What is FOCUS?

FOCUS is a program to track and improve appropriate use of cardiac imaging procedures. The program utilizes three primary components:

  • point-of-care decision support tool
  • performance improvement process
  • learning community

In addition, FOCUS is designed to be a Radiology Benefits Manager (RBM) alternative. FOCUS emphasizes the importance of collecting data on the appropriate use of cardiac imaging test prospectively as a part of the ordering process and then evaluating patterns of appropriate use over time to direct improvement.

Why has ACC developed FOCUS?

ACC has developed FOCUS in recognition of the need for the profession to measure and improve appropriate use of cardiac imaging and member requests for a transparent, profession-led alternative to RBM’s.

Why is FOCUS better than an RBM?

FOCUS has NO hard denials and instead concentrates on providing tools for institutions to engage in a self evaluation and performance improvement process. FOCUS tools and reports can help educate providers about appropriate use criteria patterns while aiding them in choosing the right test for each patient.

The entire process is electronic and no phone calls or appeals are required. Documentation on average should take 30–90 seconds.

What are Appropriate Use Criteria (AUC)?

Appropriate Use Criteria are ACC physician-developed standards describing typical patient presentations in which procedures may be considered. AUC are developed according to a rigorous methodology and have been tested in various settings [REFS].

What is a PIM

A PIM is a Performance Improvement Module. Providers whose inappropriate rate falls below the 50th percentile (comparison among all using the tool for a health plan) will use the FOCUS PIM to develop and implement an action plan for improvement.

The primary responsibility for an institution will be to complete a review of their performance, identify targets for improvement and complete a web questionnaire to assess their institution’s readiness, action plan, and results.

How will FOCUS benefit my institution?

FOCUS removes the hassle of working with an RBM and allows providers to regain control of 2 ordering tests for their patients. FOCUS also provides MOC Part IV credit and can be used to fulfill lab accreditation requirements related to appropriate use.

Will FOCUS cost my institution money?

There is no financial fee to participate in FOCUS. However, ACC understands that there will be costs to the practice to collect this information and engage in performance improvement. It is anticipated that these costs will be much less and less disruptive to clinical workflow.

Is FOCUS linked to payment of imaging claims by health plans?

Yes. At the end of each patient case, FOCUS will generate a unique decision support number that will be linked to your health plain claims. Any claim without a decision support number will not be paid by the health plan.

Payment is NOT contingent upon the classification of the patient case. Payment only requires use of the FOCUS tool and does not depend on how the institution uses the advice provided by the FOCUS tool.

Will FOCUS deny imaging test orders?

No there are NO hard denials in the FOCUS program.

Who is responsible for entering patient information into FOCUS?

FOCUS is designed to be used at the point of care when a test order is placed; however, institutions should decide how the use of the tool best fits into their clinical workflow. Physicians, nurse practitioners, practice managers, or other staff may enter the data.

Does data collection have to be completely electronic?

ACC has developed a one page paper data form that can also be used to collect patient information required by the FOCUS tool. The form can be used to ensure all the necessary information is captured during the patient encounter. Each patient case should be entered electronically into FOCUS PRIOR to the performance of the test, and ideally prior to the completion of the patient visit during which the test is scheduled.

How long will it take to enter patient information and receive an advice screen and unique decision support number?

FOCUS has been designed to take 30-90 seconds to enter patient information, select a test, review an advice screen indicating an appropriate, inappropriate or uncertain rating, and generate a decision support number.

Will training be provided?

ACC will provide Webinars, tutorials, and other customer support to answer any questions. FOCUS is designed to be very user friendly and require minimal training.

What are the other benefits of FOCUS?

Providers can use FOCUS for ICANL accreditation and can also receive Maintenance of Certification (MOC) Part IV credit.

Who owns the data collected?

Institutions will own their own data. ACC will have access to all data and may use it in aggregate to perform secondary analysis. Health plans will be provided quarterly reports of institution and physician level performance.

How will I know how I am doing in FOCUS?

On demand reports as well as quarterly reports will be available to each individual physician and institution.

How will ACC address gaming?

Gaming is very difficult to accomplish in a way that reflects true random clinical encounters. Data will be analyzed for signals of gaming. The ACC also retains the right to audit patient cases either through the medical record and/or health plan claims to verify data elements submitted.

What if my inappropriate rate is already low?

FOCUS does not aim to drive the inappropriate rate to zero; some patient cases will present an exception to the AUC standards. The FOCUS tool allows for documentation of these exceptions. Exception documentation will not remove a case from the inappropriate rate. However, over time, ACC will review these reasons and modify the criteria as necessary to include standard exceptions.

Getting Started

How do I access the FOCUS PIM?

What do I need to begin using the PIM?

Participants just need a free account to use the PIM.

Where can I find screen shots that walk me through using the Improvement Module on for radionuclide imaging?

Please check back soon for information specific to

Why does the PIM require a tax identification number?

Tax ID numbers are used only to compare participants with others who share their tax ID numbers.

Who can help me if I have a technical question?

Contact for assistance.

About the PIM

What exactly does the improvement tool do?

The modules are web-based tools that guide physicians through the collection of patient data on appropriate use to identify performance gaps and ultimately implement a quality improvement plan for their practice.

How do I improve my appropriate use rate through FOCUS?

We don’t yet have all of the answers on how to improve. Practices are experimenting across the country and this is the reason FOCUS was developed. The module provides a structured way to identify performance gaps and develop a quality improvement action plan. Best practices will be developed through sharing discoveries in what works best from these actions plans.

Do I need to use the improvement tools to participate in FOCUS?

No, the improvement tools are optional. While they are excellent tools for determining and tracking your appropriateness rate, if you already have a tracking process in place the ACC tools may be redundant. Please share how yours is working!

How will the Improvement Module support clinical research? What specific questions is the data analysis group focusing on in order to mine the database?

FOCUS and the improvement tools are not part of a clinical research project. A research study has already been conducted and published on practice patterns related to appropriate use. The module is a tool to capture your RNI ordering pattern and allow you to track your appropriateness rate. ACC hopes to aggregate this data and demonstrate a reduction in inappropriate orders, but is not planning to use individual site data for clinical research. The module is there to help you understand your appropriate use pattern so you can help contribute to the community of ideas about how to improve.

Using the PIM

What should I do if I hit the “submit” button before I completed entering patients in stage 1?

Email with your name & email address stating that you have accidentally hit the “submit” button and would like to continue entering patients in stage 1.

Is it OK to enter a few fictitious patients just to learn how to use the tool?

Absolutely. Simply don’t save those cases.

What if I am unsure about how to categorize or enter patients?

If you are a non-clinical employee or don’t know which category to classify your patients under, go with the most recent prior procedure/symptoms. If it is still unclear refer to ACC’s Appropriate Use Criteria document for RNI.

Do the AUC clearly define low, intermediate and high risk patients?

Risk is defined by a modified Framingham criteria (ATP III) for asymptomatic patients and Diamond and Forrester tables for symptomatic patients. Links to a Framingham risk calculator and the Diamond and Forrester tables are included in the module when these questions are presented.

Can I enter data at different times or does it have to be all at once?

You can enter data at multiple times. A patient case will be saved once you have answered the questions. The submit button does NOT need to be clicked in order to save entered data.

In Stage one, is it permissible to acquire 30 days data prospectively rather than retrospectively?

Yes. It is also permissible, if collecting retrospectively, to go back farther than 30 days to collect the minimum number of orders (10 RNI orders) for the first Stage of the Improvement Module. The goal is to help you establish a baseline in Stage One.

How many cases do I need to enter?

If you are doing this for ICANL you need to enter 5 percent of your total case volume.

The minimum is 10 cases but we strongly encourage entering at least 30 patients in each stage to get a more accurate picture of your practice patterns.

Can I go through the PIM more than once?

Yes, however each account requires a unique email address therefore to go through the PIM multiple times you will have to register again with a different email.

It is not possible to wipe the account clean after a participant has been through the PIM once

What questions (data points) are requested for each perfusion study entered/Where can I find the paper data form participants can use to collect patient information?

The paper data collection form can be found on ACC’s online drop box.

Who are my AUC rates compared to at the end of the first stage?

“My rate”: Your AUC rate based on the patient cases you entered “My specialty rate”: AUC rate of all others who classified themselves under the same specialty “My practice rate”: AUC rate of all participants under the same tax ID number

What can I do if I need help starting my action plan or would like to see what others have done?

Send an email to requesting information on action plans

How are Community members using the improvement tool or AUC in practice?

Many practices are using nurses, lab technicians, and quality improvement staff to enter the data. Physicians also may choose to use the tool to help guide their ordering, although the improvement module is not designed for this purpose. In addition, m any practices are reviewing a calendar month of orders retrospectively while others are entering cases in batches prospectively. The decision largely depends upon the data available in your practice to complete the case forms retrospectively. Either is acceptable. Some practices are also entering data to assess the appropriateness of orders coming into their laboratory, and therefore, entering data by interpreting physician. Other practices are entering data to assess the appropriateness of orders placed by their physicians. Either is acceptable as long as it is consistent across your practice.

How are other practices approaching their hospital administration about FOCUS?

We will be posting an IHI tips sheet. The FOCUS Community will generate several answers to this question, and the ACC is here to help support you as you work through this process.

Can I give this tool to my primary care or hospitalists colleagues who would like to use the tool to decide what type of stress test to order?

Absolutely. FOCUS is open to all.

List Serv

How can I join the listserv?

Click here to join the FOCUS list serv >>>

How can I join the online FOCUS Community?

Updated information coming soon.

How can participants contribute to the listserv/ communicate with other FOCUS members working with the improvement tool?

Participants can write to the listserv by sending emails to


How do I claim my ABIM credit?

To claim credit you must go through the ABIM website.

What are the requirements for iCANL accreditation?

As part of the ICANL accreditation process, appropriate use must be measured at least once during the accreditation period. Labs are required to measure appropriate use in consecutive patients to equal 5 percent of their annual volume of cardiac radionuclide imaging studies. The total number of patient cases entered must equal 5 percent NOT the number of cases entered in each individual stage.


Where can I find the AUC mobile app tool?

This tool is currently being updated, however we can notify you once it is available.