86
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	202
Follow-up Rate %	43
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	70
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	110
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	40
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	55
Follow-up Rate %	73
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	14
Total nonsurgical lung biopsies in	45
Nonmalignant/Nondiagnostic Biopsy Rate %	31
	Yes
	Yes
Stage I	2
Stage II	3
Stage III	2
Stage IV	5
Stage I %	17
Stage II %	25
Stage III %	17
Stage IV %	42
Total screen-detected lung cancers	12
Name	Rochelle Waddell
Title	Service Line Coordinator for Lung Cancer Screening
Email	rwaddell@arh.org
Phone	(606)-435-7209
User ID	Rochelle Waddell
Facility ID	1887

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	3,846
Total number of people screened in	3,846
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,701
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,701
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	2,145
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,806
Follow-up Rate %	76
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	86
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	202
Follow-up Rate %	43
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	70
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	110
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	40
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	55
Follow-up Rate %	73
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	14
Total nonsurgical lung biopsies in	45
Nonmalignant/Nondiagnostic Biopsy Rate %	31
	Yes
	Yes
Stage I	2
Stage II	3
Stage III	2
Stage IV	5
Stage I %	17
Stage II %	25
Stage III %	17
Stage IV %	42
Total screen-detected lung cancers	12
Name	Rochelle Waddell
Title	Service Line Coordinator for Lung Cancer Screening
Email	rwaddell@arh.org
Phone	(606)-435-7209
User ID	Rochelle Waddell
Facility ID	1895

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	3,846
Total number of people screened in	3,846
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,701
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,701
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	2,145
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,806
Follow-up Rate %	76
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	86
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	202
Follow-up Rate %	43
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	70
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	110
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	40
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	55
Follow-up Rate %	73
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	14
Total nonsurgical lung biopsies in	45
Nonmalignant/Nondiagnostic Biopsy Rate %	31
	Yes
	Yes
Stage I	2
Stage II	3
Stage III	2
Stage IV	5
Stage I %	17
Stage II %	25
Stage III %	17
Stage IV %	42
Total screen-detected lung cancers	12
Name	Rochelle Waddell
Title	Service Line Coordinator for Lung Cancer Screening
Email	rwaddell@arh.org
Phone	(606)-435-7209
User ID	Rochelle Waddell
Facility ID	1908

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	3,846
Total number of people screened in	3,846
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,701
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,701
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	1,872
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,807
Follow-up Rate %	67
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	86
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	202
Follow-up Rate %	43
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	70
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	110
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	40
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	55
Follow-up Rate %	73
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	14
Total nonsurgical lung biopsies in	45
Nonmalignant/Nondiagnostic Biopsy Rate %	31
	Yes
	Yes
Stage I	2
Stage II	3
Stage III	2
Stage IV	5
Stage I %	17
Stage II %	25
Stage III %	17
Stage IV %	42
Total screen-detected lung cancers	12
Name	Rochelle Waddell
Title	Service Line Coordinator for Lung Cancer Screening
Email	rwaddell@arh.org
Phone	(606)-435-7209
User ID	Rochelle Waddell
Facility ID	1896

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	3,846
Total number of people screened in	3,846
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,701
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,701
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	1,872
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,807
Follow-up Rate %	67
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	86
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	202
Follow-up Rate %	43
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	70
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	110
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	40
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	55
Follow-up Rate %	73
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	14
Total nonsurgical lung biopsies in	45
Nonmalignant/Nondiagnostic Biopsy Rate %	31
	Yes
	Yes
Stage I	2
Stage II	3
Stage III	2
Stage IV	5
Stage I %	17
Stage II %	25
Stage III %	17
Stage IV %	42
Total screen-detected lung cancers	12
Name	Rochelle Waddell
Title	Service Line Coordinator for Lung Cancer Screening
Email	rwaddell@arh.org
Phone	(606)-435-7209
User ID	Rochelle Waddell
Facility ID	1888

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	3,846
Total number of people screened in	3,846
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	1,701
Total number of people who received baseline screening LDCT scans in (with and without SDM)	1,701
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	2,145
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	2,806
Follow-up Rate %	76
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	86
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	202
Follow-up Rate %	43
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	70
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	110
Follow-up Rate %	64
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	40
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	55
Follow-up Rate %	73
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	3
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	14
Total nonsurgical lung biopsies in	45
Nonmalignant/Nondiagnostic Biopsy Rate %	31
	Yes
	Yes
Stage I	2
Stage II	3
Stage III	2
Stage IV	5
Stage I %	17
Stage II %	25
Stage III %	17
Stage IV %	42
Total screen-detected lung cancers	12
Name	Rochelle Waddell
Title	Service Line Coordinator for Lung Cancer Screening
Email	rwaddell@arh.org
Phone	(606)-435-7209
User ID	Rochelle Waddell
Facility ID	1257

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	5,114
Total number of people screened in	5,114
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	4,989
Total number of people who received baseline screening LDCT scans in (with and without SDM)	4,989
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	4,654
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	4,654
Follow-up Rate %	100
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	149
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	149
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	110
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	110
Follow-up Rate %	100
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	115
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	115
Follow-up Rate %	100
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	27
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	17
Total nonsurgical lung biopsies in	53
Nonmalignant/Nondiagnostic Biopsy Rate %	32
	Yes
	Yes
Stage I	33
Stage II	8
Stage III	7
Stage IV	4
Stage I %	63
Stage II %	15
Stage III %	13
Stage IV %	8
Total screen-detected lung cancers	52
Name	Carolyn Austin
Title	Lung cancer screening program coordinator
Email	Carolyn.Austin@bmcjax.com
Phone	(904)-202-7456
User ID	Carolyn Austin
Facility ID	1565

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN
Thoracic Oncology	Yes
Select all that apply	AATS, NCCN, STS, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry, Central or state cancer registry, NCI
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes
Name	fekjkjfgtg
Title	fff
Email	melissa.morrison@northside.com
Phone	(000)-000-0000
User ID	Deb Jeskey
Facility ID	1009

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	1,566
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS, NCCN, USPSTF
Total number of people who received baseline screening LDCT scans in where SDM is documented	452
Total number of people who received baseline screening LDCT scans in (with and without SDM)	452
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	990
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	1,035
Follow-up Rate %	96
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	65
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	74
Follow-up Rate %	88
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	52
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	34
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	No
Stage I	0
Stage II	0
Stage III	0
Stage IV	0
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Snow Tardif
Title	BSN, RN Program Manager
Email	snow.tardif@mainehealth.org
Phone	(207)-396-8324
User ID	Snow Tardis
Facility ID	1546

Screen according to CMS, NCCN, USPSTF criteria; if your program screens patients outside these established criteria, please identify your process for identifying patients’ screening appropriateness and which additional risk factors are considered for screening eligibility.	Yes
Comments	USPSTF guidelines
A patient-centered discussion (about the benefits and harms) occurs before or at the time of low dose CT screening - for every baseline screening at a minimum.	Yes
Comments	This is done by the Primary Care Physician when Veterans are enrolled in our Program.
Adherence to standards based on best-published practices for controlling screening quality, radiation dose and diagnostic procedures as outlined by American College of Radiology Practice Parameters.	Yes
Utilize structured reporting and standardized follow-up and management decisions based on current, established screening classification systems and management algorithms (LungRADS, NCCN Clinical Guidelines, I-ELCAP).	Yes
Comments	LungRADS
Consult with or refer to a lung cancer multidisciplinary* and cancer care team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Comments	This is done weekly at our facility.
Integrate a standardized process within the screening workflow for patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Utilize a process for tracking, measuring, and reconciliation of annual and interval follow-up adherence in screening.	Yes
Collect and review internal clinical outcomes in a quality improvement process.	Yes
Calculated Section Total	9
Qualification Status	Qualified
Submission of LDCT screening data to a multi-site registry (e.g., ACR LCSR, IELCAP, or other).	No
Monitor for lung cancer stage shift among screen-detected lung cancers.	Yes
Comments	This is done through our local tracking system.
Name	Zubair Hassan, MD-Chief of Medicine Services
Title	Director of the Lung Cancer Screening Program
Email	Zubair.Hassan@va.gov
Phone	(316)-685-2221
User ID	Carol Manes
Facility ID	1810

Nodule Reporting	Yes
Nodule Review Board / MDT	Yes
Communication Process	Yes
Cessation Support	Yes
Total number of patients with incidental pulmonary nodule(s) who received follow-up imaging by LDCT protocol (radiation dose is < 3 mGy CTDIvol for individuals with below normal or normal BMI) in	0
Total patients with incidental pulmonary nodule(s) completing follow-up CT imaging in	0
LDCT Protocol Compliance Rate %	0
Tracking Adherence	Yes
Select all that apply	Tracking software
Outcomes Review	No
Surgical lung resections with benign (nonmalignant) pathology in patients with IPN in	0
Total surgical lung resections in patients with IPN in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in patients with IPN in	0
Total nonsurgical lung biopsies in patients with IPN in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
Score	5
Institutional Workflows	Yes
Institutional Tools	Yes
Comments	EON
Name	Cari Williams
Title	Oncology Nurse Navigator
Email	cari.williams@imail.org
Phone	(406)-238-6302
User ID	Cari Williams
Facility ID	1583

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	615
Total number of people screened in	615
Screen-eligible Rate	100
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	218
Total number of people who received baseline screening LDCT scans in (with and without SDM)	218
SDM Documentation Rate	100
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	283
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	509
Follow-up Rate %	56
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	8
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	13
Follow-up Rate %	62
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	2
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	6
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	4
Total nonsurgical lung biopsies in	5
Nonmalignant/Nondiagnostic Biopsy Rate %	80
	Yes
	Yes
Stage I	3
Stage II	1
Stage IV	2
Stage I %	50
Stage II %	17
Stage III %	0
Stage IV %	33
Total screen-detected lung cancers	6
Name	Cari Williams
Title	Oncology Nurse Navigator
Email	cari.williams@imail.org
Phone	(406)-238-6302
User ID	Cari Williams
Facility ID	1583

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Marcey Bowhuis
Title	RN
Email	marceybowhuis@corewellhealth.org
Phone	(616)-486-5993
User ID	Marcey Bowhuis
Facility ID	1414

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Marcey Bowhuis
Title	RN
Email	marceybowhuis@corewellhealth.org
Phone	(616)-486-5993
User ID	Marcey Bowhuis
Facility ID	1462

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Marcey Bowhuis
Title	RN
Email	marceybowhuis@corewellhealth.org
Phone	(616)-486-5993
User ID	Marcey Bowhuis
Facility ID	1458

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Marcey Bowhuis
Title	RN
Email	marceybowhuis@corewellhealth.org
Phone	(616)-486-5993
User ID	Marcey Bowhuis
Facility ID	1457

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Marcey Bowhuis
Title	RN
Email	marceybowhuis@corewellhealth.org
Phone	(616)-486-5993
User ID	Marcey Bowhuis
Facility ID	1561

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Marcey Bowhuis
Title	RN
Email	marceybowhuis@corewellhealth.org
Phone	(616)-486-5993
User ID	Marcey Bowhuis
Facility ID	1560

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Marcey Bowhuis
Title	RN
Email	marceybowhuis@corewellhealth.org
Phone	(616)-486-5993
User ID	Marcey Bowhuis
Facility ID	1460

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Marcey Bowhuis
Title	RN
Email	marceybowhuis@corewellhealth.org
Phone	(616)-486-5993
User ID	Marcey Bowhuis
Facility ID	2034

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Marcey Bowhuis
Title	RN
Email	marceybowhuis@corewellhealth.org
Phone	(616)-486-5993
User ID	Marcey Bowhuis
Facility ID	1454

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Marcey Bowhuis
Title	RN
Email	marceybowhuis@corewellhealth.org
Phone	(616)-486-5993
User ID	Marcey Bowhuis
Facility ID	2035

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Marcey Bowhuis
Title	RN
Email	marceybowhuis@corewellhealth.org
Phone	(616)-486-5993
User ID	Marcey Bowhuis
Facility ID	1461

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Marcey Bowhuis
Title	RN
Email	marceybowhuis@corewellhealth.org
Phone	(616)-486-5993
User ID	Marcey Bowhuis
Facility ID	1459

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Marcey Bowhuis
Title	RN
Email	marceybowhuis@corewellhealth.org
Phone	(616)-486-5993
User ID	Marcey Bowhuis
Facility ID	1455

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Marcey Bowhuis
Title	RN
Email	marceybowhuis@corewellhealth.org
Phone	(616)-486-5993
User ID	Marcey Bowhuis
Facility ID	1453

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Marcey Bowhuis
Title	RN
Email	marceybowhuis@corewellhealth.org
Phone	(616)-486-5993
User ID	Marcey Bowhuis
Facility ID	1452

Total number of people screened in who meet CMS, NCCN, USPSTF criteria	0
Total number of people screened in	0
Screen-eligible Rate	0
Screen by which criteria (select all that apply)	CMS
If Other, describe your screening eligibility criteria	0
Total number of people who received baseline screening LDCT scans in where SDM is documented	0
Total number of people who received baseline screening LDCT scans in (with and without SDM)	0
SDM Documentation Rate	0
All CPT 71271 LDCT lung cancer screening exams in utilized low dose protocols with the dose index volume (CTDIvol) noted in the exam report, and a CTDIvol of 3mGy or less for a standard-sized patient (with lower or higher CTDIvol for smaller or larger patients), per ACR Practice Parameters.	Yes
All radiologists participating in reading 71271 LDCT lung cancer screening exams in utilized LungRADS to report exam results.	Yes
Consult with or refer to a Nodule Review Board or Multidisciplinary Team for the management of any concerning (thoracic or extra-thoracic) findings in the screening process.	Yes
Possess an integrated and standardized process within the screening workflow for routine patient and referring provider/care team communication on screening results and management plan.	Yes
Provide cessation support to all screening patients with consistent integration of (at a minimum) the Ask-Advise-Refer Process: Ask about current smoking status, Advise to quit, Provide or Refer for evidence-based cessation services as appropriate.	Yes
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s) who completed this exam	0
Total number of people due for repeat annual LDCT screening in based on prior category Lung-RADS® 1 or 2 finding(s)	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< one year) follow-up scan in who completed it	0
Total number of people with category Lung-RADS® 3 finding(s) due for an interval (< 1 year) follow-up scan in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in who completed it	0
Total number of people with category Lung-RADS® 4A finding(s) due for an interval (< 1 year) scan or diagnostic study or intervention* in	0
Follow-up Rate %	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for an interval scan or diagnostic intervention/study* in who completed it	0
Total number of people with category Lung-RADS® 4B or 4X finding(s) due for interval (< 1 year) scan or diagnostic intervention/study* in	0
Follow-up Rate %	0
Surgical lung resections with benign (nonmalignant) pathology in	0
Total surgical lung resections in (excluding therapeutic resections where malignancy diagnosed pre-surgery)	0
Nonmalignant Resection Rate %	0
Nonsurgical lung biopsies with benign or nondiagnostic pathology results in	0
Total nonsurgical lung biopsies in	0
Nonmalignant/Nondiagnostic Biopsy Rate %	0
	Yes
	Yes
Stage I %	0
Stage II %	0
Stage III %	0
Stage IV %	0
Total screen-detected lung cancers	0
Name	Marcey Bowhuis
Title	RN
Email	marceybowhuis@corewellhealth.org
Phone	(616)-486-5993
User ID	Marcey Bowhuis
Facility ID	1451

Patient Discussion	Yes
Biomarker Testing	Yes
Medical Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, NCCN, ASCO
Radiation Oncology	Yes
Select all that apply	TNM Stage Classification for Lung Cancer, ASTRO, NCCN
Thoracic Oncology	Yes
Select all that apply	NCCN, TNM Stage Classification for Lung Cancer
Pathology	Yes
Select all that apply	CAP, NCCN
Multidisciplinary Team	Yes
Care Plan	Yes
Cancer Registry	Yes
Select all that apply	Hospital-based cancer registry, Central or state cancer registry
Cessation Support	Yes
Score	10
Qualification Status	Qualified
Outcomes Review	Yes
Board Certified	Yes

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