Radiology Business Journal | June/July 2013

June/July 2013

Standardization: Devising a Blueprint for Radiology page 18

Featured in this issue

Showdown in Missouri: Decision Support Versus RBMs

page 14

The In-office Ancillary-services Exception: Time to Ground the Skyrocket? page 26 DICOM or Nothing: The Case for Standards in Quantitative Imaging

page 34

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June/July 2013

Standardization: Devising a Blueprint for Radiology page 18

Featured in this issue

Showdown in Missouri: Decision Support Versus RBMs

page 14

The In-office Ancillary-services Exception: Time to Ground the Skyrocket? page 26 DICOM or Nothing: The Case for Standards in Quantitative Imaging

page 34

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CONTENTS

June/July 2013 | Volume 6, Number 3

18

Features

18

Devising a Blueprint for Radiology: Standardization

Standard nomenclature, structured reporting, and approved imaging protocols are all part of the movement to ensure quality radiology.

26

The In-office Ancillary-services Exception: Time to Ground the Skyrocket?

The president’s budget proposes ending the in-office loophole in the Stark anti–self-referral laws, but the idea faces stiff opposition from other specialities.

34

DICOM or Nothing: The Case for Informatics Standards in Quantitative Imaging

Standardization will facilitate the transition from narrative to quantitative reporting.

By George Wiley

By Greg Thompson

By Cheryl Proval

26

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CONTENTS

Departments

8

AdView

What You See Probably Isn’t

10

The Bottom Line

June/July 2013 | Volume 6, Number 3

The MAC–CMS DIsconnect

12

Priors 12 Legislative | Washington 2013: Imaging at the Grindhouse 14 State Health Policy | Showdown in Missouri:

EDitor Cheryl Proval · cproval@imagingbiz.com Art Director Patrick R. Walling · pwalling@imagingbiz.com Technical Editor Kris Kyes

By Cheryl Proval

Publisher Curtis Kauffman-Pickelle · ckp@imagingbiz.com

Associate Editor Cat Vasko · cvasko@imagingbiz.com Online Editor Lena Kauffman · lkauffman@imagingbiz.com

By Thomas W. Greeson, JD, Esq, and Paul W. Pitts, JD, Esq

Contributing Writers Thomas W. Greeson, JD, Esq; Paul W. Pitts, JD, Esq; Julie Ritzer Ross; Greg Thompson; George Wiley Associate Publisher Sharon Fitzgerald · sfitzgerald@imagingbiz.com

Decision Support Versus RBMs By Julie Ritzer Ross

15 Health Policy | Gatekeeper Part II: Understanding Clinical Nuance

42 44

Production Coordinator Jean Lavich · jlavich@imagingbiz.com Webmaster Robert Elmquist · relmquist@imagingbiz.com

Advertiser Index Final Read From the imagingBiz Web Journals

34

Corporate Office imagingBiz 210 W. Main St., Suite 101 Tustin, CA 92780 (714) 832-6400 www.imagingbiz.com PResident/CEO · Curtis Kauffman-Pickelle VP, Publishing · Cheryl Proval VP, Administration · Mary Kauffman

Radiology Business Journal is published bimonthly by imagingBiz, 210 W. Main St., Suite 101, Tustin, CA 92780. US Postage Paid at Lebanon Junction, KY 40150. June/July 2013, Vol 6, No 3 © 2013 imagingBiz. All rights reserved. No part of this publication may be reproduced in any form without written permission from the publisher. POSTMASTER: Send address changes to imagingBiz, 210 W. Main St., Suite 101, Tustin, CA 92780. While the publishers have made every effort to ensure the accuracy of the materials presented in Radiology Business Journal, they are not responsible for the correctness of the information and/or opinions expressed.

Please address all subscription questions to Jean Lavich at jlavich@imagingbiz.com.

6 Radiology Business Journal | June/July 2013 | www.imagingbiz.com

Looking Forward and Looking Back:

On 20 Years in Imaging

by Cat Vasko

T

he radiology industry has seen its shares of ups and downs during the past two decades. “In 1993, health care was in a period of chaos much like the one we are experiencing right now,” Mark Talley, COO of Medical Management Professionals (MMP), says. “As time went by and things settled down, there was a period of rapid growth in radiology, primarily driven by advances in imaging technology.”

G. Darrell Hulsey, president and CEO of MMP, concurs. He says, “Clinically, radiology has made significant advances in the past two decades, all contributing to better and more streamlined care.”

Together with David Stone, Hulsey and Talley are cofounders of MMP, which was launched 20 years ago, in May 1993. Stone, who is executive vice president of MMP, notes, “We are right back there again—except this time, the disruption is really going to happen. What made people successful in the 1990s, and what will make them successful again, is the ability to change and adapt to emerging payment and delivery methods.”

Adaptability and Survival Having observed 20 years of industry upheavals, the three cofounders of MMP all point to adaptability as a critical factor in surviving change. “A tumultuous market will not define a company’s character, but it absolutely will reveal it,” Hulsey says. “Any strategy that is going to work, in the long term, has to be based on finding the right people (with the right character and work ethic) and then empowering those people to make decisions, every day, that drive the company toward achieving its goals.”

Talley says that this kind of fluidity has proved essential to MMP’s business as radiology groups’ billing and revenue-cycle–management needs have evolved. “Since the DRA, practices have been squeezed on reimbursement; billing

MMP cofounders G. Darrell Hulsey, David Stone, and Mark Talley.

can be done less expensively out of larger, regional offices, so we have focused the majority of our recent growth into several larger regional service centers. The lesson is to assess the market, see what it is wanting, and offer it.”

Stone notes that part of adaptability is evolving to stay close to the customer’s needs, even as the business expands in size—a critical concern for practices facing a consolidating market. “As you get larger, how do you maintain that feeling of being small enough to be close to the customer?” he says. “With all this consolidation occurring, practices should be paying attention to how to stay local, even as they become part of bigger organizations. They will have to stay attuned and listen actively to their customers’ needs.”

Data-driven Future As the health-care marketplace continues to evolve, the three cofounders point to data as the primary means through which radiology practices will be able to understand their customers’ needs and stay receptive to change.

“With different payment methodologies on the horizon, when it comes to negotiating effectively with payors and hospitals, the practices with the best data will win,” Stone says.

Hulsey agrees. “Of the world’s data, 90% were created in the past two years,” he says. “Right now, in health care, the data are disparate, but eventually, someone will put them all together and create outcomes-based measurement. That will be a behavior change for

health care, focusing on how to serve patients best and how to capture those data points.”

Specifically, Talley predicts, radiology practices will face an imperative to measure factors related to patient satisfaction and to report on those factors to their various constituents, including hospitals, delivery systems, and payors. “Radiologists need to think about patient satisfaction: quick turnaround times for exams and giving screening results before patients leave the imaging center,” he says.

Strategic Imperatives As successful strategists themselves, the three cofounders see a few imperatives on the horizon for radiology practices. Stone cites relationship building as a critical concern. “Groups have to refocus on relationships with an expanded list of clients—not just referring physicians, but also hospitals, health systems, and patients,” he says. “That list may also expand to include other forms of organizations, such as accountable-care organizations, or combinations of hospitals and payors.”

Talley points to the pending influx of newly insured patients and the productivity and efficiency that accommodating them will require. “It will force groups to look closely at their own productivity, to be sure everyone is working hard and fully used,” he says. “Once the newly insured are getting screening exams, other care will follow from that as well.”

Hulsey observes that all the tactical planning in the world is meaningless without the right culture underpinning it. “Radiology groups have developed this entrepreneurial sense of independence, over the years,” he says. “Now, groups need to create a culture of accountability to one another and to the people they serve— of doing the right thing, even when no one is watching.”

AdView

What You See Probably Isn’t As radiology takes important steps to standardize care, an equivalent effort is needed to convey the specialty’s indefinable something

F

ifteen years ago, when I first started to write about radiology, any attempt to manage or standardize the practice of medicine was met with resistance and derision. Notice that when putting together this issue, we ruled out calling our cover story, “Devising a Cookbook for Radiology.”

In the interim, medicine has adopted a more introspective and self-analytical demeanor, resulting in what can only be characterized as a full-on cultural revolution. As our cover story (page 18) reveals, radiology not only has adopted the techniques of continuous quality improvement, but has begun to standardize techniques and processes.

While some of the impetus is coming from within the specialty, radiology also is feeling pressure from the outside. Now that income is at risk for both hospitals and physicians, the patient-care benefits of quality have economic implications that will be compounded over the coming years.

Furthermore, a consolidation trend in the provider market has resulted in numerous multihospital integrated delivery systems wanting a standard method of care delivery that has been vetted and clinically validated— across all sites. In May, I had multiple conversations at the 2013 RBMA Radiology Summit in Colorado Springs, Colorado, about mounting pressure on radiology practices— especially those covering just part of a health-care system—to develop standardized protocols and processes across the system.

This outward-originating force is requiring greater coordination and collaboration among unrelated practices (look for more about that in the August/September issue of Radiology Business Journal).

arrive at standards for the practice and delivery of radiology, it’s important that an equivalent effort be made to elucidate the art and craft of the practice of medicine in general—and radiology, specifically. Science has made radiology tremendously more effective since Röntgen isolated the first ray, but the art of radiology encompasses more than science: A radiologist must cultivate the ability to see both what is and what isn’t there.

Interpreting an image means knowing anatomy, projecting the image into the third dimension, aggregating everything known about the patient with the interpreter’s experience to date, and then offering the best context, support, and evidence by which a referrer can make a diagnosis. As tempting as it may be, it’s not a job for dilettantes.

Artist/scientist James Turrell says it best, in a video that is part of a retrospective of his work at the Los Angeles County Museum of Art (LACMA): “People think that what they see is something received, but it is something created. It took me a while to understand light and learn to work with it.”

With his full white beard and mustache, Turrell is reminiscent of Röntgen, on the cover of the June 16, 2013, New York Times Magazine, which offers insight into the origins and essence of Turrell’s work—as well as the extraordinary effort that it takes to mount one of his exhibitions.1 We now have an unprecedented opportunity to see Turrell’s work, with major retrospectives on display in Los Angeles, California; New York, New York; and (soon) Houston, Texas.

Raised Quaker and, therefore, on the light within, Turrell’s medium is the cousin of x-rays, visible light, and his tools are architecture and a deep understanding of the science and psychology of perception.

One needs to spend just several hours in the LACMA exhibition to get a sense of the nature—and pitfalls—of visual perception.

The Light Within

Back to the cover story in this issue of Radiology Business Journal: without establishing standards and standardization,

Not to minimize the standardization movement, but as important steps are taken to

Seeing Is Believing

8 Radiology Business Journal | June/July 2013 | www.imagingbiz.com

radiology will be hard-pressed to convey the value of its je ne sais quoi. Providing evidence-based parameters, protocols, and measures that are the hallmarks of quality (and then measurements, as proof ) is the difficult work ahead for the specialty— whether or not President Obama’s budget proposal to end the in-office ancillaryservices exception is included in the 2014 budget (see article, page 26).

Having just interviewed cardiologist Wm. Guy Weigold, MD, for our Radinformatics. com publication, I have no doubt that there are specialists who are qualified to read their body parts. This is not a threat to the future of the radiologist. A lack of standards, though, is a danger.

Coincidentally, radiologist Eric Hyson, MD, is called out for his expertise by Lisa Sanders, MD,2 in her “Diagnosis” column in the same issue of the New York Times Magazine in which the Turrell article appears. Hyson identified the telltale treein-bud abnormality that is the mark of Lady Windermere syndrome, three months before the patient’s throat culture grew out Mycobacterium avium-intracellulare.

Standards and the ability to see what is and isn’t there, bound by the bond of trust between physicians, are radiology’s best insurance against obsolescence.

Cheryl Proval cproval@imagingbiz.com References 1. Hylton WS. How James Turrell knocked the art world off its feet. New York Times Magazine. http://www.nytimes. com/2013/06/16/magazine/how-jamesturrell-knocked-the-art-world-off-its-feet. html?_r=2&&pagewanted=all.

Published June 16, 2013. Accessed June 21, 2013.

2. Sanders L. The cough that wouldn’t stop.

New York Times Magazine. http://www. nytimes.com/interactive/2013/06/16/ magazine/diagnosis-cough-that-wouldnt-stop. html?pagewanted=all. Published June 14, 2013.

Accessed June 21, 2013.

The Bottom Line

The MAC–CMS Disconnect With teleradiology increasingly a factor in the delivery of radiology services, practices need more clarity from CMS on the place-of-service requirements

A

s we previously reported,1 last fall, CMS published its supposedly final guidance2 on place-of-service requirements for the professional and technical components of diagnostic tests.

Transmittal 2563 (later replaced by Transmittals 2613 and 2679) revised the instructions contained in chapter 13 of the CMS manual system for Medicare claims processing. The most recent transmittal became effective on April 1, 2013. On April 25, CMS issued a frequently asked question (FAQ)3 set to respond to additional concerns about the place-of-service instructions. Among other clarifications in the FAQ list, CMS reported that it will be developing a national enrollment policy for telehealth and telemedicine services.

The transmittal’s guidance contained instructions for when global billing is and is not permitted. It also required the address and zip code of the interpreting physician to be placed on the 1500 claim form or its electronic equivalent.

It is regrettable that the transmittal also reaffirmed the CMS paymentjurisdiction rules. CMS stated that claims for interpretation services should be billed to the Medicare administrative contractor (MAC) responsible for the jurisdiction where the service was furnished (unless the interpretation was performed in an unusual and infrequent location, in which case the claim is to be adjudicated where the physician most commonly practices).

The payment-jurisdiction rule is particularly relevant when the professional component is routinely performed in a state (or MAC jurisdiction) that differs from that in which the technical component is performed. This is most often the case in teleradiology and in urban areas that cross state lines.

Since the publication of the transmittal, a number of our clients have attempted to enroll with the MAC where the interpreting physician is located. For various reasons, those attempts have been denied.

We have shared with CMS that when a radiology group attempts to enroll with the MAC with jurisdiction over the place where the radiologist performs interpretation services, representatives of various MACs have indicated a reluctance to accept the home office of the employed radiologist as the practice location of the radiology group on the 855B form. Given that the radiology group’s only contact with the state is that radiologist providing remote interpretations, there is no other viable address for the radiology group to list as its practice location within the MAC’s jurisdiction.

In addition, some states (such as California) have strict rules prohibiting the corporate practice of medicine. This results in situations where the radiology group’s legal entity in not recognized in the state where the employed radiologist resides and remotely interprets tests. For example, an LLP formed in another state can’t be registered with the California secretary of state’s office to operate a medical corporation.

In California, a physician cannot practice medicine as an LLP; therefore, the out-ofstate radiology group would not be eligible for registration with the California secretary of state or the California medical board, but both are steps that the radiology group should take in connection with enrolling with the California MAC (Palmetto). This is just one example of the challenges facing a radiology group enrolling in multiple MAC jurisdictions.

As another example, one of our radiologygroup clients has radiologists furnishing interpretation services from locations in six different states, plus the state of its primary domicile: Maryland, Washington, California, Illinois, Colorado, New York, and Connecticut. As a result of the paymentjurisdiction rule, the group is required to enroll with multiple MACs and register to do business in each of these states in order to bill for these professional interpretations.

That client has been attempting to enroll with the out-of-state MACs, but it’s getting

by thomas w. greeson, JD, Esq, and Paul W. Pitts, JD, Esq push back from those MACs. We believe the CMS plan to develop a national enrollment policy for telehealth and telemedicine services to be an encouraging development.

An Alternative Approach We have offered an alternative suggestion to CMS that would be far simpler, administratively, than the current MAC jurisdiction requirements. We are recommending the use of zip-code billing to one’s local MAC using the same approach that had been used from 2005 through 2010, when CMS permitted radiology groups and imaging centers to submit claims to their local MACs for purchased interpretation services.

Under that approach, the IDTF billing for the out-of-state service reported the interpreting physician’s zip code in order to match the appropriate geographical practicecost indices (GPCIs). This concept was limited to antimarkup tests with the publication of antimarkup payment instructions4 in 2010.

Until that time, the MACs had access to a common working file that allowed them to pay in accordance with the correct GPCI for the interpretation service, based on the zip code in which it was performed.

We hope that CMS will apply this simple and straightforward billing concept to the adjudication of all reassigned claims for interpretation services, subject to the new zip-code billing instructions, so that the MACs can easily and quickly adjudicate interpretations performed across state lines. Something as basic as this would go a long way toward alleviating the problems that the recent changes in claims-processing instructions have introduced.

Thomas W. Greeson, JD, Esq, is an attorney, a partner resident at Reed Smith LLP, and a member of the firm’s Life Sciences Health Industry Group; tgreeson@reedsmith. com. Paul Pitts, JD, Esq, is an attorney, a partner at the firm, and a member of the industry group; ppitts@reedsmith.com.

NOTE: The references for this article are posted in the online version, at www.imagingbiz/rbj.

10 Radiology Business Journal | June/July 2013 | www.imagingbiz.com

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Washington 2013: Imaging at the Grindhouse

I

maging has been through a long legislative and regulatory grind since the first big blow was struck with the DRA, and there is little to indicate that much will change on that front in 2013, according to Ted Burnes, MPA, director of RADPAC, the political-action committee of the ACR®. With Maurine Dennis, MPH, MBA, a consultant for the RBMA, Burnes copresented “Radiology Economics and RADPAC Update” on May 22, 2013, at the RBMA Radiology Summit in Colorado Springs, Colorado.

Burnes explains that a pre-election year—especially one as contentious as this one, in which both parties are hoping for a shift in the balance of power in Congress—is all about messaging (as opposed to legislating) for lawmakers.

“Everything they do is a messaging agenda,” he says.

He points to the recent 37th vote for repeal of the Patient Protection and Affordable Care Act (PPACA), a largely symbolic gesture undertaken by a Republican-controlled House of Representatives that knows that its efforts toward repeal won’t get past the Senate, much less the White House. The vote was an opportunity for freshman lawmakers to indicate their opposition to the PPACA prior to voting on changes to it, which might be interpreted as tacit approval.

Thus, bystanders can expect little in the way of action on repealing the Multiple Procedure Payment Reduction (MPPR) for the professional component implemented in the 2012 Medicare Physician Fee Schedule (MPFS), and the medical-device tax is likely to be here to stay as well. “It will be hard to overturn this because it produces $30 billion in savings,” Burnes notes. “It’s hard to find a number to replace that, if it goes away.”

Self-referral also is a nonstarter this year, he believes. While a previous assessment had estimated that $6 billion

could be saved over 10 years if legislation to curb self-referral were to be approved, a more recent Congressional Budget Office estimate scored the savings attributed to imaging at $1.8 billion. “That is just not enough to sway members of Congress,” Burnes says. Some minor bills pertaining to reimbursement for the work of radiologist assistants and radiologic technologists also are likely to fall by the wayside: He says, “We’re lucky if we can get two things in a meeting that we can pitch on the Hill.”

Potential Wins and Losses The current environment means that RADPAC is saving its firepower for bigger initiatives, including a utilization-management policy focused on mandating physicians’ use of clinicalappropriateness guidelines for medical imaging. This was “very well received on the Hill,” Burnes says, and the familyphysician community has indicated its support (in an informal manner).

Burnes also reports that Congress is amenable to working on the formula for the sustainable growth rate this year. One House bill is “heavily weighted to primary care,” he says, while another proposal, in the draft stage, suggests undergoing a three-phase process: first, transitioning to more predictable payment rates; second, reforming the Medicare payment system to provide better incentives for high quality; and third, reforming to account for efficiency of care.

“There is interest in doing decision support, which is perfect for us,” Burnes

12 Radiology Business Journal | June/July 2013 | www.imagingbiz.com

says. “We feel that there’s good opportunity for us to get some of our legislative issues included in this package.”

Dennis took a detailed look at how the proposed 2013 MPFS stands to affect radiology next year. Most troubling, she says, is the renewed focus on potentially misvalued RVUs—which, of course, means overpaid (not underpaid) RVUs. “In their minds, this includes basically all of radiology,” Dennis says.

During the 60-day comment period following the release of the proposed rule (expected in July), CMS will accept public nominations for potentially misvalued codes. “No one is going to pay attention if you nominate an undervalued code, but if someone nominates all radiology codes, CMS is going to take a look at that, so this is something to be concerned about,” she notes.

Also of interest is a local initiative that might become a national trend: the Colorado Clean Claims Task Force.

Piggybacking on a directive from the US DHHS secretary, the Colorado Department of Health Care Policy has developed a standardized set of payment rules and claim edits for providers and payors in the state. The MPPR for radiology was added to the slate. “Needless to say, the ACR and RBMA have been very involved in this issue—it’s ongoing,” Dennis says.

“We’ve been working to make sure our voices are heard on the coding side.”

Burnes says that providers, including radiologists, should expect no relief from the ills of sequestration anytime soon.

“They are already talking about applying the same 2% cuts next year,” he says.

“It’s our understanding that it will not be compounded, but it’s too early to determine.

When you talk to House Republicans, this is the only way they feel they can control spending out of DC, and they are not budging. This is an issue we’ll deal with for the next two or three years.”

—Cat Vasko

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s tat e h e a lt h p o l i c y

Showdown in Missouri: Decision Support Versus RBMs

by Julie Ritzer Ross

T

wo years ago, a friend of Missouri state Rep Caleb Jones (R) sustained a shoulder injury while playing with his child. While a physician suggested that an MRI exam might be in order, the man’s healthinsurance provider would not cover the cost of the study and instructed him to seek care from a sports-medicine practice.

Forced to jump through multiple hoops to address his injury, the man endured prolonged pain and frustration before learning that he had not just bruised his shoulder; he had sustained a fracture— with which he had been walking around for two weeks.

“Hearing this story opened my eyes to the convoluted process of obtaining a radiological diagnosis of any kind,” Jones says. Ever since, he has been on a quest to enact legislation to remove radiology benefit managers (RBMs) from the patient-care equation in Missouri (at least partially). Although an initiative to this effect was stymied earlier this year, Jones—who announced, in mid-June, his intention to run against state Rep John Diehl (R), majority leader, in the upcoming race for Missouri’s speaker of the House—is not ready to concede his battle.

The initiative took root when Jones expressed his concerns about his friend’s experience to David Jackson, a lobbyist at Pelopidas, LLC, a professional-services network that counts legislative lobbying in Missouri among its engagements.

Jackson introduced Jones to Liz Quam, cofounder of the Imaging e-Ordering Coalition and executive director of the Center for Diagnostic Imaging (CDI) Quality Institute. The institute is part of CDI (Minneapolis, Minnesota), which has imaging centers in 10 states (including Missouri).

Jackson discovered that MedSolutions, Missouri’s contracted RBM, was receiving $2.1 million per year from the state for 200,000 or so Medicaid enrollees—and that the state had essentially spent that money to have the RBM hard-stop 5,000 exams, at roughly $420 per denied study.

“MedSolutions issued a report to the Missouri Department of Social Services, highlighting claims submitted, accepted, denied, and so forth,” Jackson explains.

Further, the RBM was skirting Missouri’s requirement that a state-licensed physician conduct utilization review by putting state-licensed physicians on its payroll.

The Decision-support Alternative Jones subsequently put forth HB 867 (Authorization for Providers of Medical Assistance Benefits), a bill designed to allow health-care providers to use decision support as an alternative to prior authorization to determine the appropriateness of services to be received by Medicaid recipients.

Although similar legislation had passed muster with members of the Missouri Senate, difficulties ensued. The bill was submitted to the House’s standing Health Care Policy Committee, but about 24 hours before the committee concluded its review of submitted items, MedSolutions hired two highly influential lobbyists to “get it off the table,” Quam says.

“Unfortunately, we did not have enough time to pull together arguments and rebuttals of our own,” Jackson reports. Jones says that he will not stop trying to get HB 867 enacted. “I fully plan on filing the same legislation next year, and the year after that,” he says. “I will

14 Radiology Business Journal | June/July 2013 | www.imagingbiz.com

not rest until it goes through, and the misuse of state tax monies” to fund RBM use ceases to occur.

He will have plenty of support from entities such as CDI and the CDI Quality Institute. “We have a stake, as part of the Imaging e-Ordering Coalition and of Missouri state medical groups,” all of which “are working to promote better RBM practices and Medicaid changes for the better,” Quam explains.

Robert Y. Kanterman, MD, medical director at CDI–St Luke’s and chief of radiology at St Luke’s Hospital (Chesterfield, Missouri), offers insight into the impact of prior authorization on patient care. “The pattern, now, not only compromises patient care; it is extremely disruptive to relationships between referring physicians and patients,” Kanterman says. He has testified before the Missouri House on RBM-related issues.

He adds, “We also are finding it challenging and disturbing that healthcare decisions—radiology diagnostic decisions, in our case—are increasingly made in out-of-state call centers by people who are not the ones who have seen the patient (and may not have enough of a medical background to make the decisions). In addition, we are having to employ an increasing number of staff to deal with the administrative hassles associated with getting exams approved, as are our referring physicians. Using

decision-support tools could prove to be a more optimal model for choosing the right exam in a more efficient manner.”

Wisconsin Succeeds Progress in this area is being made elsewhere. In early June, the Wisconsin Department of Health Services announced the launch of the ForwardHealth Alternative Pathway/Gold Card exemption program. It was devised in partnership with the Wisconsin Medical Society; the Wisconsin Radiological Society; and the Marshfield Clinic (Eau Claire, Wisconsin), a nonprofit health system that operates the state’s largest group practice (with more than 700 physicians) and more than 50 community-care centers and hospitals.

ForwardHealth, Wisconsin’s Medicaid program, has required prior authorization for CT and MRI studies conducted in outpatient hospital and nonhospital settings since December 2010. Upon approval of the provider’s request for exemption, however, ForwardHealth will

now recognize a decision-support tool for advanced imaging as an alternative to prior authorization.

Tim Bartholow, MD, CMO of the Wisconsin Medical Society, deems the exemption program likely to be a precedent setter for the incorporation of other site-of-care decision-support tools into Medicaid programs. He states, “This is a tremendous example of physicians working with payors in developing a process to integrate technology and ensure better care and value.”1 —Julie Ritzer Ross Reference 1. Wisconsin Medical Society. Exemption program for CT, MRI prior authorizations launched.

Medigram. https://www. wisconsinmedicalsociety.org/resources/ medigram/2013-archive/medigramjune-6-2013/exemption-program-forct-mri-prior-authorizations-launched/.

Published June 6, 2013. Accessed June 24, 2013.

h e a lt h p o l i c y

Gatekeeper, Part II: Understanding Clinical Nuance

A

. Mark Fendrick, MD, is a selfdescribed generalist. His research (as a professor of internal medicine and director of the University of Michigan’s Center for Value-based Insurance Design) has probed the cost of the common cold, explored the value of new imaging techniques, and quantified the value of Katie Couric’s colonoscopy in preventing colon cancer in the United States as worth more than $1 billion in National Institutes of Health funding.

“I was introduced to the US Congress as the shallowest guy in academic medicine, which you—as subspecialists—would take as an insult, but I took as a compliment,” he quips in his segment of “The Radiologist As Gatekeeper: Should We Take a More Active Role?” The session was presented on November 28, 2012, at the annual RSNA meeting in Chicago, Illinois. Fendrick shared the podium with Bibb Allen, MD; Alan Kaye, MD; and moderator Ruth Carlo, MD.

While Fendrick was impressed with the panelists’ head-on approach to health-care reform, he characterized the behavior of other specialty organizations as ostrichlike. He recalls, “The first thing I said, in a talk given to the American College of Cardiology, was, ‘Before you get angry at me, the approach we are trying to outline will actually increase your income.

It may change what you are doing, but it is not the threat it is being made out to be to the practice of any type of medicine— because (as all of us know) there is more than enough money in the system.’”

Furthermore, Fendrick points out, no one, when talking about bending the cost curve, is talking about cutting health-care costs in any way. “If you look at projected trends relative to the doomsday scenarios, hundreds of billions of dollars, in new money, are projected to be spent, all across the board,” he emphasizes, adding that the more radiologists focus on the issue of value over volume, the better off they will be.

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Volume to Value Radiology’s path from volume to value should be based on three tenets, Fendrick says: the creation of evidence, the creation of tools, and (most important) the creation of incentives, the subject of much of his research activity. “I hope we spend a fair amount of time talking about how we move from a fee-forservice payment model to one that is based on the health we create,” he says.

“We need to realize, moving forward, that outcome equals income. I don’t know why this has never been the case, but how you perform—the good that we are supposed to create, which is health— will, ultimately and finally,” determine how health-care providers are judged (and paid).

Fendrick urges radiology to consider its value proposition seriously, in the context of the health that it creates—even though the dialogue in Washington and in state governments is exclusively about cost.

For instance, Fendrick recognizes that the emphasis, in imaging circles, is on the ineffective and inappropriate use of imaging.

“Why isn’t there equal attention (which is the focus of my research) to the underutilization of the effective imaging technologies that we have? You have to understand that as there is overuse on one side, there is clear underuse on the other side.”

The answer, Fendrick believes, is to merge supply-side incentives with demand-side incentives. On the demand side, the creation of consumer-directed, high-deductible health plans and definedcontribution models means that patients are almost universally being required to contribute more to the cost of their health care. “What we are finding is that as patients are required to pay more (out of pocket) for all services, they not only stop buying the stuff that we don’t want them to buy, but they also stop buying the things that we beg them to buy,” Fendrick emphasizes.

Rationalizing Incentives In order to rationalize incentives on both sides of the health-care relationship, physicians must find a way to communicate clinical nuance to policymakers. “What we all know—but what payors and policymakers don’t understand—is that medical services

I have strongly suggested that we should be paid more for the things that produce the most amount of health, and we should be paid less for things that don’t.

Patients should have easier access to those services with the highest level of evidence of impact or benefit.

—A. Mark Fendrick, MD

differ in the value that they create,” he says. “I have strongly suggested (for more than a decade) that we should be paid more for the things that produce the most amount of health, and we should be paid less for things that don’t. Patients should have easier access to those services with the highest level of evidence of impact or benefit. Patients should have to pay more for things with no indication.”

On the supply side, real battles will break out among physicians over determining which health services should be highly valued, Fendrick predicts. On the demand side (and in his role as a practicing physician), Fendrick has seen, firsthand, patients whose chief complaint is that they need an MRI exam. “They don’t even tell me which joint is bothering them—or whether it’s their head or their knee,” he says. Misplaced incentives, media health-care coverage, and other factors have led to complete distraction from the fact that there is clinical nuance in the things that physicians do.

Some progress in the convergence of supply- and demand-side incentives can be seen in physician pay-for-performance incentives and value-based insurance design, which “makes the good stuff easier for patients to get and the bad stuff harder,” Fendrick says. “Although there seems to be a lot of focus on the overuse issue, you need to focus much, much more on the underuse of imaging, the transformative nature of imaging, and how it has made the practice of medicine so much easier . . . across all specialties.”

One of the most popular elements in the Patient Protection and Affordable Care Act (PPACA) is the page in the 2,700-page law that mandates the provision of highvalue preventive services (as determined by the United States Preventive Services Task Force and other organizations)— including mammograms and colorectalcancer screenings—at no cost to patients.

“Where you and virtual colonoscopy fit

16 Radiology Business Journal | June/July 2013 | www.imagingbiz.com

into those guidelines depends on your research,” Fendrick says.

Paying Farmers Not to Plant Fendrick, a frequent visitor to Washington, DC, shares the story of how the idea of clinical nuance made its way into the PPACA during a discussion about pricing stent placement with some US senators. He told them that in the setting of an acute myocardial infarction, a coronary stent is the most valuable thing that we have in medicine. It saves lives a remarkably high percentage of time.

He adds, “Many of you know that at your institutions, this specific service is markedly underutilized, for a lot of reasons: not getting to patients in time, having no cardiologist available, or the catheterization laboratory being unavailable. I suggested paying cardiologists a lot more, in that setting, for stent placement.”

When Fendrick moved on to describe to the senators the 30% of stents placed unnecessarily, a senator stood and asked if he was going to suggest that cardiologists be paid not to put in stents, in those situations. Before Fendrick could respond in the affirmative, Sen Chuck Grassley (R–IA) said, “If we can pay farmers not to plant corn, we can pay cardiologists not to put in stents.”

Fendrick says, “It was that moment of reason that actually got the concept of clinically nuanced payment and benefit design into the PPACA.” In conclusion, Fendrick invited attendees to give him a list of underutilized services in radiology to bring forward to national policy specialists. “I would like you to take this idea of clinical nuance (that services differ), combined with the idea that incentives must change for all of you, from volume to outcomes, as you think about where you sit in this whole process,” he suggests.

—Cheryl Proval

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Standardization | A Blueprint for Radiology

Devising a Blueprint for Radiology:

Standardization

Standard nomenclature, structured reporting, and approved imaging protocols are all part of the movement to ensure quality radiology By George Wiley

S

tandardization in radiology can take a dozen different paths, and it is clearly complex—but why is there a need for standardization in the first place? Debra L. Monticciolo, MD, FACR, is vice chair for research at Scott & White Healthcare (Temple, Texas), a nonprofit health system. She is a professor of radiology at the allied Texas A&M Health Science Center College of Medicine and is a subspecialist in mammography. Monticciolo is chair of the ACR® Commission on Quality and Safety.

Of course, quality and safety are among the primary reasons that standardization is a talking point for so many who hold stakes in radiology’s future.

“You have to go back to the way medical practice developed—in this country and elsewhere,” Monticciolo says. “Physicians go out and practice.

They respond to their local environments and their patients’ needs. They develop their own ways of doing things. It’s not that there’s anything wrong with that, but these variations in care, over time, can be amplified when you get to taking care of large numbers of patients systematically.

You don’t want things being done in 20 different ways if they can be done in two different ways.”

From the standpoints of both safety and quality of care, patients are best served when practice standards are developed and used by all providers, Monticciolo says. She uses an example from the ACR’s effort to develop its Dose Index Registry to protect patients from excess radiation during one or multiple imaging exams.

“When we first looked at something as simple as a CT exam of the head with contrast, in the systems that we looked at—at the hospitals that were initially

Preload: Preview v The push toward the management of population health has created a movement backing the standardization of health care.

v Measurement and reporting offer other opportunities for standardization, smoothing the way for the assessment of outcomes downstream.

v As medicine’s arguably most wired specialty, radiology has an IT infrastructure that can support standardization efforts—if standard nomenclature is used.

v In some cases, large health systems served by multiple practices are providing the impetus—and mandate—for standardization.

18 Radiology Business Journal | June/July 2013 | www.imagingbiz.com

When we first looked at something as simple as a CT exam of the head with contrast, in the systems that we looked at—at the hospitals that were initially working on this—we discovered that this single exam was being named in 1,200 different ways.

—Debra L. Monticciolo, MD, FACR

working on this—we discovered that this single exam was being named in 1,200 different ways,” she says. “You can’t do anything if you can’t gather data. There needed to be one name for the procedure; then, we could look at how we can do things better.”

Curtis Langlotz, MD, PhD, a professor of radiology and vice chair for informatics in the radiology department at the University of Pennsylvania Health System in Philadelphia, has spent years developing a common nomenclature for imaging procedures and processes. He says, “There is a growing consensus across health-care disciplines—not just in radiology—that variability in care is undesirable. We can’t always agree on the optimal level of care, but we can often agree that care at the extremes is suboptimal.”

Mitchell D. Schnall, MD, PhD, is a professor of radiology and, since October 2012, chair of the radiology department at the University of Pennsylvania Health System. Schnall also chairs the ACR Imaging Network (ACRIN). He is personally working on quantitative biomarker standardization in clinical trials involving cancer patients, driving home the point that it is those who order imaging exams who are impelling radiology toward standardization.

“Other people are asking us for standardization. Our users are starting to ask for it. The oncologists like to see standard and quantitative reports. This is what the customer base is asking for,” Schnall says. Digital technology plays a part, too.

Convergence Anthony A. Mancuso, MD, is professor and radiology department chair at the University of Florida College of Medicine

There is a growing concern across health-care disciplines—not just in radiology—that variability in care is undesirable. We can’t always agree on the optimal level of care, but we can often agree that care at the extremes is suboptimal.

—Curtis Langlotz, MD, PhD

in Gainesville. Mancuso says that timing has a lot to do with what radiology is undergoing. Standardization represents a convergence of accumulated radiological knowledge and applications made possible by IT and digital communication.

“We know what we don’t know,” Mancuso says. Exams that work well for given clinical scenarios are well documented. Digital technology makes standardized protocols and procedures more efficient to implement. Speechrecognition transcription systems that build structure into the exam-reporting process will soon allow data to be mined from imaging exams as never before, Mancuso adds.

“There are tremendous systems out there. You can now embed some principles, in creating a proper reporting structure, that make it very efficient,” he says.

In May, the US DHHS announced that a tipping point has been reached: Physicians and health-care systems have responded to federal financial incentives to create electronic health records (EHRs). By the end of 2013, the DHHS estimates, more than half of physicians and 80% of hospitals will be using EHRs. In 2008, prior to the inclusion of financial

incentives in the American Recovery and Reinvestment Act of 2009, only 17% of physicians and 9% of hospitals were using EHRs.1 What to Standardize The digital medical evolution and the focus on accountable care as an alternative to fee-for-service reimbursement both fit into the efficiency and quality benefits that standardization promises. Despite this, standardizing radiology isn’t going to be easy. It will take a long time, Schnall says.

He’s impatient when people discuss standardization in the same breath as DICOM, the set of communications standards allowing imaging equipment, PACS, and RIS to exchange data in a uniform way. “I get annoyed when I hear people say that we can do this because we did DICOM,” Schnall says. “This is so much more complicated than DICOM that the reference does not do it justice.

We are talking about practice standards that are fundamentally different. This is very different from DICOM: It’s much harder to define. DICOM was easy.”

Which elements in radiology need to be standardized? “We must standardize everything that affects the outcome for patients,” Schnall says, “from patient

www.imagingbiz.com | June/July 2013 | Radiology Business Journal 19

Standardization | A Blueprint for Radiology

Any standard is rule based, so the rules have to be efficient.

Standardization eliminates waste, if it’s done correctly (assuming that it doesn’t add a bureaucratic burden).

—Anthony A. Mancuso, MD

preparation to the time between a contrast injection and a scan.”

Mancuso agrees; he says that the entire radiology round trip, from order entry to report delivery, needs to be standardized.

“Any standard is rule based, so the rules have to be efficient,” Mancuso adds.

“Standardization eliminates waste, if it’s done correctly (assuming that it doesn’t add a bureaucratic burden).”

Mancuso and his colleagues at the University of Florida College of Medicine have been working on radiology standardization for years. Even so, Mancuso estimates that they are only 50% of the way to where they want to be.

They are on the verge of implementing a standardized reporting system, but it isn’t in use yet. They also have no decisionsupport system in place for referrers, although that’s coming. Standardization is all about refinement and consolidation, Mancuso adds.

Nomenclature Perhaps nothing about standardization is more important than making sure that each discrete imaging procedure is called by a single name. The name is used to define consistent, predictable protocols that enhance quality and safety, as well as to allow outcomes to be assessed and compared.

Mancuso and his staff have developed standard names for imaging procedures (SNIPs). SNIPs indicate modalities and anatomy, and they are used in ordering, scheduling, performing, interpreting, and billing for exams. SNIPs, Mancuso explains, “became our infrastructure for creating the orderable exams that we do. Then, on top of that, there are the specific indications for the imaging protocols.” The protocols can be seen at protocols.xray.ufl.edu/live_protocols/

snips/?elements/page_request/snip/ update_select_tree/browse_panel.

When the clinician orders, he or she selects a SNIP, which links to the exam and the report template for what the clinician wants to know, Mancuso says. His department has just finished translating the SNIP tables and names into ICD-9 billing codes. “We try to do everything at an expert level—and consistently,” Mancuso says. “Everything can’t be standardized, but we can be sure there are proper pathways for the vast majority of things we do.”

RadLex SNIPs form the University of Florida College of Medicine’s localized and adapted version of a broad-based nomenclature effort that is still gathering speed: RadLex, sponsored by the RSNA. The RadLex Playbook, released in 2011, is a standardized lexicon of procedure steps and possible orders covering 342 procedures.

For a head CT exam with contrast, the RadLex Playbook has one entry (instead of the 1,200 names that Monticciolo and her colleagues encountered). Of course, RadLex contains many other head-related CT studies that might have been counted in Monticciolo’s original effort, but each is now named, numbered, and described specifically in RadLex. Each is a discrete procedure.

Langlotz has been working on RadLex for nearly a decade. Christopher Sistrom, MD, PhD, the physician/analyst at the University of Florida College of Medicine who developed SNIPs “was working in coordination with the RadLex Playbook,” Langlotz says. This is not unusual, he adds. “Each practice will have its own list of procedure codes (sometimes called a charge master). The point is not for each

20 Radiology Business Journal | June/July 2013 | www.imagingbiz.com

practice to use RadLex Playbook codes out of the box, but to map its charge master to the Playbook codes. That way, we can benchmark between practices using comparable codes. The ACR’s Dose Index Registry uses the RadLex Playbook for just that purpose,” he says.

Langlotz notes that RadLex creates a foothold for other standardization efforts, but does so quietly. “RadLex is like plumbing: It must function properly, but if you have to think about it, it’s not doing its job. RadLex serves as an infrastructure and foundation for many other important initiatives, including structured reporting and natural-language understanding.

It’s essential, but it’s not something radiologists should need to worry about,” he says.

RadLex has already been adopted by institutions, providers, and vendors to a degree that Langlotz did not foresee. He says, “When we conceived of RadLex, almost 10 years ago, I don’t think anyone anticipated the level of adoption we see today.”

Structured Reporting Until recently, many radiologists used narrative reporting, but this is changing as more adopt structured reporting. There is resistance, of course.

Some radiologists view their narrative reports as an art form—easy for referring clinicians to grasp and quick for the experienced radiologist to produce.

For some, structured reporting—which involves narrative, per-exam checklists, and perhaps annotated measurements— is cumbersome and time consuming.

Structured reporting has, Schnall says, “sort of a bad name, because the many interfaces are not very efficient for radiologists, and they don’t want to lose efficiency. We are working now on how to develop interfaces that don’t cause loss of time. The templates require lots of clicks.

They are not efficient interfaces, but we are starting to see those develop, and we will be able to use them efficiently.”

He continues, “Standards are very important, whether there is quantification or not. In general, the output of radiology is not data. We provide unstructured text, and everybody uses his or her own descriptive terms. The idea of

standardization (in both quality and quantity) is to create databases to predict outcomes for the next patient. That’s the way radiology is headed.”

In breast imaging, for example, use of the ACR BI-RADS® Atlas has standardized terminology. Schnall says, “Everybody knows what a 2 means; everybody knows what a 3 means. I can mine data from a mammography system and know a lot about what they mean for the next patient. I can look at callbacks, and if I buy a mammography machine, I can tell, right away, the effect that it has.

Do cancers and biopsies increase? I can’t say that when I buy a new MRI system. I have no standard way to represent that.”

RSNA Advocacy The RSNA is promoting structured reporting: Named and numbered exams have a specified reporting protocol that is available at www.radreport.org. “The RSNA’s structured-reporting initiative,” Langlotz says, “gives radiologists the tools they need to begin standardizing their reports. More than 200 standardized report templates are available. The templates are based on the RadLex standard nomenclature. To make it possible for radiologists to download the templates directly into their reporting systems, we have created an Integrating the Healthcare Enterprise technical standard for radiology-report templates.”

He continues, “We want to give radiologists the tools to smooth their transition to more standardized reporting. The key is to retain or improve the efficiency of radiologists. Standard reports can automatically incorporate information from the imaging modality.

Information such as ultrasound measurement, radiation dose, or contrast data need not be redictated, reducing errors and saving time.”

National programs such as meaningful use and the Physician Quality Reporting System have also provided “strong incentives for structured reporting,” Langlotz says. “More and more practices are moving to structured reporting. In our practice, we are standardizing ICU chest reports, reporting of abdominal masses affecting solid organs, and PET/ CT studies of cancer. Those practices

One of the great hopes for imaging, going forward, is that it will be a major source of information and guidance for personal therapy. There are a lot of things we need to make quantitative in order to predict the outcome of personalized therapy reliably.

—Mitchell D. Schnall, MD, PhD

aggressively moving toward structured reporting are finding technical limitations in the reporting systems they use. One of the goals of the RSNA structuredreporting initiative is to remove those barriers—to create a smooth migration path from narrative reports to structured reports.”

Quantitative Imaging At ACRIN, Schnall is investigating quantitative imaging, another element of standardization, by developing biomarkers and imaging indicators to describe and treat cancers. This is being done through clinical trials. “One of the great hopes for imaging, going forward, is that it will be a major source of information and guidance for personal therapy,” Schnall says. “There are a lot of things we need to make quantitative in order to predict the outcome of personalized therapy reliably. There are any number of imaging biomarkers to standardize and assess through multicenter trials.”

He adds, “We look at our role as taking promising technology and figuring out how to deploy it across multiple institutions, getting equivalent data, and seeing if that technology does have value in one or another diagnostic setting— taking it all the way from proof in principle to multicenter feasibility studies to clinical validation.”

Schnall continues, “We’ve got any number of techniques, at various levels of validation, when it comes to quantitative imaging. The technique that is probably furthest along is a version of dynamiccontrast MRI that we use in breast cancer cases in which the cancer will be taken out, but pretreated with chemotherapy

to shrink it first. These are larger breast cancers. We have validated the methodology; we’ve shown that this can be measured consistently. We’ve shown that it can predict the pathology, and we have data that we’ll soon be publishing to show that it may predict long-term patient outcomes.” In the long term, Schnall says, radiologists will convert to structured reporting—and on top of that, to quantitative reporting.

Software vendors have offered decision-support systems for use by ordering clinicians for years. As Mancuso reports, vendors haven’t stopped there.

They are now offering voice-activated reporting systems that automatically structure radiology reports and that use natural-language identifiers to make mining data from the reports feasible.

www.imagingbiz.com | June/July 2013 | Radiology Business Journal 21

Business Intelligence Series #9

Efficient Expansion on Medicare Margins: Eisenhower Radiology Medical Group Eisenhower Radiology Medical Group (ERMG) has accomplished what many would consider impossible: rapid, recent expansion during a recession, with a patient base composed primarily of Medicare beneficiaries. The 17-radiologist group, located in Rancho Mirage, California, has added three imaging centers to its roster in as many years, according to Blair Dick, business administrator for the practice. “One of the biggest challenges we’ve faced was expanding from one facility to four in this economic environment, which is one of the worst we’ve ever faced,” Dick says. “We did it because we wanted to position ourselves to accommodate the increased demand for imaging services that will result from health-care reform.”

“Our challenge is maintaining higher-end service and quality while knowing that the reimbursement pressure is going to continue.” — Blair Dick, business administrator

advantage of business intelligence provided by its billing partner, Zotec Partners. “Zotec helps us determine where our focus needs to be when we consider expansion,” Dick says. “We have a very high Medicare population here, which is good and bad news: It means high utilization, but lower reimbursement. We have to be able to make a go of it with 70% Medicare patients and the rest from HMOs and PPOs, which are not providing much more reimbursement than what we see from Medicare.”

With a demanding patient population that uses imaging regularly, ERMG saw an opportunity in the outpatient market. “There are plenty of services on the inpatient side that would be—if done on the outpatient side— both more convenient and less costly for patients,” Dick says. “We have to make decisions on what modalities and mix of procedures we need to do to offer the complete experience for our patients, and we’ve consulted with Zotec quite a bit on that. It really understands the business and can even share what it sees other practices doing around the country. It’s one of the benefits of working with a bigger company.”

Rancho Mirage is an affluent suburb of Palm Springs that has a patient population composed primarily of retirees on Medicare. “We have a very demanding medical staff at Eisenhower Medical Center,” Dick says, referring to the Rancho Mirage hospital with which the practice has a long-standing relationship, including joint-venture arrangements for outpatient imaging facilities. “We consider ourselves fairly high end; we try to keep our equipment very current, and we have very nice facilities. Our challenge is maintaining that higher-end service and quality while knowing that the reimbursement pressure is going to continue.”

In a recent example, ERMG moved some of its interventional services to one of its four Eisenhower Imaging Center outpatient facilities. With the help of business intelligence provided by Zotec, the practice was able to determine that its volumes would support the change.

“Under the joint venture with the hospital, we’re able to bill in a global arrangement, which gives us an advantage,” Dick says. “Zotec was extremely helpful in assessing whether it would make sense for our business.

Not only will it be more beneficial for the radiology group, but it will also be more cost effective for patients.”

Understanding the Population

Seeing the Big Picture

To understand better whether its patient population can support the addition of new service lines, ERMG takes

With the help of business intelligence, ERMG is better able to forecast its future needs to ensure its

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continued success in the market. “We have such a wealth of knowledge now, even compared with what we had five years ago,” Dick says. “Zotec has done a great job, not only in terms of providing us with good reports on a monthly basis and being able to tailor them to what we need, but also in having a product that allows us to go in, anytime we want, and look at things in real time. We can see the information any way we can think of looking at it: by patient demographics, geography, or payor mixes.”

That capability has an impact on more than the practice’s ability to assess whether it can sustain new facilities, Dick says. “Something a lot of radiology groups struggle with is bringing on new radiologists— and whether the new person should be a partner or an employee,” he says. “You have to be able to anticipate what the best structure of the group will be, in terms of partners versus nonpartners, over the next few years. Bringing on bodies is a product of your volume, and understanding that, through business intelligence, can help us determine what kind of staff we need.”

“You can make decisions quickly and with more confidence. To me, that is what is really beneficial about being with Zotec.” — Blair Dick

Business intelligence also helps the practice balance between high-end services (CT, MRI, and nuclear medicine) and services that benefit patients, but offer lower reimbursement, such as radiography. “When imaging centers really exploded as businesses, it was all about going after the high-end business, but that’s really a disservice to the customers,” Dick says. “We want to be seen as full service in our community. Business intelligence from Zotec helps us decide whether we can offer interventional services alongside basic radiography, in a given facility; it helps us balance those services.”

It’s most critical, perhaps, that business intelligence empowers the practice and its leaders to assess its options more quickly than ever before. “You can make decisions quickly and with more confidence,” Dick says. “To me, that is what is really beneficial about being with Zotec.”

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Standardization | A Blueprint for Radiology

We’ve seen the future, and we like it.

That can be extremely difficult to implement, though, when you are involving different radiology groups.

Reporting is still considered the art of the individual physician.

—David Monaghan, MHA Intermountain Healthcare

Natural-language data mining (which allows patient outcomes to be tracked and best-practice imaging tests to be identified and refined further) is possibly the cap piece of standardization, as it is now envisioned. Langlotz says, “No matter how much we focus on standard nomenclature and structured reporting, it’s important to remember that much of the report will remain in narrative form, so access to automated natural-language understanding and text-based search tools is critically important.”

Ultimately, Mancuso adds, systems providing everything from decision support to structured final reports will have autocorrect elements. “The next thing will be to develop active management systems,” he says, “to selfcorrect these things on the fly: to say (to providers or to systems in general), ‘The pathway you’re taking is not efficient, and it is costly. Explain, or go back to this approach that seems to work.’”

Adoption by Hospital Systems Hospital radiology administrators are certainly aware of standardization, structured reporting, and decision support. They contend daily not only with trying to make imaging itself more efficient, but with improving their patient-handling processes as well.

Intermountain Healthcare (Salt Lake City, Utah) is a nonprofit system of 22 hospitals, a medical group, and nearly 200 physician clinics, spread over Utah and Southern Idaho. Intermountain Healthcare operates its own healthinsurance company.

David Monaghan, MHA, is vice president for imaging services at Intermountain Healthcare. He says that the system has more than a dozen

employed radiologists, but most of the radiologists it relies on, in six different groups, interpret studies under contract.

Monaghan estimates that Intermountain Healthcare performs about 1.5 million imaging exams per year.

Intermountain Healthcare already has put in place a single PACS and RIS, Monaghan says, and is now standardizing as many elements as it can of what he calls the radiology value chain. The overriding goals are “predictable and consistent outcomes and a consistent service experience,” he says, “along with data capture. We don’t look at imaging as just radiology; we’re looking at the other specialties that acquire images. There are a lot of redundancies.”

Structured reporting is on the wish list and is being promoted, he says. “We’ve seen the future, and we like it. That can be extremely difficult to implement, though, when you are involving different radiology groups. Reporting is still considered the art of the individual physician.”

To bring along reluctant radiologists, Intermountain Healthcare is focusing on shared accountability, using a guidancecouncil approach. Monaghan says, “We are moving toward risk-based population care, so standardization is needed: an integrated delivery model with all the radiologists—and the benefits of consistent outcomes.”

What physicians find most convincing, he adds, is having data, so Intermountain Healthcare is focusing there to convince radiologists to do things its way. “It’s almost always having data that sells,” he says. For example, Intermountain Healthcare did a children’s hospital study to determine the lowest radiation level for pediatric head CT exams that would result

24 Radiology Business Journal | June/July 2013 | www.imagingbiz.com

in an image that could be interpreted, Monaghan says. Having found that safety standard, Intermountain Healthcare now requires its use throughout the network.

Monaghan adds, “That one doesn’t have an opt-out feature.”

Immediately Classic Research Intermountain Healthcare handles equipment service in-house, Monaghan notes. Even so, it is looking at partner vendors, by modality, to assess whether their service offerings could reduce cost and improve efficiency. “We want select partners in select modalities,” Monaghan says. “We look at that as a standardization gain as well.”

Intermountain Healthcare recently moved its imaging appointment schedulers into patient account services so that time could be saved by asking patients about clinical care and billing in a single phone interview. Monaghan says, “That all focuses on patient engagement.”

Intermountain Healthcare also is standardizing the use of existing technology through its IT support teams.

“We have one RIS, but people were using it differently in the way that they would schedule which process to do first,” he explains. “That can result in different outcomes, and the time stamps can be different. The patient might be in the waiting room for an hour, drinking contrast, but that wouldn’t show up; we are trying to get the processes and the technologists in lockstep.”

Standardization involves a great deal of what Monaghan calls “immediately classic research: As soon as we do it, and it works, we start to implement it,” he says. There also are the systemic things that radiology can’t control, but among the areas where it would like to see changes, Monaghan says, the first is access to images from the electronic medical record. “That’s where we start to mess with somebody else’s cheese, and radiology isn’t the highest priority,” Monaghan says.

The Halo Effect Jim Sapienza, FACHE, MA, MHA, MBA, is systemwide administrator of imaging services for MultiCare Health System (Tacoma, Washington), a not-

for-profit provider that operates five hospitals, six emergency departments, and 20 outpatient centers in four Western Washington counties. MultiCare Health System contracts with three radiology groups (about 110 radiologists) to interpret close to a million exams per year, he says.

Sapienza defines four areas of standardization that MultiCare Health System is pursuing: workflow, equipment, protocols and processes, and outcomes (or measurements tied to outcomes).

“Ultimately, all this work strives to improve quality control in imaging—to raise the bar,” he says. “Higher quality reduces the cost of care.”

A major standardization initiative, he says, has been reducing turnaround time in getting radiology reports back to emergency-department physicians. “We wanted leading indicators, rather than lagging indicators,” he says. “We figured that if radiologists set up workflows to focus on emergency-department turnaround time, they would eventually get around to improving all turnaround times.”

This turned out to be the case.

Emergency-department turnaround time was reduced to around 20 minutes, and other turnaround times shrank as well.

“A study might once have had a week or two as its turnaround time, but now, a nonurgent MRI exam has a turnaround time of two hours or less,” Sapienza says.

“They set up workflows. The focus was on emergency-department turnaround time, but that had a halo effect on all turnaround times.”

Turnaround-time standardization led to workflow, protocol/process, and outcomes improvements, Sapienza notes, so three of his four areas of standardization were improved by attention to one systemic problem. “Lean training says that without standards, there can be no improvement,” he adds.

Another step that MultiCare Health System has taken is the use of reporting templates to reduce the need for editor/ transcriptionists. “In 2012, one of our six indicators was the number of self-edits,” Sapienza says. “Some radiologists had been self-editing for years (and finalizing reports themselves). One of the things

We wanted leading indicators, rather than lagging indicators. We figured that if radiologists set up workflows to focus on emergency-department turnaround time, they would eventually get around to improving all turnaround times.

—Jim Sapienza, FACHE, MA, MHA, MBA MultiCare Health System

we did to get to 100% self-editing was to clean up the template and make sure it was a structured exam.”

He adds, “We were 90% self-edited, and we gave notice that we wanted to be at 100% in 18 months. In seven months, the radiologists went to 99.8%. Now, on average, we might have 10 reports a week that aren’t self-edited. Some ultrasound reports can be daunting because of the data points that need to be entered. They might send those to the editors to make sure that they get checked.”

medicine. People should be accountable for their best output, but should not feel stifled,” he says.

Mancuso seems confident that standardization will be seen as more innovation, not as an impediment to it. “In the past 10 years, the ability to standardize has really set itself out there,” he says. “Productive human beings want to do better. It clearly is a stimulant.”

Standardization’s Downside There is some fear that standardization will halt advances in medicine (and radiology, in particular) in their tracks.

Innovation has revolutionized radiology; nobody wants to think that imposing standards, as necessary as it might be, will halt that.

“We don’t want to standardize everything,” Monticciolo says. “We don’t want to do fast-food service; we don’t want cookie-cutter care, but we do want to standardize. We still need individual care.”

Schnall notes that modality vendors have always competed based on innovation and new technology more than on price, and standardization might “remove some flexibility,” he says, making it harder for manufacturers to compete.

“We don’t want to take away creativity.

We don’t want to inhibit the ability to develop new methods. We don’t want to undermine that,” Schnall says.

Mancuso also raises the issue.

“Medicine is complex, so we don’t want to eliminate creativity or the exercise of wisdom. We don’t want to remove the human element or judgment entirely from

Reference 1. US DHHS. Doctors and hospitals’ use of health IT more than doubles since 2012. http://www.hhs.gov/news/ press/2013pres/05/20130522a.html.

Published May 22, 2013. Accessed June 11, 2013.

George Wiley is a contributing writer for Radiology Business Journal.

www.imagingbiz.com | June/July 2013 | Radiology Business Journal 25

Self-referral | Budget Proposal to End the IOASE

The In-office Ancillary-services Exception:

Time to Ground the Skyrocket?

The president’s budget proposes ending the in-office loophole in the Stark anti–self-referral laws, but the idea faces stiff opposition from other specialties By Greg Thompson

S

ome battles are destined to be fought over and over again. The fight to eliminate the IOASE is one such skirmish; it refuses to go away, after more than a decade of debate.

Both sides are firmly entrenched, but the battle has been joined, in no small measure, by the federal government.

The salvo from President Obama begins on page 40 of the 244-page 2014 budget: The Medicare Payment Advisory Commission “cautions that physician self-referral of ancillary services leads to a higher volume when combined with feefor-service payments, a finding consistent with [Government Accountability Office (GAO)] . . . analysis. The budget encourages more appropriate use of ancillary services by only allowing providers who meet certain accountability standards to self-refer radiation therapy, therapy services, and advanced imaging services.”1 According to the Office of Management and Budget, eliminating the exception could save $6.1 billion over the course of a decade.1 The president’s budget expands Stark laws to include not only diagnostic imaging, but also radiation oncology, clinical-laboratory services, and physical therapy—which (together) make up the $6.1 billion figure.

Cynthia Moran, the ACR’s assistant executive director for Government Relations, Economics and Health Policy, says, “It did not include anatomic pathology, but that could be next. The more services they look at, the bigger the net becomes.” Likewise, the more services included in the calculation, the greater the savings.

Preload: Preview v After years of ACR® lobbying, the inoffice ancillary-services exception (IOASE) is getting the attention of lawmakers. v The Obama budget for 2014 proposes an end to the IOASE for radiation therapy, therapy services, and advanced imaging services, saving $6.1 billion over 10 years.

26 Radiology Business Journal | June/July 2013 | www.imagingbiz.com

v Opponents, including the American College of Cardiology (ACC) and the American Academy of Orthopaedic Surgeons (AAOS), cite patient access as a primary reason for maintaining the exception. v Even with the odds stacked against it, the proposal, nonetheless, has more support than it has ever had in the past.

I

n this age of profound changes in health-care–delivery models, radiologists must find new strategies for staying viable. One such approach is Imaging 3.0™, an initiative led by the American College of Radiology to help shift the culture of radiology. Imaging 3.0 provides measures that ensure quality and safety; it also requires coordination and collaboration among physicians and patients, and it empowers patients in their imaging care. A new addition to Imaging 3.0 is the ACR Diagnostic Imaging Center of Excellence™, or DICOE, achievement: This program takes a radiology department or practice to the next levels of imaging efficiency and of the safety and quality of care. This process goes beyond accreditation to recognize the best imaging practices and diagnostic care through comprehensive assessment of the entire medical-imaging enterprise, including structure and outcomes.

The Pinnacle of Medicalimaging Care

In order to receive the DICOE distinction, imaging facilities must be accredited by the ACR in all modalities that they offer for which ACR accreditation is available. They must participate in the Dose Index Registry® and General Radiology Improvement Database, in addition to adhering to the radiationsafety guidelines of Image Wisely® and Image Gently®. An ACR team (comprising a radiologist, a medical physicist and a radiologic technologist) will conduct an on-site survey to review all aspects of the facility’s operations.

In May 2013, the ACR recognized the nation’s first-ever DICOE facilities.

They are Hackensack University Medical Center, or HUMC, in Bergen County, N.J., and Mount Desert Island Hospital in Bar Harbor, Maine, which served as the betatesting sites for the program.

Harry Agress Jr., M.D., F.A.C.R., chair emeritus of the department of radiology at HUMC, says, “When a patient sees that HUMC is an ACR DICOE facility, it says that this is an institution that has gone beyond the norm to achieve a national standard of excellence. This achievement shows our patients that we want to take the extra step for them—that we take their imaging extremely seriously and that we’ll do whatever we can to give them the best possible care.”

Using DICOE As a Benchmark

The imaging team at HUMC always believed that it had built a top radiology department and established best practices, but it had no way of knowing how well it was actually doing, compared with other departments. “There are honors within many other areas of medicine; however, there were very few avenues for recognition of an entire radiology department—until now,” Agress says.

Agress believes that DICOE takes accreditation to a considerably higher level. “This is a comprehensive evaluation of our entire department and everything that goes into the process of patient care,” he says. “More than ever, patients are looking for that kind of recognition: They want to find the best. Thanks to the ACR, there’s now a way for them to see which hospitals have the best radiology.”

As radiologists take the lead in advancing quality across the continuum of patient care, hospital administrators are also taking notice. “The DICOE award strengthens our relationship with our hospital administration,” Agress says.

“Being one of the very first in the country to be recognized by an organization as well respected as the ACR shows that we are very committed to excellence.”

continued on the next page

Now, top-quality radiology teams can demonstrate that they are practicing Imaging 3.0™ and can receive recognition for outstanding diagnostic imaging and patient care by achieving the new ACR Diagnostic Imaging Center of Excellence™ distinction.

Helping a Small Hospital Stand Out

As a small, rural hospital on the coast of Maine, Mount Desert Island Hospital also understands the impact that achieving DICOE makes on the community. John Benson, M.D., F.A.C.R., medical director of medical imaging, says, “We have a highly skilled team using advanced technology.

We have generous donors, and we’re well supported by our local community, but there’s always a perception that bigger is better, and there’s a 500-bed hospital just 50 miles away.”

He continues, “Achieving DICOE can put a small hospital on the map. It shows

standards and realized that we needed to do some background work, such as shoring up our accreditations, signing up for required registries and tweaking our quality-assurance plan,” he says. “It was a very thorough assessment, and it was relevant to a medical-imaging department.

During the visit, we also took away several new ideas—for example, critical-results tracking—that we are implementing in our system. There were definitely changes for the better that we’re making as a result of the DICOE evaluation.”

Going through the DICOE process also delivered unexpected benefits to the HUMC radiology department. “This effort

“Having this kind of recognition for excellence is exactly what payers and the federal government will be considering in the new health-care model.”

—John Benson, M.D., F.A.C.R. that you can have a superior radiology practice, even without the resources of a large hospital. A patient can feel safe, and our referring physicians know that they can trust us as a top-quality partner in the decision-making process.”

For Benson, the DICOE award is the culmination of his team’s hard work in building a high-quality imaging service.

“DICOE is saying to our patients and colleagues that we have a great team, we have very high standards of practice and we have top-notch quality-assurance programs. We’re recognized by the ACR as one of the best facilities in the country in delivering imaging services. That’s a really big feather in our cap.”

Establishing a Framework for Excellence

Both DICOE recipients believe that preparing for the process and participating in the site survey were invaluable learning tools. “When we first saw the DICOE application, we realized that there were many things that we were already doing well, but we also saw some areas that needed improvement,” Agress says. “Using the DICOE standards gave us a framework for reviewing our entire department and defining our strengths and weaknesses.”

Benson and his team had a similar approach. “We looked through the

required tremendous teamwork. It brought people from many different disciplines— physicians, nurses, technologists, physicists, administrators and support staff—together as a team,” Agress says.

“It provided a great opportunity to get feedback and coordination from all aspects of our practice and to learn from one another. Going through the process also helped strengthen communication within our department.”

Driving Business Value

Since the DICOE program measures imaging efficiency and the safety and quality of care, its attainment can potentially help radiology practices realize important financial benefits and demonstrate radiology’s excellence to policymakers. “I expect that our business will increase as a result of being recognized as a center of excellence,” Benson says. “It will certainly help our hospital compete with other nearby hospitals.”

Now that the DICOE award has been established, its initial recipients believe that more and more patients, referring physicians and payers will be seeking facilities that have been acknowledged as top performers. “The advantages of receiving the DICOE award are multifaceted,” Agress says. “For referring physicians, it demonstrates that we’re

the kind of place to which they want to send patients to have their studies done.

Patients can see that we have gone to another level of quality in imaging care.

In terms of payers and evolving federalgovernment standards, demonstrating quality has become more and more important, and it will continue to be one of the major competitive factors in healthcare reform. Confirmation of high-quality care has never been more imperative.”

The DICOE award has come at a critical time for the radiology community. “Radiology has been under the gun for many years, and the next few years will not be any different.

The economic environment is rapidly changing, and we’re moving to a value model, rather than the volume model,” Benson explains. “Quality is becoming increasingly important, especially with some of the alternative payment approaches, such as the use of accountable-care organizations. Having this kind of recognition for excellence is exactly what payers and the federal government will be considering in the new health-care model. Now is a great time for this new initiative.”

Call to Action

Agress stresses that it’s time for the radiology community to shape its future—versus being shaped by it.

“Rarely does a patient come into a hospital without needing some form of imaging that will help his or her physician make major decisions about diagnosis and treatment,” he says. “A patient’s care is extremely dependent on how well we, as radiologists, do our jobs. We see our roles not only as those of interpreters of images, but also as those of consultants and contributors to patient management.

Achieving the DICOE award represents an opportunity for radiology practices to play a major part in the future of medicine by promoting better quality and more efficient (and appropriate) patient care.”

Radiology practices can learn more about applying to join the elite DICOE community by visiting www.acr.org/DICOE.

When the Congressional Budget Office carved out diagnostic imaging by itself, total savings tallied $1.8 billion over 10 years. Whichever way the services are parsed, the reality is that countless provisions in presidential budgets never see the light of day. Moran believes that the time finally is right, however, for the IOASE to end.

“From the late 1990s to 2010, utilization of diagnostic imaging services went up like a skyrocket,” Moran says. “You saw a huge proliferation of in-office use by orthopedists, neurologists, urologists, and a whole slew of specialties—probably most in orthopedics and cardiology. So many studies show increasing volume in self-referral. You could attribute the increase in utilization to ownership.”

Political Kryptonite The ACR has been trying to end the IOASE for the past 15 years, essentially sticking to the argument that utilization increases are at least partially driven by financial conflicts of interest. Despite the consistent lobbying, self-referral is “divisive political kryptonite,” Moran says, for a variety of reasons.

“It is very difficult to tell physicians who make a significant financial commitment for their practices that they can’t offer that service,” she says. “There are many physician specialties in which income has been significantly improved due to the specialists’ ability to offer imaging services in their offices. For one specialty to point to other specialties and say that it can’t do something is always an uphill battle. Congress is loath to get in the middle of these battles. They call them turf battles for a reason.”

For years, it has largely been “diagnostic radiology against the rest of the world, on self-referral,” Moran says, but she believes that the renewed interest in Stark selfreferral laws is driven by other specialties that agree with the ACR position. “It’s only been in the past

It is very difficult to tell physicians who make a significant financial commitment for their practices that they can’t offer that service. There are many physician specialties in which income has been significantly improved due to the specialists’ ability to offer imaging services in their offices.

—Cynthia Moran ACR

few years, but the radiation-oncology world is extremely concerned about the impact of self-referral and the delivery of therapeutic-radiation services,” she says. “Pathologists are very concerned, along with clinical laboratories and physical-therapy providers. It adds up to a broader cacophony about the concerns of inappropriate utilization due to selfreferral.”

According to Moran, the origins of the cacophony can be traced back to an ACR initiative from about two years ago. ACR officials requested that Congress ask the GAO to look into the effects of self-referral policy on Medicare reimbursement and utilization of Medicare services. Rep Pete Stark (D–CA)—at the time, the ranking member of the House Ways and Means Committee—made the formal request, along with Rep Henry Waxman (D–CA) of the Energy and Commerce Committee.

When the study was finally published, it specifically zeroed in on diagnostic imaging. “I think the reason the administration finally decided to look at this was because the GAO came out with its investigation and attributed over $1 billion in savings just to the diagnosticimaging component,” Moran says.

Stiff Opposition Organizations that include the AAOS have weighed in with position papers contending that physician ownership of ancillary services makes possible better physician oversight of the quality of care being delivered; improved care coordination among providers, through shared knowledge of patient and case

information; greater patient adherence to treatment plans, by eliminating scheduling delays, prolonged waits, and the need to travel to other offices (which is critically important for orthopedic patients—especially the elderly—with mobility problems); and an integratedcare model that combines health-care providers of various fields to promote a team-based approach to musculoskeletalcare delivery.

No fewer than 23 diverse medical organizations (including the AAOS) sent a letter2 to Waxman and Rep Fred Upton (R–MI) in late April 2013. In addition to asking specifically for preservation of the IOASE, the organizations openly question the rationale and projected cost savings for ending the exception. They write that no quantifiable analysis exists supporting the administration’s estimate that ending the IOASE would result in the predicted cost savings. Instead, they state, care would be shifted to more expensive settings, raising costs to CMS and to Medicare enrollees.

Eugene Sherman, MD, FACC, is chair of the Advocacy Steering Committee for the ACC, one of the 23 organizations that signed the letter. At least in the case of cardiology, Sherman says, the exception does not apply to the majority of physicians in 2013. Even if it did, he says, there would be no need to do away with the exception.

Sherman explains that six years ago, about 70% of cardiologists were in situations in which they needed the in-office exception as part of their practice structures. Today, he says,

www.imagingbiz.com | June/July 2013 | Radiology Business Journal 29

Self-referral | Budget Proposal to End the IOASE

The things the ACC has put in place— appropriateness criteria and tools to help physicians in ordering these tests properly—have shown great benefit in reducing utilization. There is nothing nefarious going on in the privatepractice setting.

—Eugene Sherman, MD, FACC American College of Cardiology

Over the past 10 years, we’ve rarely seen advanced imaging studies done on patients in the same day that they are seeing physicians in an office visit. There is nothing ancillary about a diagnostic-imaging study.

—Cynthia Moran ACR

it’s the opposite. “We’re concerned as to why this administration does not understand what’s going on in the real world,” Sherman says. “In the most recent Medicare utilization numbers ... utilization for cardiovascular imaging continues to drop. The things the ACC has put in place—appropriateness criteria and tools to help physicians in ordering these tests properly—have shown great benefit in reducing utilization. There is nothing nefarious going on in the privatepractice setting.”

He continues, “Eliminating the inoffice exception is costly and interferes with the timeliness and appropriateness of care, and it does not alter imaging patterns or utilization. There have been no studies that show that. Many of us think looking at it the other way may actually be worse, in terms of utilization.”

In Sherman’s eyes, the benefits of patient convenience can’t be overlooked in the in-office debate. As an example, he cites a physician in a small community outside of Everett, Washington. “His town has 30,000, but he serves an area of 150,000,” Sherman explains. “Many of his patients drive one to two hours to see him.

I am sure he does many of his imaging studies on the day of their visit. That’s how you serve communities like that. Bigcity radiologists do not understand what we, as cardiologists, do.”

Moran counters, “Over the past 10 years, we’ve rarely seen advanced imaging studies done on patients in the same day that they are seeing physicians in an office visit. There is nothing ancillary about a diagnostic-imaging study, and there have been numerous studies showing that the convenience argument is null and void.”

The Utilization–Ownership Link Vijay M. Rao, MD, FACR, is David C. Levin professor and chair of the department of radiology at Jefferson Medical College and Jefferson University Hospitals (Philadelphia, Pennsylvania).

She says that cardiology is in a somewhat different situation than other specialties are, but she explains that reduced utilization in cardiology has come as a direct result of specific conditions.

“After the DRA went into effect, lots of those cardiology practices came into the

30 Radiology Business Journal | June/July 2013 | www.imagingbiz.com

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Self-referral | Budget Proposal to End the IOASE

The GAO said that providers who began self-referring in 2009, referred to as switchers, increased MRI and CT referrals by 67% in 2010, compared with 2008.

—Vijay M. Rao, MD, FACR

hospital because reimbursements were substantially cut,” she says.

Beyond cardiology, Rao says, utilization in the Medicare population has gone up across the entire spectrum of medical specialties. “The GAO said that providers who began self-referring in 2009, referred to as switchers, increased MRI and CT referrals by 67% in 2010, compared with 2008,” she says. “How do we explain that? The answer is that they have ownership of the equipment, and that’s where the financial interest is.”

More than 300 articles show, she adds, “that physicians who do their own imaging, via self-referral, utilize imaging services at a much higher rate, compared with physicians who do not self-refer.”

According to Rao, a 2011 meta-analysis3 showed that the frequency of imaging ordered by physicians who self-refer was nearly 2.5 times higher than that of physicians who do not self-refer for

imaging services. “It’s a fact,” she says.

“These are not just anecdotes. This is not perception. There are absolutely rigorous data to prove this, over and over.”

Are all of these self-referrals valid and clinically appropriate? For Rao, the answer is an unequivocal no. “A lot of the imaging growth in the self-referral arena is inappropriate,” she says, “and it is for financial gain.”

Reading the Tea Leaves Sherman can’t predict the likelihood of an end to the IOASE, but he is adamant that its elimination would be a disservice to patients—and no help in the battle to increase savings. “If you eliminate the exception for the 30% or so of cardiologists who are still in a privatepractice setting, in many communities, you will create great hardships,” he says.

“You may even find physicians migrating away from those communities because

this is an important part of the service that they offer, in the financial base for their practices.”

Rao admits that she is not very optimistic that the IOASE will be eliminated, citing very strong lobbyists among the opposition groups. She predicts, instead, that all existing facilities will be grandfathered in and that rules might be a bit more restrictive, going forward—along the lines of prohibiting individual physicians from putting in new CT or MRI systems.

Ultimately, Moran would like to see the DHHS secretary take on the self-referral exception administratively and take diagnostic-imaging exceptions off the table.

“The secretary has the authority to do this via regulation and rulemaking,” she says.

“The bottom line is that patients must be assured that the diagnostic-imaging studies that have been ordered are based on their medical conditions—and that there is absolutely no potential conflict of interest as to why those studies were ordered.”

She continues, “We would argue that even the taint of potential financial conflict of interest jeopardizes the validity of a lot of services. Radiology has been on the receiving end of numerous reductions

by Congress and the administration due to the perception that diagnostic-imaging utilization is inappropriate. Congress or the administration should address the issue head-on and close up the Stark laws to exclude this kind of possible abuse.”

Greg Thompson is a contributing writer for Radiology Business Journal.

References 1. US Office of Management and Budget.

Fiscal year 2014 budget of the U.S. government. http://www.whitehouse. gov/sites/default/files/omb/budget/ fy2014/assets/budget.pdf.

Published April 10, 2013. Accessed June 16, 2013.

2. https://media.gractions.com/E5820F 8 C 1 1 F 8 0 9 1 5 A E 6 9 9 A 1 B D 4 FA 0 9 48B6285786/c070d5c1-1792-41449b7f-c4aba96dff6d.pdf. Published April 29, 2013. Accessed June 16, 2013.

3. Kilani RK, Paxton BE, Stinnett SS, Barnhart HX, Bindal V, Lungren MP. Self-referral in medical imaging: a metaanalysis of the literature. J Am Coll Cardiol. 2011;8(7):469-476.

32 Radiology Business Journal | June/July 2013 | www.imagingbiz.com

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QUantitative Imaging | The Case for Standards

DICOM or Nothing:

The Case for Informatics Standards in Quantitative Imaging Standardization will facilitate the transition from narrative to quantitative reporting By Cheryl Proval

A

Preload: Preview v As quantitative imaging becomes more important to radiologists, so does the use of standards in arriving at the analysis, measurement, and coding of information required in quantitative reporting.

v The most attractive candidate for quantitative-imaging standards is DICOM, which already has a great deal of support in the vendor community and contains many objects designed to support quantitation.

v Why is the move toward quantitative imaging gathering momentum?

Researchers need to reuse data in downstream systems, and radiologists are under regulatory and competitive pressure to demonstrate quality.

v Ironically, academic users are just as guilty as commercial vendors when it comes to keeping the parts of DICOM that work for them, but discarding it in favor of private code when DICOM is too cumbersome.

OM DIC

s radiology enters the era of quantitative imaging, it is well advised to carry with it an old friend, the DICOM standard, according to David A. Clunie, PhD, CTO of CoreLab Partners. He lays out his case in “(Informatics) Standards for Quantitative Imaging,” which he presented on November 28, 2012, at the annual meeting of the RSNA in Chicago, Illinois.

Clunie is hardly a disinterested observer. His informatics credentials include serving as editor of the DICOM standard, as cochair of the Integrating the Healthcare Enterprise Radiology Technical Committee, and as a member of the RSNA’s Quantitative Imaging Biomarkers Alliance. Although he works primarily in research, his message has serious implications for clinical practice and commercial product development: Standardization is no less important in quantitative imaging than in image acquisition, and it will play a pivotal role in the transition from traditional narrative reporting to quantitative reporting.

The DICOM standard initially focused on standardizing the images that come from imaging modalities, but it has migrated into clinical applications that yield results for cerebral blood flow, regions of interest (to get the size of Hounsfield units), PET standardizeduptake values, and measurements— usually distance, but increasingly, area and volume. “In other words, quantitative imaging is nothing new; it’s just that it is growing in importance and expanding in scope in terms of its range of clinical uses,” Clunie says. “In a way, quantitative imaging (as we think of it now) has

34 Radiology Business Journal | June/July 2013 | www.imagingbiz.com

QUantitative Imaging | The Case for Standards

a different emphasis than traditional narrative reporting. What is different is a focus on greater rigor in deployment, with respect to quantitative imaging.”

In narrative reporting, you see an image on the screen and compare it with a previous time point visually, after which you dictate your opinion. Quantitative

Using the example of plotting the change in a lesion’s volume over time, either for an individual patient or a group of patients, Clunie emphasizes the importance of being able to extract key data from a patient’s record. “In order to be able to do this downstream analysis, your report must not be a dead

In order to be able to do this downstream analysis, your report must not be a dead end. The information we are producing should be more than just cutting and pasting or transcribing.

—David A. Clunie, PhD CoreLab Partners

reporting goes beyond mere description; it proceeds to the analysis, measurement, and coding of information that can be reused in downstream systems. “We can use the same standards; we just have a greater need for numbers and codes within the standards and a greater amount of structure in the output,” Clunie says.

Traditionally, he notes, the radiologist looked at an MRI exam of the brain, saw something, and said that there was a hairy mass present. There might have been some context to indicate that it was a glioblastoma, but today, there is more to it: The radiologist uses an automated or semiautomated tool to attempt to find the lesion boundaries and then, the tool reports the volume, which is critical for looking at progression of the lesion over time.

Quantitative imaging depends upon the precision of both the numerical and the categorical information, Clunie emphasizes. In addition to the lesion measurements, the following coded information is desirable: characteristics of the finding, anatomical location of the finding, coded indication of why the study was performed, time of exam, and a code representing the finding itself. The goal, Clunie explains, is not just a piece of plain text, but a searchable, repeatable, and consistent account of the exam results, using a standard lexicon or lexica that can be reviewed retrospectively by the physician (or prospectively, in the case of a randomized clinical trial).

end,” he explains. “The information we are producing should be more than just cutting and pasting or transcribing.”

Acknowledging that dictation continues to be the dominant form of reporting, Clunie adds, “There is no reason that dictation cannot be assisted by the quantitative information that has been extracted upstream—perhaps by the modality; perhaps by an analytic tool that has been run before the images got to you; or perhaps by a tool that you use interactively as you dictate, using prepopulated merge fields.”

Beware the Pretty Pictures Screenshots and DICOM– encapsulated PDFs have gained popularity as more modalities have gone quantitative, Clunie notes, and these can, indeed, save attractive tables and graphics, either from the modality or from the reporting application. The problem with these pretty pictures is that they are the proverbial dead end to which Clunie refers, understandable by a human, but not by a program.

“It is much better to be able to produce a structured output from your work that includes the numbers and codes— because you can use that for comparison next time, it is searchable and minable, and it is also the basis for qualityimprovement measurements. As the government becomes more interested in evaluating your performance, the ability

36 Radiology Business Journal | June/July 2013 | www.imagingbiz.com

to provide quality measurements in an automated manner, rather than having to run around and build up your submission manually, becomes important,” he says.

The answer, Clunie says, is the adoption of informatics standards that support the infrastructure to achieve this objective. He says, “When you make a decision about something or produce a report, it needs to be stored, reused, and accessible for medicolegal reasons—but more important, for patient care.”

Given the example of change over time in the individual patient, it is not only possible but practical to interpret an image, encode the findings, and reuse the quantitative inputs and outputs from imaging modalities and reporting systems via DICOM—and only DICOM—Clunie says. The standard, though, has its weaknesses.

It all begins with the image, and many radiologists would agree that the problem of reading the output from a given modality largely has been solved in clinical practice through the adoption of DICOM. In some cases, however, the modality or operator does not adequately populate fields for critical attributes that are needed for quantitative imaging: anatomy, protocol, technique, physical units to which the pixel values correspond, amount of contrast used, and the timing of contrast or motion.

In a perfect DICOM world, all of this information is automatically entered into the DICOM header; in reality, this sometimes occurs haphazardly. “This is largely a workflow issue,” Clunie notes.

“The modalities have the opportunity to copy much of this from the modality worklist if they want to, but that presupposes that the modality worklist from the RIS also contains the information in the first place.”

In other situations, information needs to be entered manually because it is not known prior to image acquisition.

There also must be a place on the screen to enter the information (and store it in the database), as well as a modality implementation that can copy it to the DICOM header.

Sometimes, the standard lags behind innovation: “There is no question that as novel imaging techniques emerge, it takes

a while before new attributes are added to the standard,” Clunie says. “Things such as helical-scan pitch took a while to get added to the standard, despite the many scanners on the market. Diffusion b value was also a late addition to the standard, yet diffusion imaging is now an important part of clinical practice.”

The issue of encoding measurements generated from images, however, is wrought with controversy—and chaos— Clunie says. To build his case for a more disciplined further use of the DICOM standard in reporting quantitation, he zeroes in on the DICOM objects developed specifically for quantitative imaging: regions of interest; per-voxel values (or parametric maps); and intermediate work products that pass between analytic tools (spatial registration, fiducials, and realworld values).

Encoding Regions of Interest In Clunie’s appraisal, there are far too many ways to encode regions of interest, even within the DICOM standard, but he reserves his greatest ire for proprietary formats. “These are evil and must be stopped,” he says. “The same applies to encoding information only in the database.”

Until recently, one vendor’s technology encoded all annotations made in its internal database only, and they would not appear on a CD or when migrating data from one PACS to another, Clunie recounts. He also dismisses the DICOM mechanisms for curves and overlays as

weak and needing replacement.

He grudgingly approves of presentation states: Though not well suited to quantitation, they are sometimes the only choice available in PACS. “Many modern PACS have moved to encoding a sort of screenshot of an annotation in a presentation state,” he explains. The best choice for quantitation is the DICOM structured report, specifically designed for this purpose, Clunie says—but because it is more work to create and display, it is not always the solution selected by vendors and software developers.

DICOM structured reports (Figure 1) have what it takes for effective quantitation of a region of interest: They are organized in a hierarchical structure, and they include codes, numbers, coordinates, and image references, which is why they are widely used in well-established quantitative modalities (such as echocardiography and obstetric ultrasound). “As such, they are very flexible,” Clunie says, adding that this is a problem. “You need to constrain the flexibility using templates. These templates are designed for a specific use; mammography computer-aided detection, for example, is a very popular template that is widely deployed,” he reports.

By constraining the flexibility, Clunie explains, interoperability is enhanced between the applications designed to author or understand that template.

Structured reports also are easily transcoded to XML and then mined for data using an XML tool of choice.

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Figure 1. The DICOM structured report (as visualized); image provided by David A. Clunie, PhD.

QUantitative Imaging | The Case for Standards

In Praise of Structured Reports Essentially, a DICOM structured report can be viewed as a tree of nodes, with each node being a question and an answer (a name–value pair). “The answer may be a textual answer, it may be a coded answer, or it may be numeric,” he explains.

“For example,” he adds, “you can say that necrosis is present or absent, or you can use a different style and say there is a feature that is necrosis. This flexibility presents some challenges downstream, but the commonality in codes used in different implementations allows one to mine this information.”

The template is a table that defines the questions and their value sets (the range of possible answers for any situation). The user might be called on to choose from a list of values manually, or the image processing might automatically populate those fields. “You may have business rules that allow you to define codes to put into the structured report—for example, that a lesion is too small to measure because it is less than some threshold or the

limiting resolution of the technique you are using,” Clunie adds.

While it is not necessary to know the details of what’s inside a DICOM structured report, Clunie allows, you can expect there to be references to the image containing a lesion, or to either the coordinates of the lesion on the image or a segmentation that represents the lesion. Because many tools now produce segmentations rather than coordinates, it’s also important to support DICOM segmentation objects, which encode regions of interest as arrays of voxels (like images) rather than as contours. Also important are radiotherapy structure sets, which are widely used outside radiotherapy, Clunie says.

DICOM radiotherapy structure set objects are based on isocoordinates, using 3D coordinates of regions to treat and/or to spare; these coordinates are patient (rather than image) relative.

Segmentations and radiotherapy structure sets are encoded using the standard DICOM binary representation just as images would be, and they can easily

OM DIC

38 Radiology Business Journal | June/July 2013 | www.imagingbiz.com

be transcoded to other DICOM objects such as structured report or presentation states. You can map the patient-relative 3D coordinates back to the image-relative 2D coordinates via source images or a structured report image library.

Parametric Maps In the PET and functional–MRI worlds, radiologists produce numerical or statistical information (a standardizeduptake value or a z score, for example) in which each voxel represents a quantitative piece of information—not necessarily directly related to the signal that is acquired, but derived from some kind of postprocessing. In a similar way, Clunie says, label maps are used to indicate that a voxel corresponds to a particular piece of tissue or a type of tissue (white matter, gray matter, or a probability of being one or the other), and there might be some overlap.

DICOM encodes parametric and label maps either as images or as segmentations, respectively, depending on the use case.

Such segmentations and images are essentially rasterized voxels in a 3D space.

With per-voxel encoding of numeric or label values, it is extremely important to extract the quantitative information and store it as numeric values—again, not as a pretty picture, Clunie emphasizes.

“For human consumption, one typically displays a pretty picture where you’ve used color to represent a continuous range of numeric values and superimposed it over an anatomical structure; these are often saved only as a screenshot,” Clunie says. If you preserve the quantitative value of the result, you then have the ability to vary the displayed values for greater or lesser intensity or transparency. More important, you can quantify a region of interest, such as the standardized-uptake value or z score for an individual voxel or a newly drawn region of interest.

Clunie acknowledges that DICOM currently is limited to encoding integer values for each pixel or voxel. “Often, the quantitative values are floating-point values; for example, the dynamic range is from 0 to 20, as opposed to from 0 to 65,535,” Clunie notes. “The simple way to deal with that is to scale floating-point

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QUantitative Imaging | The Case for Standards

values to integers. Just as for CT (for which we often don’t encode Hounsfield units literally, but have, instead, a rescale slope and intercept), in PET, we encode floating-point standardized-uptake values as integer pixel values and we rescale them to the floating-point standardizeduptake values.”

Clunie describes how DICOM working groups are being encouraged to extend the standard by adding floatingpoint pixels, even if only for research purposes. “This is something researchers have long wanted—and modality vendors have resisted—but this will change,” he predicts.

The DICOM approach of parametric and label maps can leave fusion (or superimposition) to the application.

“There’s no harm in sending secondarycapture images that a normal human can look at to the PACS as well, in case the application is not capable of fusion, but the pretty pictures are no substitute for genuine, quantitative, useful information,” Clunie says.

The Workhorses Clunie details the value of DICOM’s intermediate work products for encoding information that passes between analytic tools: spatial registration, fiducials, and real-world values (or physical units). DICOM has registration objects for rigid and deformable registration.

Rigid registration uses a matrix to map the relationship between two sets of images that are referenced explicitly or two frames of reference that are labeled by unique identifiers. The DICOM deformable registration object includes matrices, as well as deformation fields.

“There is also a specific DICOM fiducial object to record individual locations used in registration,” Clunie adds. “These three objects can be used to save manual or automated results of registration for further work because many quantitative-imaging applications involve registration or segmentation of multiple spatially related datasets.”

For instance, radiologists who need synchronized scrolling, synchronized cursors, or fusion across 3D datasets could reuse registration objects that were saved as DICOM objects, Clunie suggests.

Real-world value maps are a concept introduced into DICOM because sometimes, a voxel means more than one thing, Clunie explains. “You can interpret a voxel as activity concentration, or you can interpret it as standardized-uptake value body weight, standardized-uptake value lean body mass, or some other parameter,” he says. “The same voxel needs to feed to several different pipelines to compute a different value: We call these real-world value maps.”

Real-world value maps might be encoded as linear functions, as lookup tables for things that are not linear, or as some other equation entirely. “It’s a point operation,” Clunie says. “Basically, every voxel goes to a pipeline that takes the range of stored values and maps them to real-world values. This is independent of the grayscale pipeline, which is only intended to get to what we see on the screen.”

Clunie’s DICOM case is made: “There are many different objects that are standardized in DICOM, specifically for the purpose of quantitative imaging. The analysis workstation can produce those, and they can be stored and distributed

Previous DICOM structured reports

Current DICOM images from modality

Previous DICOM images from PACS

Analysis workstation

through the PACS, then fed back for comparison next time around,” he says (Figure 2). Codes are also critical, for quantitation, to define the specific aspects of the study, including entities (lesions, tumors, and tissue types); location (anatomic sites); characteristics (edges and enhancements); measurements (volume, sum of areas, and mean); and units (Hounsfield units and millimeters).

Many code sources exist already, including the Systematized Nomenclature of Medicine Clinical Terms, or SNOMED; Logical Observation Identifiers Names and Codes, or LOINC; RadLex; the DICOM Coding Scheme, or DCM; the National Cancer Institute Thesaurus, or NCI; and Unified Code for Units of Measure, or UCUM—as well as ACR BIRADS®, ICD-9, and ICD-10. More are being defined every day, Clunie says. In practice, these standardized codes are widely implemented in radiology only where use is critical and reimbursable (for example, structured reports in echocardiography and obstetric ultrasound, as well as radiotherapy structure sets in radiotherapy planning and quality control). The meaningful-

DICOM segmentation

DICOM registration DICOM structured report

PACS; store, distribute, and review

DICOM real-world value DICOM parametric map images

Figure 2. In quantitative imaging, the analysis workstation uses DICOM standardized objects, stored and distributed via PACS, to permit future comparison; image provided by David A. Clunie, PhD.

40 Radiology Business Journal | June/July 2013 | www.imagingbiz.com

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That wasn’t news to me. In fact, I’d heard it so many times that it had become a predictable objection to outsourcing.

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QUantitative Imaging | The Case for Standards

use program and its strong emphasis on codes are likely to benefit radiology in this regard, but Clunie also says that there is a role for individual institutions to play by standardizing internal procedure codes.

Adoption Hurdles “We need more widespread tools that implement DICOM to make it easier for researchers and vendors to use,” Clunie says. “We have support for the basic DICOM objects in many libraries and tool kits, but we need more convenient application programming interfaces for high-level abstractions—which make it easier to encode quantitative information without having to get into the downand-dirty details of DICOM, which are tedious. There is also a steep learning curve.”

Clunie adds, “Unfortunately, a major part of the problem is that many product managers do not see the value in sharing or saving the results in the first place.

They are happy to consume standard image input, but believe that customers are satisfied with screenshots as output, and that such pretty pictures are sufficient to convey the clinical information necessary. They believe it is sufficient to save and restore the state only locally and internally.”

He continues “If you have a sophisticated workstation or server quantitative application, however, when you want to migrate to a new vendor or a new software version, you are screwed.

If you want to be able to save and restore the state in a long-term way, you need to do it in a standard way.” Clunie also calls for greater support from RIS, PACS, and modality vendors, as well as thirdparty viewers, many of which still use proprietary annotation formats (including the popular open-source OsiriX).

Clunie says that you might not like DICOM (and many researchers hate it), but there is a long history of vendor and modality support for it. In promoting the standard, Clunie launches his own offensive against what he calls antistandards.

“There is a mistaken perception, in the medical-imaging community, that DICOM is only for images,” he

says. “DICOM is not only for images: DICOM is for images and image-related information,” and myriad standard objects are available for use.

Many vendors store their systems’ output in completely proprietary formats specific to the vendor, model, and version. Private data elements in standard DICOM objects and private DICOM service-object pair classes are better than completely proprietary formats, but they are really just proprietary formats layered on top of DICOM, Clunie says.

The homegrown file formats of academic departments are just as bad, he adds. “For some reason or another, they decide that DICOM is inadequate,” Clunie explains, “and research-funding leadership, unfortunately, has been snowed here.”

On his list of antistandards, Clunie includes the Annotation and Image Markup, or AIM, project of the nowdefunct National Cancer Institute’s Cancer Biomedical Informatics Grid, or caBIG, In Vivo Imaging Workspace as a case in point. In Clunie’s opinion, most gaps exist in implementation and deployment, not holes in DICOM, and he believes that there is no place for proprietary file formats or generic consumer file formats.

He says, “They possess no patient and workflow metadata, no support in the PACS, and little or no support in viewers and workstations (other than the ones you just built yourself); anybody can claim something is a standard, but that doesn’t make it so.”

Acknowledging a chicken-and-egg problem, Clunie says that new DICOM objects might be introduced in one modality or workstation, but won’t be displayed on another. “The PACS will save it for you—and next week, or next year, or next decade, someone will use it—but in the meantime, you have a patient-oriented place to store it,” he says.

In conclusion, Clunie calls for order: “There is no place for nonstandard or inappropriate formats, not just for input, but for output as well,” he says. The best standard for the job of quantitative imaging, he believes, is clear: DICOM. Cheryl Proval is editor of Radiology Business Journal.

42 Radiology Business Journal | June/July 2013 | www.imagingbiz.com

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For Leaders in Medical Imaging Services

The Radiology Practice in the Mature Market:

Success Tactics

A

By Cat Vasko

By Cat Vasko

s radiology’s marketplace has achieved maturation, practices— more than ever—can (and should) take their cues from other industries, according to Curtis Kauffman-Pickelle, CEO of imagingBiz and a longtime consultant to radiology practices.

“Radiology, as an institution, needs to look to successful models in businesses outside of medicine—the models that have been proven successful at making transitions in difficult times. We are clearly in one of those times when change is absolutely a constant,” he says. “Radiology is experiencing a maturation that parallels the maturation in product and market life cycles.”

Continued at www.imagingbiz.com/medical_ imaging_review

Transitioning to Integrated Delivery: Measuring and Redesigning Care

Smart Growth in a Tough Market: Texas Radiology Associates By Cat Vasko

Notes From a Cardiac AV Superuser: Wm. Guy Weigold, MD

adiology’s business environment has changed considerably since the heyday of the late 1990s and early 2000s, when the equation for success was comparatively simple, Paul Staveteig, MD, says. “Now, the environment is different,” he explains. “The only way to survive in this marketplace is to be able to look at things very critically and make decisions very quickly.”

Staveteig is a physician partner with Texas Radiology Associates (TRA) in Plano (www.texasradiology.com).

By Cheryl Proval

F

Continued at www.imagingbiz.com/medpracticebiz

Continued at www.imagingbiz.com/radinformatics

By Cat Vasko

S

uccessful health-care organizations will reengineer both their structures and their processes as reimbursement shifts toward managing populations, and measurements are required both to support this transition and to document its value, according to Jake Nunn. Radiology’s diagnostic role in the continuum of care provides a unique opportunity for participation in this transition, he says.

Nunn is director of imaging clinical integration with Aurora Health Care,

Continued at www.imagingbiz.com/health_it

One consequence of that maturation is consumerism, with the result that imaging businesses are increasingly competing not just with one another, or even with other organizations in the healthcare sphere, but with customers’ experiences of any business.

“What I preach, to the practices I work with, is that all of your customers—from the patient and the patient’s family to the referring physician and the hospital partner—will measure you by the experiences they have with you, and those experiences, increasingly, are related to the best experiences they’ve had anywhere,” Kauffman-Pickelle says.

Breast Tomosynthesis and the PACS: The Journey to Sustainable Workflow

R

T

he emergence of a new, powerful imaging modality is cause for both celebration and consternation, and digital breast tomosynthesis (DBT) has proven no exception to this rule, according to participants in a June 8 educational forum at the 2013 meeting of the Society for Imaging Informatics in Medicine, held in Grapevine, Texas.

Early results from sites offering DBT to their patients have been nothing short of extraordinary: X-ray Associates of New Mexico in Albuquerque, for instance, reports a 48% reduction in its recall rate, Continued at www.imagingbiz.com/imagingbiz_ ejournal

or a cardiologist, Wm. Guy Weigold, MD, spends an unusual amount of time in front of a monitor. “I happen to be a cardiologist who has expertise in cardiac CT,” he explains. “I spend the majority of my time looking at images.”

Weigold is director of the cardiac CT program at the MedStar Washington Hospital Center in Washington, DC, and he directs that institution’s cardiac CT core laboratory (part of a large cardiovascularimaging laboratory that also offers cardiac

Visit www.imagingbiz.com to view the complete articles published in the imagingBiz Web Journals.

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