Radiology Business Journal August September 2010 by imagingBiz

FOR LEADERS IN MEDICAL IMAGING SERVICES

August/September 2010

Exposed Radiation Safety in the Imaging Suite

Featured in this issue The Top 20 Imaging-center Chains: 2010 Report | page 30 Changing PACS: A Cure for Transition Anxiety | page 36 Physician-performance Metrics: Productivity and Beyond | page 44

www.imagingBiz.com

Di gi t alEdi t i onSpons or edby Amer i c anCol l egeofRadi ol ogy

FOR LEADERS IN MEDICAL IMAGING SERVICES

August/September 2010

Exposed Radiation Safety in the Imaging Suite

Featured in this issue The Top 20 Imaging-center Chains: 2010 Report | page 30 Changing PACS: A Cure for Transition Anxiety | page 36 Physician-performance Metrics: Productivity and Beyond | page 44

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August/september 2010 | Volume 3, Number 4

FeAtures 18

exposed: radiation safety in the Imaging suite

By George Wiley While the FDA explores the challenges of implementing dose-limiting regulations for equipment vendors and health-care providers, radiologists, cardiologists, and physicists are moving forward with real-world applications.

the top 20 Imaging-center Chains

By Kris Kyes Growth in the sector has slowed, but procedural volumes per center are climbing.

pACs passages

By Cat Vasko Three facilities transition from one PACS platform to another, navigating the data-migration minefield, training multiple users, and configuring access for a range of clinicians.

measuring up: Integrating performance benchmarks Into the practice

By Erin Burke With government and payor pressure on the rise and reimbursement on the decline, radiology practices are getting serious about measuring performance.

mIppA Accreditation Countdown: ACr, IAC, or Joint Commission?

By George Wiley The three accreditation programs sanctioned by CMS as MIPPA compliant are vastly different, with each designed to appeal to a different constituency.

4 Radiology BusiNess JouRNal | august/september 2010 | www.imagingbiz.com

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CONteNts

August/september 2010 | Volume 3, Number 4 publIsher Curtis Kauffman-Pickelle ckp@imagingbiz.com eDItOr Cheryl Proval cproval@imagingbiz.com Art DIreCtOr Patrick R. Walling pwalling@imagingbiz.com teChNICAl eDItOr Kris Kyes AssOCIAte eDItOr Cat Vasko cvasko@imagingbiz.com

CONtrIbutINg WrIters Erin Burke George Wiley ADvertIsINg DIreCtOr Sharon Fitzgerald sfitzgerald@imagingbiz.com

DepArtmeNts 8

Adview beyond the blame game By Cheryl Proval

the bottom line turbulent Waters By Neeraj Chepuri, MD

priors 12 strategic planning | physician employment, 15 16

56 58

the second time Around Quality | standardizing Imaging protocols: vIsN 23 Case study letters | mail Call

prODuCtION COOrDINAtOr Jean Lavich jlavich@imagingbiz.com COrpOrAte OFFICe imagingBiz 17291 Irvine Blvd., Suite 406, Tustin, CA 92780 (714) 832-6400 www.imagingbiz.com presIDeNt/CeO Curtis Kauffman-Pickelle vp, publIshINg Cheryl Proval vp, ADmINIstrAtION Mary Kauffman

Advertiser Index Final read What Imaging leaders should Know About teamwork By Curtis Kauffman-Pickelle

12 6 Radiology BusiNess JouRNal | august/september 2010 | www.imagingbiz.com

Radiology Business Journal is published bimonthly by imagingBiz, 17291 Irvine Blvd., Suite 406, Tustin, CA 92780. US Postage Paid at Lebanon Junction, KY 40150. August/September 2010, Vol 3, No 4 ÂŠ 2010 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, 17291 Irvine Blvd., Suite 406, 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.

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AdView Beyond

the Blame Game By owning the radiation-safety problem, radiology will send it packing

t is not accuracy of interpretations, or contrast-media administration, or wrong-site surgeries, or infection control in the MRI suite. No, the specialty’s numberone safety issue is radiation exposure, subject of this month’s cover story. In a sadly ironic twist of fate, the very source of the profession’s power of inquiry has become its Achilles heel. A further irony is that the use of software intended to mitigate dose might have exaggerated it. While recent instances of overexposure have been the source of negative attention, they also provide a good argument for keeping the radiologic technologies squarely in the hands of a specialty trained to administer them. Though uncomfortable—particularly because of some newspapers’ reporting inaccuracies and oversimplifications—the crisis is resulting in the further education of patients, referring physicians, radiologists, and technologists. That, ultimately, is a good thing. The impulse might be to circle the wagons, but a better response would be to surround the problem and take ownership on every level. Part of this process is understanding how these unfortunate events could have occurred. J. Anthony Seibert, PhD, president-elect of the American Association of Physicists in Medicine (AAPM) and professor of diagnostic imaging physics at the University of California–Davis, offers some perspective on the dose-limiting software in use at several of the institutions where the overexposures occurred. When used properly, the software compensates for differences in attenuation when imaging noncircular body parts, he explains. If you have a fixed milliamperage, more radiation is transmitted through the thin parts of the body than through the thick parts, resulting in a noise level that is

relatively lower in the thin parts than in the thick parts. Seibert says, “What automatic exposure control attempts to do is change the milliamperage interdependent on the angle of projection through the body, so it will be higher through thicker parts of the body and lower through the thinner parts.” The software on the scanner implicated in some of the overexposure incidents is controlled by a noise-index parameter, Seibert explains. “The noise index is a measured variability of the x-ray beam as it penetrates through the body, and in the reconstructed image, it is the standard deviation, within a region of interest, in a relatively uniform part of the image,” he says. “If you want low noise (meaning high dose), you can set the noise index low, and what happens is the radiation will be high to meet the low-noise requirement. Automatic exposure control can be misused, if you don’t know how to use it.” Another potential cause of overexposure would be changing the slice thickness from 5 mm (the common way a CT perfusion study is acquired) to the thinnest possible slice setting, at 0.625 mm—a factor of eight— without making an adjustment to the noise index. “It just so happens that the variance within the reconstructed image from the scanner is going to be proportional to 1 over the slice thickness, and the variance is the square of the standard deviation,” Seibert notes. “Training is important, and understanding and verifying that people are trained also is very important. It does work both ways. It’s not just the manufacturers’ responsibility; it’s a collective responsibility, and there are holes on both sides of the fence.” Organizations, like people, are tested over time, and an appropriate response can help ensure that the test is not repeated. Medical specialties also have been subjected to tests. About three decades ago, a television newsmagazine ran an indictment of the safety record of the anesthesiology specialty, which was

8 Radiology Business JouRnal | august/september 2010 | www.imagingbiz.com

in danger of being crushed by exorbitant malpractice fees. The American Society of Anesthesiologists responded by providing seed money to launch the Anesthesia Patient Safety Foundation, admitting physicians, nurses, insurers, and vendors. This collaborative initiative resulted in research/development efforts that produced a patient-safety database, as well as a number of technical and operational safety advances, vastly improving the safety record of the specialty.1 What, then, is radiology to do? The AAPM held a Dose Summit in May that focused on the impact of the CT dose index volume, as well as other factors in the safe and effective use of CT. It was well attended by all stakeholders, including radiologists, physicists, technologists, vendors, and regulators. The AAPM will continue to offer education at the November RSNA meeting and at the American Roentgen Ray Society’s meeting in the spring. The ACR® has begun work on a national dose registry and is building on its Image Gently campaign. The Medical Imaging Technology Alliance is working, on the vendor side, to arrive at some common solutions. A significant grassroots response also has arisen. You are likely to be impressed when you read about some of the many doselimiting projects underway in radiology departments across the country. Clearly, many in radiology know what to do with the radiation-safety issue: Own it.

Cheryl Proval cproval@imagingbiz.com Reference 1. Hallinan JT. Once seen as risky, one group of doctors changes its ways. Wall Street Journal. June 21, 2005:A1.

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THE BOTTOM LINE

Turbulent Waters

A practice president describes the importance of leadership training for radiology group practices

he current environment in radiology is changing quickly— and the pace of change is accelerating. Radiologists are accustomed to change. In fact, some would say that radiology is the primary ﬁeld of change, but never has the pace of change been so rapid. In addition to the new technological developments that are revolutionizing the way that we practice medicine, we are seeing marked changes in the way that radiology is organized into corporate structures, as well as new ways for payors to buy imaging services. All of these changes can leave a radiologist’s head spinning, and they can lead to confusion if there is not close alignment and good communication within the group practice. This is where leadership training is highly valuable. In order to accomplish the changes that we need to make at such a high level (and so rapidly), we must have physician leaders who know how to communicate and gain alignment. Our partners are unable to take in all of the changes and come to alignment by themselves. Without leadership, we would have a mess: multiple physicians vying for specialized interests. With the gravity of the changes that we are seeing, a successful group practice needs alignment. Instead of having multiple camps pulling in different directions, the successful practice will have all partners pulling in the same direction. Radiologist partners in a group practice can’t get alignment without somebody, or some people, ensuring alignment. Leadership is a real job, and somebody has to do it. Some practices outsource leadership, hiring a professional administrator or practice manager. The professional administrators, however, often lack the backgrounds needed to understand the highly technical work of the radiologist. It’s almost certainly easier to teach a radiologist leadership

BY NEERAJ CHEPURI, MD

skills than it is to teach professional leaders something about radiology. In other words, if the current health-care environment is the ocean, and the group practice is the ship, the ship needs a captain who knows the ocean well—but also knows how to sail a ship. In the time leading up to my assumption of a leadership role in my radiology group practice of 75 physicians, I was encouraged to take a formal leadership-training course. I agreed to do so, not having much idea

most surprising part of this curriculum to me. In the end, however, it was probably the most important. By taking a close, hard look at yourself, you get a much better sense of your own strengths, weaknesses, and opportunities to improve. This was the hard work of increasing my personal capacity to provide leadership. The opportunity to work closely with 15 other emerging leaders (with whom I normally do not interact) throughout the regional health-care community was also

This introspection (sometimes guided by classmates) was perhaps the most surprising part of this curriculum to me. In the end, however, it was probably the most important. about what I would learn there (or how I would learn it). I enrolled in an 18-month curriculum, called Physician Leadership College, hosted by the University of St Thomas (at its Minneapolis, Minnesota, campus). The group was composed of 16 students, all in various phases of their careers and each taking the course for slightly different reasons. The course was intriguing because it focused exclusively on physicians, as well as because it focused on leadership, rather than management. The stated objective of the course was to increase the student’s capacity to provide leadership in the health-care environment through a combination of didactic learning, self-analysis/introspection, and network building. The didactic-learning portion of the course addressed topics such as health-care economics, accounting, marketing, quality, and strategy. It is critical to understand each of these topics before embarking on a leadership role in health care. Interspersed with these didacticlearning assignments, however, were periods of time dedicated to looking at oneself. This introspection (sometimes guided by classmates) was perhaps the

10 RADIOLOGY BUSINESS JOURNAL | August/September 2010 | www.imagingbiz.com

a great blessing. I experience all problems through the eyes of a radiologist, so it was very instructive to see the problems of health care through the eyes of a cardiologist or those of a primary-care practitioner. As I learned during my course, much of leadership in radiology has to do with seeing matters through the eyes of others. In summary, the practice of radiology is going thorough massive structural changes. Solid leadership is necessary for the transition of the radiology practices of today into the radiology practices of tomorrow. Formal leadership training helped me develop myself to ﬁll my role as a radiology practice’s leader through a combination of didactic learning, introspection, and regional networking. If nothing else, the leadership training allowed me to visualize the problems of radiology better through the eyes of nonradiologists—such as our partners and customers. Neeraj Chepuri, MD, is president and CEO, Consulting Radiologists, Ltd, a 75radiologist practice based in Minneapolis, Minnesota.

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{ priors} st r at E G i C p l a N N i N G

physician employment, the Second Time Around

new round of physician–hospital alignment is underway—this time, with a broader sweep, according to Craig E. Holm, senior vice president, Health Strategies & Solutions, Philadelphia, Pennsylvania, and D. Louis Glaser, JD, partner, Katten Muchin Rosenman, LLP, Chicago, Illinois. They presented “Employed Physicians: Improving Performance and Avoiding Excessive Subsidies” on June 23, 2010, at the Healthcare Financial Management Association’s ANI: The Healthcare Finance Conference in Las Vegas, Nevada. An interest in clinical integration and accountable-care delivery models is driving the renewed hospital interest in physician employment, with a few key differences this time. “In the 1990s, the emphasis was on primary care,” Holm notes. In addition to acquiring primarycare practices, hospitals currently are seeking specialists in fields where it is hard to obtain coverage (such as orthopedics, trauma surgery, and neurosurgery), as well as referring specialists desired by the hospital community, such as endocrinologists, rheumatologists, and cognitive medical specialists, he reports. A third category of specialists sought, according to Glaser, strikes close to home for radiologists: subspecialists within cardiology and radiology, “who have historically disdained hospital employment and are now feeling significant cuts on the professional as well as technical sides,” he observes. emploYment drivers While recent data1 from the Medical Group Management Association place 50% of practices surveyed in an employed model, Holm says that the actual number of employed physicians probably is still a minority due to the high number

of single-physician practices included in the survey. Nonetheless, physician employment—whether by a large, stable medical group or by a hospital—is on the rise. “There are some markets where virtually all physicians are employed by hospitals or large practices, as they are in Milwaukee, Wisconsin,” he notes. Since the last failed effort to integrate hospital and physician communities in the 1990s, separatism and competition between hospitals and physicians have been driven by the pursuit of supplemental income. Payor consolidation and regulatory changes, however, are causing some physicians to rethink independence. “A year ago, how many people had under-arrangement joint ventures with physicians or perclick leasing arrangements?” Glaser asks. “Nobody has them today.” Economic and regulatory-policy decisions by CMS, including growing scrutiny of the in-office ancillary exception, are driving the trend. “Cardiology is the perfect example: payment cuts and the bundling of codes,” Glaser notes. “CMS is trying to regulate by changing the pricing of a service. When that fails, it steps in and says, ‘Thou shalt not.’” Improved reimbursement rates are another factor driving physicians toward employment. Holm says that the typical uptick in commercial rates reported by physicians surveyed by Health Strategies & Solutions was 10% to 15%. The industry’s average subsidy for practices is approximately $70,000 annually, while hospitals’ best practice would be half that, according to Holm. “If a 150physician group reduces its subsidy from $100,000 to best-practice levels, $5 million to $10 million savings could be the result,” he says.

12 Radiology Business JouRnal | august/september 2010 | www.imagingbiz.com

Future unCertainties and past mistaKes Moving ahead, putting a number on physician income will become more difficult. “As you pull diagnostic and ancillary services out and put them into the hospital, you’re assured that the practice will lose money, but you may be gaining money somewhere else in the system,” Glaser explains, adding that unprecedented reimbursement cuts on both the professional and technical sides leave hospitals vulnerable to the mistake of locking physicians in at unsustainable salaries.

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priors

Holm notes that hospital–physician employment arrangements might be more viable in markets where professional fees, as a percentage of the Medicare Physician Fee Schedule (MPFS), are lower than the national average (which is about 115% of the MPFS). He also cautions that physician employment, historically, has not created clinical integration. Independent physicians and independent practices with formal business relationships can be, and currently are, engaged in alignment strategies (see table) with hospitals and health systems. “Employment is typically for a minority of medical-staff members,” he says. Some employment models, Glaser says, “do involve a high degree of alignment—and potentially, a lot of physicians—but the degree of challenge is very great. Medical directorships are easy to implement, but may not improve clinical integration.” Glaser notes that many of the acquisitions that occurred in the 1990s were based on discounted cash-flow evaluations. Current practices are more asset based, incorporating values for intangibles such as workforce in place, medical records, and the physicians themselves. Personal goodwill is a new factor in asset valuations. “We’re seeing a lot of transactions where people are not calling it a signing bonus, but rather goodwill: We’ll pay you at closing to say you’ll stay on for five years,” Glaser explains. “Retention incentives are now structured as a payment if you’re here each year, or at the end of five years, and are used instead of qualified deferred compensation.” Compensation methodologies Likewise, hospitals are experimenting with new compensation methodologies. What began in the 1990s with fixed salaries guaranteed for 5 to 40 years was amended, after watching productivity decline, to include an incentive to produce either cash or net revenue. The next iteration went to a percentage of net revenue or a work RVU system, with pay based on productivity; this was subsequently further improved by bringing in incentives on the expense side. “If you beat the budget, we’ll give you some extra money,” Glaser explains.

table. Camparison of Alignment Strategies physician alignment Categories

approach

Common objectives

Employed

n Selectively grow n Improve performance

n Strong primary-care base, supplemented with hard-torecruit or hard-to-gain-coverage specialties n Tolerable deficits

Independent

n Proactive, comprehensive outreach initiatives n Optimal hospital operations and systems, quality demonstration, IT to earn referral relationships

n Strong referral relationships

Independent but potential partners

n Systematic process to evaluate and develop formal business partnerships (joint ventures and alternatives)

n Selective business partnerships tailored to practice needs and hospital strategic priorities n Market growth

The current generation of hospital– physician plans, Glaser notes, is productivity based, sometimes with some support guaranteed on the front end (and perhaps including incentives), but now, with a focus on the quality/ outcomes side. Hospitals are interested in partnering with physicians to reduce readmission rates, reduce lengths of stay, and achieve certain outcomes. In order to protect themselves from the losses incurred in the 1990s, hospitals should proceed with caution when guaranteeing physicians an income based on current reimbursement rates; they should understand that the MGMA compensation surveys, while they are best data available, might not accurately reflect reality for all practices. They should also be aware that paying no more than fair market value is not just good business, but protection against problems covered under the anti-kickback statute. Glaser recommends making up to 20% of clinical compensation available as a bonus, structured with an overarching trigger based on annually achievable goals for quality and outcomes. “As we think about the future of value-based purchasing, this is something I recommend you start thinking about,” he advises. seleCtion/divestiture Criteria Improving performance often begins with practice-selection criteria (frequently used as divestiture criteria as well), Holm

14 Radiology Business JouRnal | august/september 2010 | www.imagingbiz.com

says. Ideally, physician leaders will establish selection criteria that address compensation trends, such as bundled payments. Referring physicians continue to generate a significant level of downstream revenue for hospitals (an estimated average of $1.5 million per physician in 2007), but there is always room for improvement, Holm says. Potential high-return initiatives for improving financial performance— and avoiding excessive subsidies— include revised medical practice delivery, operations improvement, revenue capture, elimination of redundant infrastructure, practice promotion, physician leadership, transition to private practice, and revised compensation plans. Most systems that are successful in improving performance focus on avoidable practice losses, instead of worrying about unavoidable losses such as long-term leases or amortized acquisition costs, Holm says. According to a survey conducted by the presenters that including 25 hospitals and systems in 17 states, the most significant initiatives were changing compensation methodology (67%) and practice promotion (33%). —Staff reference 1. Physician Placement Starting Salary Survey: 2010 Report Based on 2009 Data. Englewood, CO: Medical Group Management Association; 2010.

quality

standardizing imaging protocols: VISN 23 Case Study

apidly evolving technology capabilities are reason enough to standardize imaging protocols across a health-care enterprise. Add the desire to reduce costs, increase efficiency, and eliminate unnecessary exams by using imaging appropriately, and it is easy to make the case for such a project, particularly in a healthcare enterprise with multiple sites of acquisition and lots of mobility. Nonetheless, the herding-cats metaphor comes to mind when one thinks about the challenge of gaining consensus among a large group of radiologists on imaging protocols, and some told Janice Honeyman-Buck, PhD, that it could not be done. In “Defining and Managing Standardized Imaging Protocols With Appropriateness Criteria,” a June 3 presentation that she gave in Minneapolis, Minnesota, at the 2010 annual meeting of the Society for Imaging Informatics in Medicine, HoneymanBuck, editor-in-chief of the Journal of Digital Imaging, described how Veterans Integrated Service Network (VISN) 23, a VA hospital network headquartered in Minneapolis, accomplished that goal. “The issues with imaging protocols— and this is not just for this institution, but any institution with multiple hospitals or sites of acquisition—is that radiologists often have to cover multiple sites and patients move between them,” she explains. “If you are not using consistent protocols, then you may have to redo the study. We need to maximize efficiency, and we need to promote appropriate use of the technology.” Another aspect of the project, intended to eliminate unnecessary imaging, was linking each procedure with appropriateness criteria. Imaging procedures’ and protocols’ names can be vague and confusing to referring physicians, who might, for example, order a CT of the abdomen with and without contrast, rather than just with or just without, simply to cover their bases. This linking of procedures and criteria “is very important because Medicare is going

to start requiring it soon,” HoneymanBuck says. “Another thing we really wanted to make sure of was that everything Janice honeymanwas consistently Buck, phd named, so that radiologists could make hanging protocols that would be consistent across the organization,” she adds. With eight VA health systems covering more than a million veterans in all of five Midwestern states and part of five more, VISN 23 had a technology inventory of 15 CT units; 3T MRI systems (tuned to 1.5T) at nearly every site, all with different hardware, software, and firmware; multiple DR units at each site; and one or more ultrasound scanners at each site. These were the modalities of interest, according to Honeyman-Buck, who consulted on the project. The adoption of a computerized provider order entry system that would facilitate ordering the correct study precipitated the project. The project was divided into three stages. First, protocols for each study were reviewed with radiologists and technologists, who arrived at consensus. Second, the list of approved protocols was documented and distributed to each site. Third, a process for reevaluating the protocols annually and planning for change was established. the protoCols To find out what protocols were being used, Honeyman-Buck downloaded the data directly from the imaging modalities when possible, but in many cases, the data were in proprietary formats, so access to the equipment vendors was necessary. She also examined all of the documented procedure manuals from each location; each manual was different. Using a variety of sources to help define the initial set (see box), Honeyman-Buck sent a recommended list of protocols to the radiologists and technologists, asking whether they approved, and if not, how

they would change the protocols. Each study was reviewed with radiologists and technologists; iteratively, they arrived at consensus on 238 protocols: 69 for CT, 64 for MRI, 45 for ultrasound, and 60 for DR. For example, the CT protocols (see figure) included contrast specification, special instructions, acquisition specifications with timing start and end points, reconstruction specifications, orientation, thickness, series name,spacing, algorithm, direction of reconstruction, and indications. Currently, VISN 23 saves the survey images and the reconstructions only to PACS. “The reconstructions used a unique series name, so that they could implement standard hanging protocols,” Honeyman-Buck says. “The thickness, spacing, timing, and field of view were specified.” MRI protocols included a description of each series and sequence, the series name, coverage, and indications. With ultrasound sets, the technologists adjust the imaging parameters, so the protocols just described the images, measurements, protocol resources These resources were used in defining the protocols in use at Veterans Integrated Service Network 23. The ACR® Practice Guidelines and Technical Standards: http://www.acr.org/ SecondaryMainMenuCategories/quality_ safety/guidelines.aspx The Association for Medical Ultrasound: www.aium.org/publications/guidelines.aspx The CT site of Elliot Fishman, MD: www.ctisus.com The University of Pennsylvania Handbook for Radiology A radiography-focused site: www.e-radiography.net Routine MRI protocols from the University of Alabama: http://www.uasom.uab.edu/ PublicDocuments/Radiology/P&P/MRI_ Protocols_5-27-10.pdf CT and MRI protocols from the University of Florida: www.xray.ufl.edu/patient-care/ protocols/

www.imagingbiz.com | august/september 2010 | Radiology Business JouRnal 15

p riors

lEttErs

MailCall

Figure. An abridged version of the protocol for abdominal CT with contrast in use at Veterans Integrated Service Network 23.

and Doppler requirements of each study. Because a different consultant worked with the institution on optimizing its DR acquisition, Honeyman-Buck did not change any of the DR imaging parameters. The DR protocols included the name of the procedure, the indications, and the appropriate position, but they also included all of the optional views. “We set it up so that every image was its own series, so they could be moved around on the PACS workstations,” she explains. “There are always times and conditions when other types might need to be done.” In fact, radiologists are permitted to add more series to any of the protocols, regardless of modality. “We weren’t saying to the radiologist, ‘You can only do these views,’” she says. doCumentation, training, and revieW Honeyman-Buck did not intend to document the protocols in print, but ultimately, all 238 protocols were documented in large binders that were distributed to each facility. In addition, each protocol was uploaded to Microsoft® SharePoint®, running on the VISN 23 intranet server. Training and the reevaluation of protocols were accomplished using Cisco WebEx, providing maximum flexibility for affected personnel. Various training/reevaluation appointments

were scheduled over several weeks, so participants could choose times that were convenient for them. Two radiologists were assigned the task of approving and reviewing protocols in the future, to keep them current and correct. Issues encountered after the go-live date included the discovery that some protocols had been overlooked and were missing. One protocol was so incorrect that it couldn’t be performed as written on the existing equipment, and several protocols needed to be changed or added to meet the changing needs of the facilities. Nonetheless, the benefits were almost immediately apparent. Communication among radiologists was enhanced because after Honeyman-Buck initiated the project, they started meeting regularly in groups. She estimates that they achieved an 80% consensus rate overall on the protocols, with some flexibility built in for research. Adoption of the protocols throughout the system was the main element of success. “Everyone has to do it,” Honeyman-Buck says. “They have to change normal operating procedures so they can use those protocols, they need to create consistent hanging protocols, and they have to maintain the protocols over time.” The payoff is efficient, optimized use of equipment. —Staff

16 Radiology Business JouRnal | august/september 2010 | www.imagingbiz.com

I read your article, “Finger in the Wind,”1 with interest. It is good to hear that those who have the ear of Congress are finally talking about the issue of imaging by nonradiologists and the cost related to the much steeper growth curve of these imaging studies performed by selfreferring nonradiologists compared to imaging performed by radiologists. What kind of positive changes might result from such reports remains to be seen. However, I am not sure that they are on the mark with their statements regarding the need for reexamination of the professional component, with an eye on possible reduction of payment for possible decreases in the time and intensity of effort “due to advances in technology, technique, or other factors.”2 I find that the intensity and the time that are required for me to interpret a spine CT, CT angiogram, or brain MRI have increased due to the very advances in technology and techniques of which they speak. It literally takes me longer to interpret these studies now, compared to 10 years ago, because I now have many more images to interpret. With the transition to digital imaging, with no need for printing of films and the associated cost no longer an issue, we seem to be generating more images, more pulse sequences, and more reformations and reconstructions, for which there usually is not any commensurate increase in payment. Maybe they will look at all of this again and decide to increase our payments? Probably not. Thank you for the article. Thomas A. Kim, MD Chair, Department of Radiology Carle Physician Group Carle Foundation Hospital Urbana, Illinois references 1. Proval C. Finger in the wind. Radiology Business Journal. 2010;3(3):8. 2. Medicare Payment Advisory Commission. Report to the Congress: Aligning Incentives in Medicare. Washington, DC: MedPAC; 2010.

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COVER | Radiation Safety

Exposed: While the FDA explores the challenges of implementing dose-limiting regulations for equipment vendors and health-care providers, radiologists, cardiologists, and physicists are moving forward with real-world solutions

Radiation Safety in the Imaging Suite

By George Wiley

ationwide cumulative-dose indices, warning flags in electronic medical records (EMRs), and electronic imaging-history smart cards: All these are being called for to protect patients from excessive radiation exposure. The real advances on this hot-button issue for radiology, however, are taking place at the health-facility level, one patient at a time. In a watershed moment in October 2009, a luminary medical center in Los Angeles, California, announced that it had completed CT brain-perfusion scans of 206 patients over a period of 18 months, during which patients mistakenly had received eight times the called-for radiation dose per scan. The incident spawned lawsuits and a flood of media attention. The news stories were kept alive when more incidents of radiation overexposure were reported at other hospitals in California and in Alabama. Two months later, one of a pair of radiation-dose studies1,2 that appeared in the Archives of Internal Medicine estimated that as many as 29,000 patients nationwide could develop cancer from normal levels of CT-exam radiation, and that 14,500 of them could die. Enter the FDA, which began an investigation of the overexposure events. That investigation continues, but the FDA hasn’t waited for its results to act. In February 2010, the agency announced

a three-pronged initiative to control radiation exposure in patients undergoing CT, fluoroscopy, and nuclear-medicine exams. The FDA’s three attack points are promoting safe use of imaging devices, enhancing informed clinical decision making on imaging exams, and making patients aware of the risks that they face from radiation exposure during imaging. In February, the House of Representatives held hearings during which members of Congress expressed shock at the lack of regulation of radiation exposure during clinical imaging. The National Institutes of Health (NIH) also mandated that all vendors selling imaging systems to NIH include dose-tracking technology on those machines. At the end of March, the focus swung back to the FDA for a two-day series of meetings and seminars at which imagingindustry trade groups, manufacturers, and professional societies assessed steps that could be taken to control radiation exposure during imaging. Calls for Accreditation One of those testifying at the March FDA panels was E. Stephen Amis Jr, MD, FACR. Amis is professor and chair of the radiology department at the Albert Einstein College of Medicine and its teaching hospital, Montefiore Medical Center, in the Bronx, New York. He is also the former chair of an ACR® Blue Ribbon Panel on Radiation Dose in Medicine. He is the current cochair of the RSNA–ACR

18 Radiology BuSineSS JouRnal | august/September 2010 | www.imagingbiz.com

Joint Task Force on Adult Radiation Protection. Amis says that the risk from radiation exposure due to medical imaging is modest, but real. Since patients in the United States now undergo about 72 million CT scans per year, researchers are probably correct in estimating that 28,000 new cancers will result, he says. In 1980, he adds, only 3 million CT scans were done. CT is the major culprit in delivering high levels of radiation to patients, with some CT tests, according to news reports,3 packing a radiation punch equal to that of 400 radiography exams. Amis says, however, that some nuclear-medicine procedures and fluoroscopic exams also deliver high doses of radiation. Amis advocates moving quickly, on the national level, to impose controls on patient exposure. The ACR is one of two major accrediting bodies providing accreditation for CT systems. “We’d like to see every CT in the United States accredited,” Amis says. “Right now, only about 40% are accredited.” He says that accreditation forces imaging providers to submit live-patient and phantom exam data to the accrediting body to confirm that systems are functioning properly. Amis told those at the March FDA meetings that establishing a national dose-index registry, using a standardized method for calculating radiation dose for every exam, should be imposed on equipment manufacturers industry wide.

COVER | Radiation Safety

We’d like to see every CT in the United States accredited. Right now, only about 40% are accredited. —E. Stephen Amis Jr, MD, FACR, professor and chair of radiology, Albert Einstein College of Medicine and Monteﬁore Medical Center, Bronx, NY

The exposure data should be included in the EMR, he adds, but that should only happen with new machines, as they are developed. He says, “There’s not much enthusiasm for going backward.” Amis notes that it’s important to develop uniform national licensing standards for radiologic technologists. “The thing that caught everybody’s attention at the FDA meetings was that there are no uniform technologist-licensure standards. A third of the states don’t have any at all,” he says. Amis predicts standardized reporting of doses (with the results available on every machine), a dose registry, CT accreditation, and technologist licensure. “It looks as though those things are going

to happen, somewhere down the line. It will come down to federal regulation. There’s just too much interest for this to go away,” he says. Adhering To Protocols Many health-care providers aren’t waiting for regulation, however. They’re hard at work, developing ways to limit radiation exposure immediately. One line of attack is the implementation of procedures to make certain that patients undergoing specific tests receive only the minimum radiation exposure needed to produce useful results. This dose concept is called as low as reasonably achievable (ALARA). Of course, what’s reasonable

and achievable at one institution may not be deemed so at another. At Brown University’s Alpert Medical School and Rhode Island Hospital, William Mayo-Smith, MD, and his colleagues have been working for years to develop protocols to reduce exposure from CT exams. They were among the first to do so. “The focus has been primarily on CT because it accounts for 10% of exam volumes, but 70% of dosage issues,” MayoSmith says. Some protocols, such as reducing milliamperage for kidney-stone imaging, have been obvious candidates for development. “The lower dose means it’s a noisier image,” Mayo-Smith says. “Since kidney stones are bright on the CT, however, the increased noise is not a diagnostic dilemma. With CT, 20 years ago, it was one size fits all. Now, we use more sophisticated acquisition parameters to target the type of exam that’s performed to the clinical question that’s being asked. We do this by modifying the scanner parameters and protocols, tailoring them

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COVER | Radiation Safety

Google CT protocols, and our site comes up; these protocols were years in the making, and it’s an ongoing process. —William Mayo-Smith, MD, Warren Alpert Medical School, Brown University, and Rhode Island Hospital, Providence, RI

to the clinical question. The patient gets a CT, but the type that’s done varies according to clinical history.” Over the years, Mayo-Smith and his colleagues have developed many protocols for answering specific clinical questions. “A pancreatic mass has a different protocol than appendicitis, and that’s different from a kidney stone, which is different from a kidney mass, which is different from a hematoma or blood in the urine,” he says. The Rhode Island Hospital team also tries to limit scans to the body parts being examined. This, Mayo-Smith says, prevents image creep—in which, for example, the upper abdomen could be included in an exam requested to evaluate the chest for a pulmonary embolism. “In general, we now image only the area in question, being careful not to scan other regions adjacent to it,” he explains. “We also use breast shielding, which decreases dose to breast tissue.” All the hospital’s protocols are preloaded into the scanners. When the clinical information comes in with an imaging order, the radiologist prescribes the protocol, MayoSmith says. The technologists carry out those directions. “We run 24/7, with over 35 technologists using the standardized protocols,” he says. “Google CT protocols, and our site comes up; these protocols were years in the making, and it’s an ongoing process,” Mayo-Smith says, noting that the Alpert Medical School’s detailed protocols are available to referring physicians anywhere in the world. Since children are at more risk from radiation than adults are, Mayo-Smith credits pediatric radiologists with spearheading the concern over radiation exposure. Manufacturers have also responded by making machines with automatic exposure controls that limit radiation based on the size of the body part being examined. In addition, new postprocessing re-

construction techniques that require less radiation to generate a picture are in the development pipeline. “The risk for cancer induction from radiation is not well sorted out, and it’s controversial,” Mayo-Smith says. “We do know that kids are at higher risk than adults. We know, at very high radiation, the incidence of cancer is higher, but is there cancer risk from the scans being done? That’s the question. The best way to proceed, until we know more, is to adopt ALARA techniques.” Other important elements are to make sure that the exam being ordered is truly indicated, that there are not substitute exams without radiation (particularly in the younger patient population), and that the patient has not had the exam performed recently at another institution, MayoSmith says. “We have developed a computer program that searches our database for prior exams performed at the three hospitals within our parent network,” he says. “This will alert the referring physician that a CT exam may have been performed in the recent past.” Risk Flags Steven C. Birnbaum, MD, is taking another (and quite elemental) avenue toward heading off excessive exposure. Birnbaum interprets studies at the Southern New Hampshire Medical Center in Nashua. He is also a staff radiologist and radiation-safety officer at the Parkland Medical Center in nearby Derry. “I had seen the risk of cancer death the FDA was quoting on CT, which was one in 2,000 for an exam of the abdomen or pelvis. I had also read that the risk of death from a contrast allergy was one in 250,000 injections. I thought, ‘There’s much more of an issue with CT,’” Birnbaum says. He also had a strong personal motive

22 Radiology BuSineSS JouRnal | august/September 2010 | www.imagingbiz.com

for pursuing reduced exposure from CT scans. In 2005, his daughter, Molly (then 22 years old), suffered multiple fractures and soft-tissue injuries in a car accident. “When she came in with severe trauma, she was CT scanned from head to toe, which was entirely appropriate. On day two, though, she was still in the ICU, and they thought her blood count was down because the blood had been drawn from the wrong arm, so they sent her down for another CT to see if the fluid in the belly was changing,” Birnbaum says. Before her treatment concluded, she’d had a total of nine CT exams. “Some of the follow-up studies were absurd,” Birnbaum says. He also saw a case in which a patient was given 34 CT scans “before we put a stop to it. Every practice has cases like that,” he says. “CT is a wonderful test. I can’t do what I do without it. I’m not anti-CT,” he makes clear. He notes, however, that in New Hampshire, the limit for incidental exposure for workers in radioactive settings (such as those who handle radiopharmaceuticals) is 50 mSv over a lifetime. “I’m looking at 50 mSv for five CT studies of the abdomen, yet a worker with 50 mSv can get taken off the line. Patients get 300 mSv exposures, and more, regularly,” Birnbaum says. Regulators need to broaden their focus to include not just workers, but patients. “That’s where the action is,” he says. To take action himself, following his daughter’s experience, Birnbaum devised a conversion of an existing contrast-agent allergy flagging technology in the RIS to flag patients who had undergone five or more CT exams. The flags were used only in selected CT-exam categories: abdomen, neck, chest, and pelvis. To be flagged, the patients had to be younger than 40 and cancer free. “You just add it in the RIS like a flag that someone is allergic to penicillin,” Birnbaum says. “We started that 2.5 years ago. We’ve had about 75 patients flagged since then, and we did no CT in about 30% of those patients. About half of the exams were cancelled, and the other half were switched to other modalities.” Technologists are vital to the process, he says. They see the flag when an exam is ordered; they call in the radiologists and

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COVER | Radiation Safety

We start CCTA with 120 kV, but with a BMI of 30 or less, you can get by with 100 (which, in absorbed radiation, is a reduction of 40%). —Gilbert L. Raff, MD, FACC, medical director, Ministrelli Center for Advanced Cardiovascular CT Research, Beaumont Hospital, Royal Oak, MI

direct them to the referring physicians. Birnbaum is careful to explain that the flag is based on numbers of CT exams only, not on estimated cumulative exposure from those exams. In fact, he says, accurately measuring cumulative radiation exposure is extremely difficult. “You can’t use the estimates in the literature. Those are gross estimates, probably plus or minus 40%. A 10-mSv exam could really be 5 or 15 mSv. To find the actual exposure, you have to do it patient by patient. With my five exams (for a flag), I get an estimate. I do check the dose–length product values on the machine to make sure I’m not getting overexposure,” he says. Changing Exams Linda B. Haramati, MD, MS, is division head of cardiothoracic radiology at Montefiore Medical Center and a radiology professor at the Albert Einstein College of Medicine. In 2006 and 2007, Haramati was part of a team that demonstrated that radiation exposure can be reduced, for emergency-department patients with suspected pulmonary embolism, by relying on a simple algorithm to route some patients to ventilation/perfusion scans rather than to CT pulmonary angiography (CTPA). Haramati says that ventilation/ perfusion scans, which were preferred for suspected pulmonary embolism before CTPA became common, can reduce radiation exposure to the breasts of female patients. Radiation delivered to the breasts is 20 to 40 times greater for CTPA than for ventilation/perfusion scanning, she says, but many physicians aren’t aware of that. The algorithm employed to select patients for ventilation/perfusion scanning is simple. If emergencydepartment physicians suspect pulmonary embolism, a chest radiograph is taken. If that is normal, the patient is

routed to ventilation/perfusion testing. If the radiograph shows lung/pleural disease, the patient is sent for CTPA. In the study4 of the algorithm, the number of CTPA patients decreased from 1,234 in 2006 to 920 in 2007. The number of patients undergoing ventilation/perfusion scanning increased from 745 to 1,216 over the same span. Overall, the mean effective radiation dose was reduced by 20%. “In 2006, between 35% and 40% of the tests were ventilation/perfusion scans and 60% to 65% were CT. By the end of the last quarter of 2007, we had 40% CT and 60% ventilation/perfusion scanning,” Haramati says. “It reversed.” She points out, however, that Montefiore Medical Center’s radiology and nuclear-medicine departments are separate, but work collaboratively. “One of the things we were criticized for was that about 40% of our pulmonaryembolism imaging was ventilation/ perfusion scanning before we did the study, which is high. It’s normally an uncommon test, used only for patients who can’t get a CT,” she says. Nonetheless, the 20% reduction in radiation exposure took place even with the high rates of ventilation/perfusion scanning, she says, adding that the test is underutilized at many institutions. Montefiore Medical Center does imaging for about 2,000 pulmonaryembolism cases per year, Haramati adds. “Pulmonary embolism imaging is a pretty big business. It’s a common indication for CT of the chest,” she says. Haramati also points out what she calls indication creep for CTPA. “When we first started, the results were about 20% positive. Now, they are 5% or 6% positive, which means they’re doing a lot of cases with lower and lower suspicion of disease.” That mirrors radiology generally; she says, “Pulmonary-embolism imaging is part of the radiology growth picture.”

24 Radiology BuSineSS JouRnal | august/September 2010 | www.imagingbiz.com

In a recently completed study,5 Haramati and her fellow researchers at Montefiore Medical Center retrospectively studied imaging in patients with hydrocephalus, renal colic, pulmonary embolism, and heart disease; they found that in all categories, patients imaged from 2000 to 2005 had less radiation exposure than those imaged from 2005 to 2007. “That’s because there’s more and more imaging being done,” Haramati says. “This goes along with what we’ve seen in the rest of the world.” Quality Improvement A consortium of Michigan hospitals is applying radiation-reduction protocols on a broad front and using a registry to track the effectiveness of its qualityimprovement program. So far, according to Gilbert L. Raff, MD, FACC, the effort is paying big dividends, with multihospital exposure reductions, for some imaging procedures, of more than 50%. Raff, a cardiologist, is medical director for the Ministrelli Center for Advanced Cardiovascular CT Research at Beaumont Hospital in Royal Oak, Michigan. The hospital is a participant in a consortium of Michigan hospitals organized under the aegis of regional health-insurance carriers to use patient registries to track and improve health-care outcomes. Raff is also chair of the research committee of the Society of Cardiovascular Computed Tomography. He has been a key participant in leading the Michigan consortium’s effort to lower radiation exposures for patients undergoing coronary CT angiography (CCTA). Starting with 16 hospitals in its registry, the consortium found, initially, that its median radiation dose for CCTA was about 21 mSv (far higher than the expected dose, based on the research literature, of 13 to 16 mSv), Raff says. Even accounting for the fact the Michigan figures included some preparatory imaging not included in the published studies, the exposure levels were too high. The hospitals reacted by applying simple-dose reduction protocols. A year later, the CCTA dose for the 16 consortium hospitals had been cut by more than half, to a median of 9.8 mSv. Raff says, “We had a team that helped the hospitals; experts on the scanners worked with the

radiology supervisors to work through the best methods at each site. We recently sent in data that showed, 18 months later, that the doses were still sustained in the 9.9-mSv range. You don’t retrain, but there is monthly feedback, and the doses have stayed down; it’s pretty exciting that the lower doses were sustained.” To get the doses down, the Michigan hospitals employed a three-step process. The first step was preparing the patients by using beta-blockers to lower heart rate, allowing high-voltage radiation to be applied over a much shorter time interval. Raff says, “That reduces the dose. With a faster heart rate, you’re not sure exactly where you’re going to get a good picture, so you have to leave the machine on for most of diastole. That gives the patient twice as much radiation.” The second element that the consortium hospitals focused on with CCTA was body-mass index (BMI). “We start CCTA with 120 kV, but with a BMI of 30 or less, you can get by with 100 (which, in absorbed radiation, is a reduction of 40%),” Raff says. The third

thing that the consortium hospitals did to cut radiation dose was to avoid image creep by focusing on the heart. This can cut exposure by 10% to 20%, Raff says. Raff adds that the dose registry and the protocols developed for CCTA have changed the culture, within the consortium’s member hospitals, concerning radiation exposure. The consortium has now expanded to 53 hospitals, and when new hospitals come in, their CCTA exposure values are around 15 mSv, as opposed to around 25 mSv in the beginning, Raff says. “I know it’s better; I don’t have a handle on things outside Michigan. The methodologies are really not very difficult. I’m pretty confident this approach will work its way through all the CT procedures,” he says. To Raff, it makes sense to track cumulative exposure per patient. “I hope that’s through a credit-card type of thing or a network medical record, but that requires a change,” he says. “That’s the sort of thing that health-care reform is supposed to be delivering.” Raff says that he’s already seen

evidence that the newest CT scanners will make drastic reductions in radiation dose. “There are some producing scans in the 4- to 5-mSv range, and some as low as 1 to 2 mSv. These are not yet widely available, but we have one, and it really does the job,” he says. The Michigan consortium is, in fact, planning a study in which it will take data from older scanners for certain procedures and compare exposure and image quality to the same attributes (for the same number of procedures) from new machines. “The new scanners may be more challenging because those are huge reductions in dose. Some are 90% reductions, but I’ve seen some artifacts from that,” Raff says. “We may be better off with 50% or 60% reductions in dose. It’s a cost–benefit ratio. In the end, we’ll have to see what happens.” Physicists and CT Walter Huda, PhD, FCCPM/ABMP, is a medical physicist and a professor of radiology in the physics division of the

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COVER | Radiation Safety

Department of Radiology and Radiological Science at the Medical University of South Carolina in Charleston. Huda believes that radiologists bear the ultimate responsibility for ensuring that patients are not systematically receiving inappropriate doses of radiation. He says that manufacturers usually have default parameters for radiation exposure in place on imaging systems, but that radiologists and technologists will sometimes tinker with them. “It’s a hodgepodge arrangement,” he says, adding that those who are uncertain should consult ACR guidelines for diagnostic reference levels. “Every time they scan a patient, there is a dose-summary sheet on that patient that can be sent to PACS. I put the primary responsibility on the radiologists,” Huda says. Radiologists need to keep an eye on the dose summaries, he adds. Huda says that physicists have the job of helping to optimize protocols by adjusting voltage, tube rotation, scanning speed, and the like, but he maintains that the problem of radiation exposure to is quite solvable. “Radiation exposure carries small (but nonzero) risks,” he says, “but what to do is easy. Apply two rules: One, never expose a patient to radiation unless there is a bigger benefit to the patient than the risk from exposure; two, when performing an exam, never use more radiation than needed—ALARA, in other words. If you make a decision, you need to be knowledgeable and to understand the benefits and risks. It’s a judgment call, but one being made by a knowledgeable, board-certified individual.” Physicists also analyze the risks associated with various exam protocols. Huda says, “I recently did a study6 on cardiac CTA. I showed that the average risk of developing cancer was 1 in 1,000. The high risk was for the lung, not the

breast, even though the breasts got most of the radiation. Sensitivity of the patient was a factor, too.” Huda says that the automated exposure controls that manufacturers are putting on the latest systems are a promising development. With this technology, the scanner can adjust radiation exposure for different parts of the body during a scan. Moving over the breasts, it will shift focus and reduce exposure, Huda says. It will also vary exposure according to body parts’ mass. “It’s the most dose-saving method, and it doesn’t subtract from diagnostic performance,” Huda says. Huda is planning a study to show how much automated exposure controls can reduce radiation to the breasts, particularly in younger females. “It might be a 5% to 50% reduction,” he says. “My guesstimate is 35% to 50%.” Whether or not radiology departments can rely automatically on dose-limiting software was called into question when a report in the New York Times7 blamed overradiation incidents at two sites on dose-limiting software that may have contributed to overexposure. Unlike the breast-dose–saving software referred to by Huda, the software program in question is related to a noise index and is proprietary. J. Anthony Seibert, PhD, presidentelect of the Association of Physicists in Medicine and professor of diagnostic imaging physics at the University of California–Davis, speculates that the overexposures could have been the result of an unreasonably low setting of the noise index that caused the milliamperage to max out at eight times the optimal dose. The result is that now, everyone has a better understanding of the significance of the volume CT dose index. “The technology is outstripping the trainer’s ability to train and the learner’s ability to learn,” Seibert notes. “We, collectively—not just the manufacturers, but the receivers of the information—do not do enough or pay enough attention, in terms of commissioning a piece of equipment, the impact of what these values mean, the potential hazardous use of the equipment, and untoward outcomes that can occur in the use of the equipment.” Mayo-Smith advises ongoing vigilance. “It is very important that radiology

26 Radiology BuSineSS JouRnal | august/September 2010 | www.imagingbiz.com

departments create a team approach to reviewing CT protocols for dose parameters, to make sure protocols are created not only to optimize image quality, but to minimize dose,” he notes. “This is an ongoing process, particularly as new indications for CT examinations are created and new protocols are developed.” He recommends that the team include a radiologist, a physicist, and a lead technologist. Huda is not a fan of attempting to collect cumulative dose information on patients. If radiologists are following ALARA and risk–benefit judgments, he asks what the point would be. “For the cumulative effect of indicated exams, I don’t see any value in adding up the radiation,” he says. Of course, the fact that a patient has had multiple CT exams might figure into the risk–benefit decision on ensuing scans. That’s one reason that Huda calls for the exposure summary on every exam to be dictated from the PACS when a radiologist completes a report, along with a notation that the exposure level produced (or failed to produce) a readable image. That way, instances of using too much or too little exposure to yield a readable exam can be tracked as well. “I’m in the process of doing that at my institution,” Huda says. Dose Tracking George Shih, MD, is assistant professor of radiology at Weill Cornell Medical College, New York, New York. He is also a computer enthusiast. Working with a team of medical physicists at Columbia University, Shih has come up with a system for tracking CT radiation exposure for inpatients that he believes can be extrapolated to radiology in general. Shih calls his system Valkyrie. Valkyrie, Shih says, has extracted CT radiation exposure data, so far, with 100% accuracy. On newer machines, it takes the data directly from the scanner, but on older machines, where there are no scanner data, it relies on “text embedded in the images—CT screenshots,” Shih says. He adds that his team was able to use connected components to extract the exposures from the screenshots. Valkyrie is still in a nascent stage, Shih says. It’s not patented, and it’s only available

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COVER | Radiation Safety

for Weill Cornell inpatients, but for them, it works. It automatically records—on what is now a stand-alone server—the exam exposures (based on manufacturers’ estimates using phantoms), and it adjusts those figures based on the patient’s actual size and weight. If Valkyrie sees excessive exposures, it automatically contacts radiologists by email so that the problem can be corrected at once, Shih says. “Immediately, there are people alerted,” Shih says. He admits this hasn’t happened yet in a real setting because only three scanners are connected to the system, and it’s new. Any overexposure not caught before the first exam, however, should be caught thereafter, preventing more excessive exposures. “We’ve had nothing adverse yet, but we’re ready if something happens,” Shih says. Another advantage of Valkyrie is that it could be used retrospectively to extract exposure data from any PACS archive. That might lead to a better understanding of health-care–related radiation exposure, Shih says. For now, though, Shih is satisfied to have a new quality-control tool, which might or might not have a commercial or industrywide application. Dose Regulation At the March meetings called by the FDA, the major powers in the imaging industry—scanner manufacturers, medical societies, and government agencies—all lined up behind the principle of reducing radiation exposure, despite a lack of proof that widespread cancer increases will result from imaging being done as it is now. Better safe than sorry was a major theme. Today, however, there is no regulatory body charged with making certain that radiation exposure limits are applied or enforced. Only four states require medical physicists to be licensed, and many states have yet to license radiologic technologists. Who will take the lead in further regulation, if there is any, is unclear. Some call for the federal government to step in; some want the states to take charge. Alberto Gutierrez, PhD, is director of the Office of In Vitro Diagnostics at the FDA’s Center for Devices and Radiological Health. Trained as a chemist, Gutierrez is

now charged with overseeing imagingdevice radiation safety for the FDA. The FDA’s essential role, he says, is clearing scanners and other devices for safe use. “We can require the manufacturers to put in safeguards, if we believe they’re necessary for a safe and effective manner of operation,” he says. “We can make sure manufacturers put alerts on the machines and keep records. We can require checkers on dosage and alarms if procedures go beyond a certain amount of radiation. The manufacturers have agreed on putting in appropriate alerts.” What the FDA can’t do, Gutierrez says, is monitor the practice of medicine in hospitals and clinics where imaging techniques are put into play. “We can do things like clear safeguards with CMS,” to make sure that the machines are used correctly, he says. “We do play a role in that area. We partner with CMS to keep up quality-assurance practices for imaging facilities and hospitals.” Now, he adds, the FDA is meeting with industry and medical-society representatives to “talk about how to establish a national dose registry and diagnostic reference levels,” he says. Gutierrez adds, “There’s a good chance the FDA will work on guidance documents and continue careful monitoring of all the manufacturers on whether we are seeing more radiation overexposures, and if we are, we will continue to bring those to the attention of the manufacturers and the medical community to determine what needs to be done.” When it comes to regulation, Gutierrez takes a softer stance. “From the exposure events that we have seen, we don’t believe that this is an area in which we would need to change regulations, or where the manufacturers did something wrong, per se,” he says. The FDA is unlikely to seek a regulatory role for itself; Gutierrez says, “National regulation is not our purview.” Nonetheless, the days when imaging facilities and hospitals could proceed as usual, while patients’ exposure to radiation grew in company with exam volumes and the number of CT detectors, appear to be gone. The California legislature is proving the point. The California Senate recently passed SB 1237, which would, beginning

28 Radiology BuSineSS JouRnal | august/September 2010 | www.imagingbiz.com

in 2012, require—if technologically feasible—health facilities and clinics to record the dose of radiation received by a patient during a CT scan and input that dose as part of the patient’s medical record. The bill is now being considered by the California Assembly. Compliance for rural providers would be delayed until 2013. Accreditation of high-end imaging providers would also be mandated. The California Department of Public Health would have regulatory control. George Wiley is a contributing writer for Radiology Business Journal. References 1. Redberg RF. Cancer risks and radiation exposure from computed tomographic scans. How can we be sure that the benefits outweigh the risks? Arch Intern Med. 2009;169(22):2049-2050. 2. Smith-Bindman R, Lipson J, Marcus R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med. 2009;169(22):2078-2086. 3. Harris G. Scientists say F.D.A. ignored radiation warnings. New York Times. http://www.nytimes.com/2010/03/29/ health/policy/29fda.html. Published March 28, 2010. Accessed August 5, 2010. 4. Freeman LM, Stein EG, Sprayregen S, Chamarthy M, Haramati LB. The current and continuing important role of ventilation-perfusion scintigraphy in evaluating patients with suspected pulmonary embolism. Semin Nucl Med. 2008;38(6):432-440. 5. Stein EG, Haramati LB, Chamarthy M, Sprayregen S, Davitt MM, Freeman LM. Success of a safe and simple algorithm to reduce use of CT pulmonary angiography in the emergency department. AJR Am J Roentgenol. 2010;194(2):392-397. 6. Huda W, Sterzik A, Tipnis S, Schoepf UJ. Organ doses to adult patients for chest CT. Med Phys. 201;37(2):842-847. 7. Bogdanich W. After stroke scans, patients face serious health risks. New York Times. http://www.nytimes. com/2010/08/01/health/01radiation/ h t m l ? _ r = 1 & s rc = m e & re f = g e n e r a l . Published July 31, 2010. Accessed August 18, 2010.

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The Top 20 | Diagnostic Imaging Center Chains

The Top 20 Imaging-center Chains Growth in the sector has slowed, but procedural volumes per center are climbing

t seems clear that the number of US imaging centers has stopped expanding, and that imaging-center chains are no longer as eager to snap up as many centers as possible. This is not bad news, however. Procedural volumes per imaging center are growing—so the combination of greater demand for imaging and fewer centers competing for those referrals means that even lower reimbursement will be easier for today’s busier imaging centers to withstand. Radiology Business Journal and SDI, Plymouth Meeting, Pennsylvania, are cosponsors of this look at imagingcenter chains and the larger environment in which they (and their independent competitors) operate. SDI provided the data on which this report is based, as well as comparison information1 that the company had collected and analyzed in earlier years. The top 20 imaging-center chains added 65 centers between 2008 and 2010, for a growth rate of 7.5%, but a slight majority of the top 20 chains either added no imaging centers or lost some (Table 1). RadNet, at the top of the stack, also added the most centers (24); Tri State Imaging Consultants, the 10th largest chain, showed the second largest growth, adding 18 centers. The fourth largest chain, Center for Diagnostic Imaging (CDI), added 16 centers, and 15 centers were added by SimonMed Imaging, bringing it up to 19th position among the largest chains. Five other chains added smaller numbers of centers. Two chains neither added nor subtracted centers, one was new to the top 20 list, and eight lost three or more centers. InSight Imaging (the fifth largest chain) and Diagnostic Health (in 12th position) thinned their ranks most, losing 13 centers each. A small decline was seen in the total number of imaging centers (Figure 1), which includes centers that are not allied with any chain. Between 2008 and 2010, there was a 1.8% decrease in the number

By Kris Kyes

Table 1. Top 20 Chains Chain RadNet HCA

headquarters Los Angeles, CA Nashville, TN

Centers, 2008 174 95

Centers, 2010 198 89

Change +24 –6

Novant Health/ MedQuest Associates

Alpharetta, GA

–6

Center for Diagnostic Imaging InSight Imaging Ascension Health Doshi Diagnostic Imaging Services Tenet Health System Community Health Systems Tri State Imaging Consultants Cleveland Clinic Health System Diagnostic Health Catholic Health Initiative PresGar South Texas Radiology Group/ Imaging Centers COL Management A1 Medical Imaging Diagnostic Centers ProScan Imaging SimonMed Imaging Trinity Health

Minneapolis, MN Lake Forest, CA St Louis, MO Hicksville, NY

39 67 51 44

55 54 45 38

+16 –13 –6 –8

Dallas, TX Franklin, TN Rockledge, PA Independence, OH Birmingham, AL Denver, CO Tampa, FL San Antonio, TX

31 22 16 28 44 33 32 17

35 34 34 31 31 30 24 24

+4 +12 +18 +3 –13 –3 –8 +7

Lafayette, LA Sarasota, FL

24 –

24 24

0 –

Cincinnati, OH Phoenix, AZ Novi, IL

23 8 18

23 23 21

0 +15 +3

859

924

+65

ToTAL

Rocky Mountain 398 126 59

Pacific 833

13 28

10 22

616 11

168

New England 310 Great Lakes 9 863 21 Mid2 Atlantic 7 78 110 1,158 505 54 49 12 174 119 369 284 33 296 28 54 116 223 10 124 11 75 168 46 106 160 106 85 66 43 Southeast 37 92 173 1,397 80 532 North Central 310

612

South Central Southwest 310 Central 721

Figure 1. US imaging centers (by state and region), 2010.

30 RaDIology BusIness JouRnal | august/september 2010 | www.imagingbiz.com

Puerto Rico - 11

Total - 6,311

of US imaging centers, representing the elimination of 120 centers. The Southeast region had the largest reduction, losing 56 imaging centers, and the Mid-Atlantic, Pacific, and Rocky Mountain regions also registered losses. Only the Southwest Central region showed a gain, adding eight centers.

with (defined as owned, managed, or leased by) chains from the 2008 high of 4,703 to the 2010 level of 4,433. This two-year decline of about 6% does include an increase of 50 in the total number of centers over the 2009 total, however. The top five imaging-center chains

1,200 1,024

995 1,000

reduction in centers among the top five chains, shedding seven centers between 2009 and 2010. The overall regional changes in total imaging centers have been small between 2008 and 2010, with no region losing more than 4% of its imaging centers, but no region adding more than 1% to its 8,000 1,066 7,000 953 945 6,000

800

687 5,000

600 400

506

4,689

4,478

351

4,703

4,433

4,383

3,818

3,000

3,281 200

2,499

2,000

0 2003

4,000

2004

Imaging-center chains

2005

2006

2007

2008

2009

2010

1,000 Imaging centers owned, managed, or leased

Figure 2. Growth/decline of US chains, 2003–2010. There was little change in the number of imaging centers operating in the Great Lakes, South Central, North Central, and Northeast regions (although individual states within those regions showed more noticeable gains and losses). This represents a major change in the trend that favored growth in the number of centers in previous years; for example, between 2003 and 2008, all regions exhibited growth, with some showing increases of more than 30%. The same five states have the most imaging centers as in 2008, although their relative rankings have been juggled a bit. In order, the top five states in 2008 were Florida, California, New York, Texas, and Pennsylvania; for 2010, they are California, Florida, Texas, New York, and Pennsylvania. Of these, only Texas had added imaging centers since 2008, with 16 new centers opening there. Since reaching a peak of 1,066 in 2008 (Figure 2), the number of imagingcenter chains has declined, dropping to 945. This 11% reduction over a two-year period was accompanied by a decrease in the number of centers that are affiliated

do not appear to have pursued similar expansion strategies over the past five years, with growth and shrinkage alternating (Figure 3), but all showed decreases in affiliated centers between 2008 and 2009. This might have been a cautious pause taken while they waited to observe the effects of the DRA on their revenues. By 2010, three of the five chains were again acquiring imaging centers, with RadNet adding 32 centers, CDI adding 17, and HCA adding five. InSight Imaging showed the greatest 174

total (Table 2). This relative lack of change seems uneventful, but it is noteworthy because it indicates a sharp application of the brakes to previously rapid rates of national and regional growth. Between 2001 and 2008, for example, the number of imaging centers increased 55%. The fastest-growing area—the South Central region—saw a 38% increase in total centers between 2003 and 2008. The following two years showed growth of only four centers (1%) in the same region, and the most rapid growth

198 166

136 90 95

84 89

89 93 90 87 37 39 38

RadNet Inc 2007

2008

hCA 2009

2010

Novant health/ MedQuest Associates Inc

Center for Diagnostic Imaging

73 67 61 54

InSight Imaging

Figure 3. Growth/decline of the top five chains, 2007–2010. www.imagingbiz.com | august/september 2010 | RaDIology BusIness JouRnal 31

The Top 20 | Diagnostic Imaging Center Chains

Table 2. Growth/Decline of Imaging Centers (by Region), 2008–2010 Region

Centers, 2008

Centers, 2010

Change

Southwest Central

713

721

+8 (+1%)

South Central

306

310

+4 (+1%)

North Central

308

310

+2 (+1%)

New England

309

310

+1 (+<1%)

Great Lakes

867

863

–4 (–<1%)

Pacific

846

833

–13 (–2%)

Rocky Mountain

416

398

–18 (–4%)

Mid-Atlantic

1,201

1,158

–43 (–4%)

Southeast

1,453

1,397

–56 (–4%)

There has, however, been a large increase in the number of imaging centers with which integrated health networks (IHNs) maintain relationships (Table 3). While this growth is difficult to quantify because the 2008 data covered only the top five IHNs (instead of the 10 IHNs now shown), the five IHNs for which 2008 figures are available included four of the five that still hold those positions today. The top five IHNSs for 2008 had relationships with 182 centers; for today’s top five, the number of centers has

shifted to the Southwest Central region. 100% That growth, however, consisted of eight centers (1%). The Southeast, during the 26% 27% 27% 29% 80% 30% same period, lost 56 centers (4%). 34% 41% From 2003 through 2006, there was 74% 73% 73% a sharp increase in the percentage of 60% 47% 71% 70% 66% imaging centers affiliated with chains 59% (Figure 4), but no further growth is 53% being seen, so it is possible that chains 40% are postponing further imaging-center acquisitions—perhaps until they are 20% certain that increasing demand for imaging services will outweigh the 0% effects of declining reimbursement on 2003 2004 2005 2006 2007 2008 2009 2010 maintaining the chains’ profitability. Not affiliated Affiliated Since 2006, the percentage of imaging centers affiliated with chains Figure 4. Affiliation of imaging centers with chains, 2003–2010. has decreased slightly, from 74% to 70%. In addition to chains’ apparent lack of the scale from the top 20) consist of only increased to 298, indicating that a strong interest in adding to their imaging-center two imaging centers; in 2008, only 7% trend toward greater affiliation with IHNs coverage, it is possible that this small of chains owned more than 11 centers. is probable among imaging centers. This decline represents the chains’ decision to It could be that the recent drop in chain would be supported by the desire of many remove some of the least desirable centers affiliation reflects a decision by some IHNs to move care to less expensive settings, members of the smallest chains to return since imaging centers’ costs are often lower from their holdings. than those of hospitals’ outpatient radiology Many chains (on the opposite end of to independent operation. Table 3. Integrated Health Networks With the Most Imaging-center Relationships departments for the same procedure. In addition, many patients prefer to obtain Network Centers Relationship Share (of 1,519) imaging services outside the hospital, providing another incentive for IHNs to Novant Health/MedQuest Associates 93 8.1% make more services available to their patients HCA 81 5.3% in freestanding imaging centers. Ascension Health 49 3.2% 2008 is the most recent year for which Cleveland Clinic Health System 42 2.8% the average number of patient visits per Catholic Health Initiatives 33 2.2% year is available (Table 4). The Rocky Mountain region had the highest average Community Health Systems 32 2.1% number of visits per center, perhaps Trinity Health 27 1.8% indicating that there is still room for HealthONE, HCA Division 21 1.4% growth in the number of imaging centers ProMedica Health System 20 1.3% serving both this region and the Southeast MultiCare Health System 19 1.3% region (which also shows a large number ToTAL 417 27.5% of visits per center). 32 RaDIology BusIness JouRnal | august/september 2010 | www.imagingbiz.com

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The Top 20 | Diagnostic Imaging Center Chains

The need for imaging centers may be more fully met in regions showing fewer average visits per center; for example, in the Great Lakes region, there were 25% fewer visits per center than there were in the Rocky Mountain region. This represents a shift in the regional distribution of visits per center; for the previous year (2007), the Southeast region had the highest

average, at 14,025 visits, and the South Central region had the lowest average, at 7,821 visits. That region’s 2008 average of 13,448 represents a near doubling of visits per center. The small decline seen since 2008 in the number of imaging centers would be expected to increase procedural volumes by making the remaining centers handle

Table 4. Average Patient Visits per Imaging Center (by Region) Region Rocky Mountain Southeast

Centers (2010)

Visits per Center (2008 average)

398

14,595

1,397

14,384

North Central

310

13,670

Mid-Atlantic

1,158

13,639

South Central

310

13,448

Pacific

833

13,300

Southwest Central

721

11,942

New England Great Lakes 1269_Rad_Sprd_RBJ_BOT.qxd:Layout 1 ToTAL

310 5/7/10

863 3:06 6,300 PM

11,755 10,900 Page 1

13,070

more exams, and this appears to be the case (Figure 5). During the steep growth in the number of centers seen in previous years, average procedures per week declined from a high of 291 in 2002 to just 204 in 2008. For 2009, however, procedural volumes bounced back to an average of 266 per week, creating a sharp increase. Because this 30% growth in procedures per week considerably outweighs the volume redistribution predicted by the minor reduction in the number of imaging centers, it seems safe to assume either that the demand for imaging is growing quickly or that patients are having more of their imaging performed at imaging centers, rather than in hospitals’ outpatient imaging departments or in physicians’ offices. It’s possible that all three forces are at work, with the combination of fewer imaging centers, patients’ and/or referrers’ preference for using those centers, and high demand for imaging combining to increase average procedural volumes.

MAKING

7,000

400 350 300 250

271 212

291

3,000

5,450 261

4,773

216

244

248

6,414

3,068

6,431

6,150 266

264

6,000 5,000 4,000

204

4,159

200 150

267

5,760

6,037

3,000

3,366

100

2,000

1,000 1999

2000

2001

2002

Average procedures per week

2003

2004

2005

2006

2007

2008

2009

Imaging centers

Figure 5. Average number of procedures per week performed at imaging centers, 1999–2009. Despite reductions in per-patient and per-exam reimbursement, growth in procedural volumes means more than the fact that imaging centers are increasing throughput, efficiency, and total exam volumes in a bid to survive. That such volume growth has been possible— without large numbers of imaging-center

closures—implies that there is still an expanding demand for imaging. Clearly, imaging centers are not increasing their procedural volumes by stealing referrals from one another, but by responding to consumers’ growing needs. That demand, in turn, will allow more imaging centers, both within and outside chains, to keep

their doors open in coming years. Kris Kyes is technical editor of Radiology Business Journal. Reference 1. SDI. 2008 Diagnostic Imaging Center Market Report. Yardley, PA: SDI; 2008.

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PACS TrAnSiTionS | Switching Vendors

PACS Passages Three facilities transition from one PACS platform to another, navigating the data-migration minefield, training multiple users, and configuring access for a range of clinicians By Cat Vasko

ew processes in radiology are as dreaded as switching from a legacy PACS to a newer replacement. Often approached only when the former PACS is on its last legs, the transition between systems requires diligent selection from an everwidening field of solutions, lengthy migration of complex (and sometimes flawed) data, and retraining of all affected staff. It’s also, however, the next step that many hospitals and practices have been awaiting to bring 21st-century clinical and business capabilities to their imaging operations. As Tony Linkmeyer, director of medical imaging at Wilson Memorial Hospital, Sidney, Ohio, recalls, “Base systems now are three generations ahead of where we were,” with a PACS implemented in 1998. He adds, “We thought we were experts. We never even thought to ask whether the PACS we were considering could do certain things, and we found out about so many features that weren’t even on our radar.” PACS technology has come a long way since its youth; as a result, the selection process is more complex than ever before, often requiring buy-in from several parties: radiologists, technologists, IT staff, administrative staff, and managers.

In the case of Nebraska Medical Center in Omaha, Michael Battreall, director of medical information systems, brought in a wide array of end users. “We wanted folks from each of the different disciplines within the radiology department and the hospital,” he says. “We had people from outside of radiology, like the emergency department, taking a look at the pieces that would be affecting them.” Alberto Goldszal, PhD, MBA, CIO of University Radiology Group PC, East Brunswick, New Jersey, recommends a different approach: While end-user reactions, desires, and aspirations must have considerable weight, he says, it’s best to let those who know their way around a PACS bear the brunt of the decision making. For University Radiology Group’s PACS selection team, Goldszal assembled two radiologist champions (typically at the CMIO level), the practice’s RIS administrator, and its PACS administrator, as well as representatives from the IT departments of the hospitals that the practice serves. “Power users and administrators are in the best position to make those decisions,” he says. “It takes time to accrue this kind of knowledge. In reality, these things are best learned by doing.”

36 Radiology BuSineSS JouRnal | august/September 2010 | www.imagingbiz.com

Strategic Decisions During the more than eight years that Wilson Memorial Hospital was using its legacy PACS, the hospital saw its growth almost double—and noted another important change. “When we looked at where our patients were coming from geographically (by zip code), we saw that our radius approached 100 miles—we had patients coming from Columbus, Dayton, and Lima, Ohio, and from Fort Wayne, Indiana,” Linkmeyer says. “We knew we had to distribute our images better if we wanted to grow and attract business from specialists.” Linkmeyer and his team started with 40 vendors, but they quickly were able to narrow that number down to six key contenders. From there, Linkmeyer eliminated potential vendors based on capabilities that Wilson Memorial Hospital knew it wanted (such as ease of integration and experience with various modalities), as well as on capabilities that the hospital hadn’t realized were available. “I was surprised how much everything had changed,” Linkmeyer recalls. “As we went through the process, it took several meetings with each of the vendors because we didn’t ask the right questions, the first time, about all of the features. We started learning about 3D, storage methodologies,

cardiac cine, nuclear-medicine cine, and all this stuff we took for granted didn’t exist. It was an eye opener.” In the end, Wilson Memorial Hospital selected a PACS that enabled it to perform the kind of referring-physician outreach that the hospital needed without infringing on the IT staff’s protectiveness toward its network. “Our CIO was focused on letting people into the network without allowing them to touch it,” Linkmeyer says. “The image distribution of the PACS we selected has not disappointed.” For Battreall and his team, the decision-making process was more deeply affected by prior experience. “There were a number of features and capabilities we didn’t have with our current PACS that we knew we needed,” he says. “With the previous PACS, there were different databases for the radiologists and Webbased users, and trying to keep those in sync was difficult, so we knew we wanted one database. We had specific requirements regarding speed and how rapidly the exams opened. We were lacking tools for our orthopedic surgeons for their 3D templating, and we needed tighter integration with our 3D vendor so our radiologists would have a workspace where they didn’t have to get up and move from workstation to workstation.” Battreall was seeking a replacement for legacy PACS that had been in place at Nebraska Medical Center for seven years; he began with a short list of six vendors, and he established criteria with which to evaluate their products for an apples-toapples comparison. “Capabilities we needed to have and things we didn’t do right the first time (or were lacking) went right to the top of the list,” he notes. “We tried to take a very systematic approach to the change.” Goldszal and University Radiology Group had been using a legacy PACS for 12 years when they began the transition to a full-blown version of the thin-client PACS they had been using for teleradiology. “[The legacy PACS] might have been the oldest PACS from that vendor on the East Coast, which is a testament to the bulletproof technology. Of course, on today’s level, it lacks some of the features and functionalities we see in applications developed later on,” he says.

We had some really ugly old stuff. We had tapes on shelves. Even the third-party company had a heck of a time doing it well. —Tony Linkmeyer, director of medical imaging, Wilson Memorial Hospital, Sidney, oH

You have to maintain day-to-day operations with the old system while planning and phasing in the introduction of the new one. —Alberto Goldszal, PhD, MBA, Cio, University radiology Group PC, East Brunswick, nJ

University Radiology Group’s team was seeking a solution that not only would improve quality of care, but would also boost the practice’s revenue by supporting its burgeoning teleradiology business. “It was a matter of strategic partnership,” Goldszal says. “We needed a PACS that could do equally well with the distribution of data among our clinics and the incoming data from our hospitals while providing full support for a worldwide teleradiology operation.” Storage was also a concern for the practice, and Goldszal attributes the weight that it held in his decision making to the fact that University Radiology Group had been through the PACS-replacement process more than once. “When you’re getting your second or third PACS, you start thinking about long-term needs, and you start creating economies of scale in your mind,” he says. optimizing Migration When Linkmeyer’s team approached its legacy vendor about migrating data from the former PACS to the new platform, the response was “sour grapes: good luck,” he says. Linkmeyer then asked prospective PACS vendors for their recommendations, and almost unanimously, they suggested working with a third-party company that specializes in data migration. In the end, vendors’ responses to the data-migration question became a selection factor as well. “We knew we had to be prepared for what would happen

at the end of the next eight years,” Linkmeyer says. “We asked every vendor, ‘If the relationship between us sours, how do I get my information off your system and onto something else?’” Linkmeyer found himself in the same position as many organizations that are trying to replace a turn-of-themillennium PACS a decade or so later. “We had some really ugly old stuff,” he recalls. “We had tapes on shelves. Even the third-party company had a heck of a time doing it well.” Around six months after selecting the replacement PACS, in May 2007, Wilson Memorial Hospital commenced the migration process, two months prior to going live with the new system. “We only migrated five years’ data and left three behind, so it came to around 200,000 exams,” Linkmeyer says. “It took a few weeks after implementation to have it all migrated. We allowed them to work backward, so we knew some data would come trickling in late.” Goldszal is an advocate of this phased approach (see figure). “When it comes to data migration, people want to migrate everything and then turn on the new system, and it just can’t happen that way,” he says. “You have to maintain day-today operations with the old system while planning and phasing in the introduction of the new one.” He notes that it’s critical not to overburden the legacy PACS (a warning echoed by Battreall, whose team moved

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PACS TrAnSiTionS | Switching Vendors

1.1 million exams from its legacy PACS to the new system without involving the legacy vendor). “We were probably 85% of the way there when we turned on the new PACS,” Battreall says. “Our primary concern was that we didn’t want the old system to get beaten up to the point where it couldn’t get anything done.” Battreall’s group migrated all 70 terabytes of data in six months; Battreall attributes this rapid pace to the attention that Nebraska Medical Center’s staff had always paid to the data being input into the PACS. “The reason people run into issues is that they don’t take care of their data,” he says. “We made sure we had orders for all of our exams, and we took a very systematic approach to making sure what we stored was accurate. For some organizations, that can be an afterthought.”

At University Radiology Group, Goldszal and colleagues adopted an algorithm that identifies images and reports that have matched accession numbers, migrating those data—which Goldszal calls the lowhanging fruit—first. “Then, you go after the exceptions and transfer those as well, and you keep doing that, filtering with algorithms, until you get to a point where you need a human operator to determine where the data belong or discard them altogether,” he says. “The good news is that the most recent data will be the cleanest, so you migrate those first, populating the archive at the fastest possible rate. Once you have two years’ data on the new archive, you can turn on the new PACS and have an on-demand process to prioritize other data you need. From the end-user perspective, the radiologist can always

see the entire history of the patient.” Training and implementation Just before implementation of the new PACS, Linkmeyer, his PACS administrator, and a member of the hospital’s IT staff traveled to the vendor’s headquarters for training, and upon their return to Ohio, the three proceeded to train radiologists and staff on a test server. “We considered ourselves administrative superusers,” he says. “The team leaders of each area were below our level.” Linkmeyer and the team started all users at an introductory level to make them more comfortable with the new system and then trained them in more advanced capabilities over time. “My PACS administrator babysat that thing day in and day out until everyone was comfortable with it,” he recalls. “Then,

nebraska Medical Center Planning team selected

rFP issued

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Go live technologists February 10, 2009 radiologists February 16, 2009 Wilson Memorial Hospital Planning team selected

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Figure. Transition timeline for three institutions. 38 Radiology BuSineSS JouRnal | august/September 2010 | www.imagingbiz.com

PACS TrAnSiTionS | Switching Vendors

You don’t want to start training users too early, or they’ll forget what they’ve learned. We started with the radiologists one week prior to going live. —Michael Battreall, director of medical information systems, nebraska Medical Center, omaha, nE

as people became more comfortable, we gave them more freedom and control.” Battreall’s group adopted a staggered approach to training, taking Nebraska Medical Center’s technologists live on the new system one week before the radiologists. “We didn’t want to throw the technologists under the bus,” he explains. “We wanted them to be acclimated before we brought on the radiologists.” Technologist superusers trained other technologists, while radiologists were given one-on-one training. Users outside the department were trained last, en masse. “You don’t want to start training users too early,” Battreall advises, “or they’ll forget what they’ve learned. We

started with the radiologists one week prior to going live.” Goldszal’s team had an even more extended training process, complicated—or simplified, depending on your perspective—by the fact that University Radiology Group had already implemented a teleradiology-specific PACS, from its new PACS vendor, two years before replacing its legacy PACS. Goldszal says, “The teleradiology PACS works with a universal viewer, so when we went live with it, two years ago, a lot of our radiologists decided to use that viewer to look at the legacy PACS data. People started using it more and more, and we kept growing that.”

For the obstinate few who stuck with the legacy PACS viewer, on-the-job training on the new system was given. “I’m a big believer in continued training,” Goldszal notes, “so our organization’s training across all applications is a lot more intensive than at a lot of other places. We keep constantly reinvesting in training sessions and knowledge-transfer events so that our staff remains really knowledgeable.” Wilson Memorial Hospital’s new PACS allows the administrator to grant graduated access to different users: advanced diagnostic viewing to radiologists, emergency-department physicians, and some other clinicians, and a more limited toolset for on-site clinicians and referring physicians. “There’s very little difference between the two except for the tools,” Linkmeyer notes. “When we get a new physician group, we simply ask its members if they want access and issue them usernames and passwords if they do.” Goldszal’s team took a similar divide-

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and-conquer approach. “The radiologist population is very clearly defined in its needs,” he says. “Don’t treat everyone else as the same type of user.” Compared with radiologists, he adds, “Technologists doing work prior to image acquisition may need to see similar things, but they’re doing different functions. Then there are the referring physicians, who may not want to see the image at all, and more image-intensive specialists, who are likely to look at the image and may even do some consultation with their radiologist colleagues. It’s easier to manage everyone’s expectations if you know what users want and tailor their accounts to give them just that.” Nebraska Medical Center’s new PACS offers customizable viewing to all referring physicians, although the team elected not to overwhelm them with too many options initially. “It’s very userfriendly, and you can change the look and feel to get it the way you want it,” Battreall says. “We kind of scaled down the customizability and gave them a canned template out of the gate. Most

of the users aren’t that high level, and this way, they have a good start with the tools and can modify it from there, if they choose.” Completing the Transition All three organizations are adjusting to the new capabilities their replacement PACS have afforded them—and the new responsibilities that come with them. For Goldszal and his colleagues, the primary lesson has been to keep data clean for the next transition cycle. “It’s all dependent on really good behavior in data acquisition,” he says. “If you bypass those important milestones, you lose that ability to access the report down the line, so you phase it in and it pays off—your life becomes easier as you move forward.” Linkmeyer’s group also gained valuable experience when it came to the transition between two platforms. “Even though we thought we were ready for it, I just don’t think we were,” he says. “We use PACS without a RIS, and that presented a lot of challenges when it came to functionality and ease of use. Our new PACS vendor’s

people would say, ‘Just have your RIS do this,’ and I’d have to stop them right there. In hindsight, I really wish we’d had a RIS with a PACS. Two years down the road, I don’t need a RIS anymore, but our IT department and vendor really put their heads together to make this thing work right with just our hospital information system.” Battreall adds that it’s important to know where you started so you can assess how far you’ve come. In the case of Nebraska Medical Center, implementing the new PACS led to a 25% reduction in turnaround time. “We wanted download speed, online access to images, and a reduction in reading time, so we constantly monitored those to make sure we got the results we were looking for,” he says. “When you make a change of this magnitude, you have to make sure you have measures in place before you make the change so you can see if you made any improvement after the fact.” Cat Vasko is associate editor of Radiology Business Journal.

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Metrics | Physician Performance

Measuring Up:

Integrating Performance Benchmarks Into the Practice

ithin the past 10 years, the topic of physicianperformance benchmarking has progressed from contentious to being one on which entire meetings in the radiology community are based. Some industry analysts say that this evolution has occurred because measuring physician performance has become a necessity, in today’s health-care environment, due to the many challenges (including financial difficulties) that health care is facing. Given reductions in reimbursement, practices need to find ways to be more productive, according to David Haws, CFO, Pueblo Radiology Medical Group, Santa Barbara, California. “Productivity benchmarking is one of several tools you have to look at to determine if your practice is becoming more efficient, standing still, or moving backward,” he says. When Pueblo Radiology Medical Group first implemented its benchmarking program three years ago, it experienced an immediate 10% increase in physician productivity, Haws reports. That number has since leveled off, but the program still serves as a tool to assess the skills and capabilities of each radiologist. Haws says, “I don’t know how a group can survive without understanding its level of productivity. It has to be measured to ensure that each physician is benefiting the group.” Even though leaders at Pueblo Radiology Medical Group don’t stress clinical productivity as what Haws calls the end-all, be-all element of their work, he says that it is important that the radiologists know how they compare with their peers, how they can improve, and where they are succeeding (compared

With government and payor pressure on the rise and reimbursement on the decline, radiology practices are getting serious about measuring performance By Erin Burke with other group members). The medical profession is enduring considerable change, and as government becomes more involved in health care, advancing and adapting are critical to success. “A progressive program is about being willing to change and to find better ways to do what you’ve done in the past. It’s the only way to get ahead and stay ahead,” Haws says. Benchmarking is one of Pueblo Radiology Medical Group’s methods for increasing efficiency and improving performance; in addition, the practice uses a fully integrated PACS, report templates, voice recognition, and peer-review participation.

Haws says, “Benchmarking is about self-motivation and self-development. It is a way for physicians not only to set goals, but to reach them.” The numbers also provide important information that can be leveraged for marketing purposes. Pueblo Radiology Medical Group’s benchmarking reports don’t account for time spent building the practice, Harter says. Everyone in the group, however, is aware of who is performing that activity, and the time that it requires is taken into account if that individual’s numbers fall below the productivity threshold. Harter adds, though, “Most of our practice builders tend not to have productivity issues.”

Most of our practice builders tend not to have productivity issues. —Lawrence Harter, MD, FAcr, practice president, Pueblo radiology Medical Group, santa Barbara, cA

Lawrence Harter, MD, FACR, practice president, notes that the group’s quarterly and annual benchmarking results, which measure only work RVUs, allow partners to make educated decisions about internal and external staffing. In addition, the quarterly performance reports measure the productivity of individual radiologists. This helps them align themselves better with their peers, but it also allows the group to assess its performance relative to both national and regional numbers. All the measurements present findings that allow the board to assess the group’s overall performance, including which improvements need to be made (and by whom).

44 Radiology Business JouRnal | august/september 2010 | www.imagingbiz.com

To ensure that quality isn’t suffering in the pursuit of productivity, there is a formal peer-review process that occurs annually for everyone except partners (who undergo peer review every other year), Harter says. In addition, a quality committee was created to oversee a review process for sentinel events. These involve either follow-up action by the quality committee or an individual meeting between a senior physician and the physician involved in the incident. Unintended consequences In academic settings, performance benchmarking provides some of the same advantages seen in group practice, but it

also provides an avenue for radiologists to measure overall contributions, including academic endeavors. In addition, it helps physicians understand the different components involved in the team environment, Paul Nagy, PhD, explains. Nagy is director of quality and informatics research and associate professor of radiology at the University of Maryland School of Medicine in Baltimore. He also is the coauthor of an article1 that details the importance of using nonclinical RVUs in academic settings. Radiology leaders at the University of Maryland created a method for measuring academic RVUs, so radiologists are given credit for time spent on teaching and research. They also created a Web-based system that automatically calculates work RVUs, measuring radiologists’ clinical productivity by comparing the numbers, by subspecialty, with benchmarks established at other academic institutions. The results are used in performance appraisals, and radiologists have access to the data throughout the year. The department’s IT warehouse system collects productivity and performance data (updated daily) from the RIS. The system has the added benefit of ensuring that each faculty member’s current CV is available to decision makers in the department using CV Manager, which allows online editing and has the ability to collate benchmarking numbers based on specific requests. Nagy built the system with an Apache Web-based server, used in conjunction with a MySQL® database. The PHP programming language is used to generate the Web pages. In addition to work RVUs, the department uses academic RVUs to measure such contributions as writing articles for publication, teaching, and grant-related activities. The department takes the measurement a step further by weighing the importance of each contribution, including whether an article is published in a journal having high or low impact. The Web-based system, Nagy says, “has helped us become a lot more relevant in our decision making.” There is little dispute that performance benchmarks serve a valuable purpose— or that, used properly, they can benefit radiologists in both private and academic

If all a group is measuring is quantity, then that’s what it will get, at the cost of relationships and patient satisfaction. —richard Duszak, MD, FAcr, Fsir, Mid-south imaging & therapeutics, Memphis, tN

practices. Many industry experts appear to agree, however, that some danger lies in creating a culture that focuses strictly on clinical productivity. Richard Duszak, MD, FACR, FSIR, is a diagnostic and interventional radiologist practicing at Mid-South Imaging & Therapeutics (Memphis, Tennessee), and is the lead author of a two-part series2,3 on benchmarking models. “Radiologists are like any other human beings—they will modify their behavior based on metrics,” he says. “If all a group is measuring is quantity, then that’s what it will get, at the cost of relationships and patient satisfaction.” Duszak and Muroff use the term unintended consequences to refer to the detrimental effects that can occur in association with a flawed performancebenchmarking program. When a practice’s success is based on volume, some radiologists are no longer willing to respond to questions from patients or hospital administrators because they are trying to reach their productivity numbers. Duszak says, “When you stop providing those kinds of services, then the practice’s contract with the hospital is at stake.” The kind of behavior that a group or academic center wants to reinforce is something to take into consideration when developing a physician-productivity model, Duszak notes. One of the biggest challenges is performance evaluation based on fee-for-service reimbursement. Under such a system, a physician will sometimes do what earns payment, even though it might not be in the best interests of the patient, Duszak says. For example, without stopping to question the patient’s referring physician, a radiologist might repeat a test that the same patient underwent a week earlier. A byproduct of reinforcing clinical productivity is that radiologists who choose only cases that are quickly read

can increase their work RVUs through such cherry-picking, Duszak adds. Harter agrees that such a practice isn’t in the best interests of the organization, and that everyone should do his or her fair share of the work. This is why Pueblo Radiology Medical Group has preventive measures in place to ensure the equality of workloads. In the interest of maintaining fair numbers, RVUs are measured by clinical workdays, with time allotted for administrative work. Harter acknowledges, however, that there is no way to measure productivity for time spent in consultation between radiologists who are both within the group. Neglecting to measure the nonclinical contributions of radiologists sends a dangerous message, Nagy notes. “If you don’t measure it, you don’t value it is the message being sent to employees,” he says. That culture is especially detrimental to academic radiology departments, where research and teaching can be as critical to success as clinical productivity is. In addition, the clinical-productivity numbers don’t always relay a radiologist’s true working day because many radiologists spend time training and working with residents. “Radiologists want to expect certain behaviors and motivate those behaviors, and want to improve the bottom line, but it’s a careful mix,” Nagy says. He has developed a prototype radiologist report card (Figure 1) that takes a holistic approach to measuring the academic radiologist’s performance. Drawing values from disparate systems, the reports can be built manually using Microsoft® Excel®. “It would not be difficult to build this into an integrated report-generating system, but we don’t do it right now,” he says. strategic Measurement Creating a successful, comprehensive

www.imagingbiz.com | august/september 2010 | Radiology Business JouRnal 45

Metrics | Physician Performance Clinical productivity

Performance

Education

Quality

Service

Academic

Individual Section Department

Figure 1. Prototype of a holistic report card for academic radiologists developed by Paul Nagy, PhD.

performance-benchmarking program isn’t impossible, but it takes forethought, time, and education. Though productivity is one aspect that should be measured, its measurement isn’t the only tool to be used when assessing performance. Duszak says, “The first thing you should do is step back and ask, ‘Why do we want to do this?’” By asking that question, a group might find that performance measurement isn’t the answer, and that the issue in question might be, for example, a personnel problem, he adds. It’s also important to look at the areas that are the most vital to the success of the group or department, such as quality, patient safety, and relations with hospital administration. “Deciding what to measure ultimately should be based on what is important to the practice,” Duszak says. In Duszak and Muroff’s article3 on moving beyond the numbers, five questions are recommended as starting points for practices and centers that want to implement a physician-performance model: Should we measure it? What should we measure? How should we measure it? How should we manage it? How should we modify it? Once the decision has been made to create a program, many supporting resources are available. Groups with existing programs can use the same resources to discover better ways to use their reports. Pueblo Radiology Medical Group’s leaders attended practice-leader meetings and read articles to educate themselves about best practices for implementing a physician-performance

model, Harter says. The ACR® also served as a valuable resource when the group was implementing its benchmarking program. Often recommended as other useful steps are exploring the resources of the Association of Administrators in Academic Radiology, speaking with similar groups that have successfully implemented benchmarking programs, and conferring with one’s billing company/department to discuss the kinds of reports that can be generated. Harter warns other organizations that Pueblo Radiology Medical Group initially used more than one source for its data, and it experienced inconsistencies as a result. He adds that the group’s benchmarking program is a work in progress. For example, performance reports did not include physicians’ names when they were initially published for group review, but names were later included as an experiment.

available to members, the ACR has created educational sessions for those who want to learn about the intricacies of benchmarking. Judy Burleson, director of metrics in the ACR’s Quality and Safety Department, says that benchmarking has only started gaining momentum in the past 10 years; it wasn’t until around 2006 that the ACR began featuring educational sessions specific to the topic of benchmarking performance. “This year, we have really picked up steam to be able to provide resources to the radiology community,” she says. The ACR has made a point of providing resources at the regional, state, and national levels, and these resources include its RADPEER™ peer-review system. The change in educational focus is a response to the fact that radiology groups and academic centers recognize that increasingly tight budgets make efficiency critical to their survival. In

If you don’t measure it, you don’t value it is the message being sent to employees. —Paul Nagy, PhD, director of quality and informatics research, associate professor of radiology, University of Maryland school of Medicine, Baltimore, MD

The reports have since reverted to being anonymous, at the request of some of the radiologists who were uncomfortable with using names; tweaking the system is necessary to ensure that a group’s benchmarking program is as effective as possible. Beyond Productivity Regulators and payors have created additional impetus for performance measurements that go beyond quantity to include qualitative measures. Developing databases to help practices meet these requirements is an ongoing ACR initiative. The college has developed relevant databases that are available to members: the National Mammography Database, the CT Colonography Registry, and the General Radiology Improvement Database—all of which fall (with other databases) under the umbrella of the National Radiology Data Registry. In addition to the multiple databases

46 Radiology Business JouRnal | august/september 2010 | www.imagingbiz.com

addition, benchmarking reports allow physicians to provide accurate details for both evaluations and reports required by regulatory and accrediting agencies. The Physician Quality Reporting Initiative (PQRI) created by CMS doesn’t yet require physicians to provide reports, but there is an incentive payment of up to 2% of total estimated Medicare Part B fees for diagnostic radiologists who report on three of the four relevant measures designated for 2010. Several more measures pertain to interventional radiology. By 2015, radiologists will be among those required either to submit such reports or to accept penalties (which will gradually increase to 2% by 2016). The Joint Commission requires physician evaluations as part of its accreditation program. “Credentialing/ privileging is a very important part of the accreditation process, and its Focused Professional Practice Evaluation and Ongoing Professional Practice Evaluation

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Metrics | Physician Performance

patient safety are positive outcomes of implementing a physician-performance model. One of the remaining challenges, however, is overcoming the resistance of those radiologists who don’t like the idea of being monitored. Radiologists are smart, intellectually curious people; telling them to do something isn’t a good approach because they need to buy into the program, Duszak says. They are naturally competitive and want to be the best at their jobs, in addition to earning the respect of their peers. A program will be more successful if physicians accept it, instead of merely being told to participate. “In the interest of maintaining quality, it has to be a grassroots effort,” Duszak says. He recommends educating radiologists about the changes that will take place upon the implementation of a benchmarking program. “They need to understand why the group is benchmarking and how it will be done,” he says. By gradually educating them over time, practices can encourage radiologists to be involved from the program’s inception and can make them more likely to embrace the change. If radiologists are made aware of the degree to which societal pressure and government involvement are forcing radiology groups and academic centers to

are both a part of that,” Robert Wise, MD, vice president of the Joint Commission’s Division of Standards and Survey Methods, explains. He says that benchmarking can be a valuable tool for radiologists because the numbers can indicate potential problems of which the physicians might not be aware. “It doesn’t mean that if you hit a certain number, you are doing anything wrong, or that you are a bad physician; it just means that there could be room for improvement,” he says. For example, monitoring how long it takes for different radiologists to perform fluoroscopy can determine whether someone is unintentionally overexposing patients to radiation, Wise says. Reviewing numbers and protocol is a good way both to improve performance and to ensure patient safety. Radiologists also are under scrutiny in light of reports that have appeared in the popular press of patients being overexposed to radiation. The result has been an FDA initiative to reduce patient exposure; the Joint Commission is working with radiology leaders to create screening criteria to ensure patient safety, Wise says. A cultural sea change Improvements in efficiency

and

be more efficient (and more accountable for their protocols), radiologists will have a better understanding of how important benchmarking is to their organizations. Explaining RVU measurements is another important aspect of this education. “The groups that are successful are the ones that have taken the time to educate their physicians,” Duszak says. In addition, Burleson recommends making sure that leaders are heavily involved in the decision-making process and that one person is chosen to spearhead the project. “Start small and look at what the group wants to do,” she says. Casting a new benchmarking program in a positive light by using it as a method of helping radiologists succeed—not as a monitoring device or as a way to punish people—is another way to ensure more willing participation, according to some analysts. It is important, however, for leaders to implement programs without disrupting cohesive groups. “Ultimately, benchmarking is part of the job description, and it contributes to an employee’s performance,” Duszak notes. Physicians need to be told what is expected of them and need to be held accountable for their performance. Duszak shares a graph (Figure 2) representing the results of a minimal-expectation system implemented by one practice; it shows that radiologists at lower performance levels increased their productivity to meet the expectations of the practice. “We need to get away from doing things to patients and start doing things for patients,” Duszak says. “I tell physicians that we need to do this now, or someone else will do it for us.” Erin Burke is a contributing writer for Radiology Business Journal.

Figure 2. Implementation of a system indicating minimal performance expectations (red line) at the end of year 2 was associated with performance improvement in year 3 for six of 11 radiologists at one practice; all 11 showed improvement by year 4, and all met the practice’s performance expectations in years 3 through 5 (figure provided by Richard Duszak, MD, FACR, FSIR). 48 Radiology Business JouRnal | august/september 2010 | www.imagingbiz.com

references 1. Mezrich R, Nagy PG. The academic RVU: a system for measuring productivity. J Am Coll Radiol. 2007;4(7):471-478. 2. Duszak R, Muroff LR. Measuring and managing radiologist productivity, part 1: clinical metrics and benchmarks. J Am Coll Radiol. 2010;7(7):452-458. 3. Duszak R, Muroff LR. Measuring and managing radiologist productivity, part 2: beyond the clinical numbers. J Am Coll Radiol. 2010;7(7):482-489.

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Mandatory accreditation | Three Choices

MIPPA Accreditation Countdown:

ACR, IAC, or Joint Commission? The three accreditation programs sanctioned by CMS as MIPPA compliant are vastly different, with each designed to appeal to a different constituency By George Wiley

n 2008, when Congress passed the Medicare Improvements for Patients and Providers Act (MIPPA), the January 2012 accreditation deadline for providers of advanced imaging seemed distant, but it’s near enough to call for action now. For those advanced diagnostic imaging services (ADIS) providers still unaccredited, the choices available in accrediting bodies have also become clear since the law passed: The ACR®, the Intersocietal Accreditation Commission (IAC), and the Joint Commission are the only accrediting organizations approved by CMS to handle MIPPA accreditations. Under MIPPA, only IDTFs and physician suppliers billing for the technical component of MRI, CT, PET, or nuclearmedicine exams under the Medicare Physician Fee Schedule (MPFS) need to be accredited. Hospitals that bill CMS for advanced imaging are not involved in MIPPA-mandated accreditation, since they are accredited in other ways. The MIPPA accreditation requirements had long been sought by the ACR. Pamela Wilcox, RN, MBA, assistant executive director for quality and safety for the ACR, says, “The ACR was heavily involved in getting the accreditation language into MIPPA. Getting it passed in 2008 took two years. We’d been talking to Congress much longer, but this initiative was a two-year effort.” One goal of ACR lobbying

was to impose uniform quality standards on nonradiologist imaging providers, such as cardiologists and orthopedists. “We believe if Medicare is paying for ADIS, then it ought to be getting highquality images,” Wilcox says. the Mandate Mandatory accreditation by January 1, 2012, is the heart and soul of the MIPPA provision on imaging standards— section 135(a)—regarding outpatient providers. After that date, unaccredited ADIS providers billing Medicare for the technical component of the designated procedures won’t be paid. The law also lays out what all the accrediting bodies agree are basic compliance standards: • the qualifications of nonphysician personnel must be specified and met; • the qualifications and responsibilities of medical directors and supervising physicians must be spelled out and documented; • procedures to ensure the safety of staff and patients must be in place; • procedures to ensure the reliability, clarity, and technical quality of diagnostic images must be in place and must be verified; • there must be methods in place to assist patients in

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obtaining imaging records; and • imaging centers must have a way to notify (and must notify) CMS of any change in imaging modalities that takes place after accreditation. These are the six standards that accrediting bodies must establish as having been met by applicants. For the ACR, the key provision has to do with reliability, clarity, and technical quality of images. The IAC also stresses this requirement, but it relies more heavily on a review of physician-by-physician radiology reports and complex procedural protocols to make sure that standards are met. The Joint Commission takes what it calls a more holistic approach, focusing on facilities’ systemic characteristics and quality-control programs. It lets applicants determine their own methods of achieving image quality, although it does validate them. There are major differences among the three accrediting bodies. Potential applicants should understand these differences in order to select the most suitable path to accreditation. the acr ACR accreditation might be considered the gold standard by

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Mandatory accreditation | Three Choices

The ACR’s program evaluates actual clinical images from actual patients. The IAC does that too, but the IAC does not use phantoms. We think phantoms are critical. You can’t see if the equipment is operating optimally from patient films. —Pamela Wilcox, rn, MBa, assistant executive director for quality and safety, acr

many in the industry because of its rigor in assessing image quality. While the IAC and the Joint Commission might dispute that characterization, it does focus on what the ACR plays as its trump card: the quality of the images required to achieve accreditation. The ACR’s accreditation proceeds scanner by scanner, with each machine required to produce high-quality scans of actual patients, in addition to undergoing performance analysis using third-party phantoms to test each machine. “The ACR’s program evaluates actual clinical images from actual patients. The IAC does that too,” Wilcox says, “but the IAC does not use phantoms. We think phantoms are critical. You can’t see if the equipment is operating optimally from patient films.” That’s because patients vary physically, and radiologists can’t always see machine discrepancies on clinical images. With phantoms, where the objects being scanned are the same, machine discrepancies do show up, Wilcox says. Settings that might lead to overexposure, for instance, would show up with phantoms. The ACR requires that medical physicists check each modality annually; so does the IAC. The ACR, like the other accrediting bodies, is required to verify the qualifications of physicians and of nonphysician medical personnel. According to Wilcox, the ACR uses existing certifying bodies—the American Registry of Radiologic Technologists®, for instance—to determine whether qualifications have been met. “We don’t accredit individuals,” she says. Technologists and physicians at each facility must demonstrate that they meet certification standards.

In something new for the ACR, MIPPA requires the accrediting body or CMS to conduct unannounced site visits, so the ACR is now doing that, Wilcox says. “In each modality, we do a couple dozen unannounced site visits a year,” she says. “That’s the stick hanging over your head.” This is a small number, of course, compared with the figures for the Joint Commission, where unannounced site visits are the heart of the program. According to the ACR, applicants have 45 days after they apply for accreditation to submit images to be reviewed by ACR radiologists. Applicants—using CT as an example—must submit three exams of actual patients, one each from the head/neck, chest and abdomen. A list of appropriate studies is set forth by the ACR, and applicants can choose which of these exams they wish to submit. These studies, along with phantom images from the same scanner, are reviewed by ACR peer reviewers. The ACR advises allowing four to six months for these reviews. If the images are judged to meet standards, if the applicant’s radiology reports meet ACR guidelines, and if the other standards set forth by MIPPA are met, the ACR issues an accreditation. All the accrediting bodies accredit for three years. If an ACR applicant is found to be deficient or has failed, the applicant has 15 days to appeal in writing, resubmitting the original images only. Appeal results are issued in 30 to 45 days. Wilcox notes that earlier campaigns by private insurers to require accreditation have already resulted in most MRI providers being accredited. For CT, she says, maybe half the pool remains to be accredited. “As of July, we had 4,500 facilities that have applied, and 4,000 of

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those have achieved accreditation. I guess the 4,500 is about half those that need to be accredited. There are another 4,500 to go on CT,” she says. Wilcox adds that the ACR has a big lead among the three accrediting bodies in numbers accredited, since it accredits most radiology clinics and outpatient providers that have radiologists doing the imaging. The ACR has a program for accrediting nonradiology providers, but many of those applicants, Wilcox says, turn to the IAC. the iac The IAC is sometimes seen as an upand-coming organization that is moving to challenge the ACR, particularly by creating more user-friendly online accreditation applications. The ACR’s 45-day inflexible deadline for image submission following application is like signing up for boot camp, some might feel. The IAC is more focused on nonradiology imaging providers, it accredits more machines found in physicians’ offices, and it is more representative of medicine at large, rather than of radiology. It also has the reputation, in some circles, of being more progressive in customer service. That IAC accreditation fits well with nonradiologist imaging makes sense, considering the IAC’s history. Sandra Katanick, RN, RVT, CAE, is the IAC’s CEO. Katanick has been with the IAC for nearly 20 years and is its first and only executive director/CEO, she says. The IAC does not lobby or advocate legislation, Katanick says. It is built around 30 sponsoring organizations—medical societies and technical associations— that provide representatives to its board of directors. The sponsors provide no financial support. “We are totally funded through application fees,” Katanick says. “Accreditation is our only business.” Early on, the ACR was an IAC sponsor, Katanick notes, but when the ACR expanded its own accrediting program, it dropped out as a sponsor because it had a conflict of interest. Katanick disagrees with descriptions of the IAC as an accrediting body mainly

for nonradiologist imagers. “We accredit a high percentage of radiology-based clinics,” she says. She agrees, however, that many nonradiologist imaging providers do become accredited through the IAC. “The ACR program is phantom based and image based,” she says. “Our program is very end-results oriented. We look at images, but we consider the final report to be equally important. That’s what is used to treat the patient. We have very stringent reporting requirements, and we make sure all the reports contain the same components.” Standardization is a major theme for the IAC. “Where we started in developing accreditation programs—and why—was the need for standardization, so we try to make sure that every reader in a facility reads in the same way,” Katanick says. The IAC requires its applicants to submit reports from different physicians so that all image interpreters are eventually reviewed. The IAC also requires applicant imaging providers (laboratories) to submit cases for review that demonstrate pathology, in order to show that physicians understand the relevant pathologies, Katanick says. “Four out of the five submitted cases have to have pathology,” she adds. “Our reviewers are accredited physicians and technologists. They rate the images, the reports, and the quality control in the laboratories.” The accreditation that the IAC grants is not only modality specific, but specific to the types of studies for which the machine will be used. The IAC has separate divisions for each modality, and each division accredits in its own diagnostic area, Katanick says. CT, for instance, is handled by the Intersocietal Commission for the Accreditation of Computed Tomography Laboratories. MRI has a similar division, as does nuclear medicine/PET. “The majority of our CT laboratories are in ear/nose/throat practices that do sinus and temporal-bone scans,” Katanick says. “The system they use is different—more like a volume cone-beam scan in dental radiography. The FDA has classified these systems as CT, so they fall under MIPPA.”

The IAC also is more protocol driven than the ACR. Katanick says, “In the protocol section of the standards, the laboratory must complete a written description. A lot of them are the OEM default protocols. We require a physician to be involved in changing manufacturers’ default protocols.” The IAC tracks appropriate utilization for its applicants, based on standards that it has developed for each modality. Katanick says, “We don’t say 70% AHC RBJ AD 7-26_Layout 1 7/27/10 9:45of AM

studies have to be appropriate, but we do require that the laboratories measure it. We say 30 consecutive patients have to be monitored as to whether the use is appropriate, inappropriate, or uncertain.” Katanick says that, as a patient, she would want to see a facility with IAC accreditation because the IAC pays more attention to final reports and quality control than the ACR does, but either choice Page 1 is better than no accreditation, she

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www.imagingbiz.com | august/september 2010 | Radiology Business JouRnal 53

Mandatory accreditation | Three Choices

Our program is very end-results oriented. We look at images, but we consider the final report to be equally important. —Sandra Katanick, rn, rVt, cae, ceo, intersocietal accreditation commission

adds. “I would not have an imaging exam done by someone not accredited by the IAC or the ACR,” she says. the Joint commission The Joint Commission, best known for its accreditation of hospitals and health systems, is a latecomer to the MIPPA accreditation of imaging providers. The Joint Commission’s programs focus primarily on outpatient imaging venues that have some connection to the hospital industry: That is the Joint Commission’s home turf. Michael Kulczycki, MBA, CAE, executive director of the Joint Commission’s Ambulatory Accreditation Program, reports that one are of focus “is hospital joint-venture imaging centers that bill under the MPFS. We also get strong interest from freestanding imaging centers, especially those with a corporate entity involved, and from multiservice ambulatory providers—the large multispecialty group practices. We accredit a number of them. Those are the three we think of as natural fits. We would accredit single physicians if they came to us, but the likelihood of that is lower on the scale,” he says. The Joint Commission accredits for MIPPA under its ambulatory-care division. “We have more than 1,840 customers we accredit in ambulatory care, and more than 100 of those are imaging customers,” Kulczycki says, adding that 40 of those are teleradiology providers. Teleradiology companies often build their customer base around hospitals. The Joint Commission differs from the ACR and IAC in that it always sends out an accrediting team to the applicant’s site. For the initial site visit, the applicant is given a readiness window, Kulczycki says, but all subsequent visits are unannounced. The Joint Commission has

developed an elaborate set of elements of performance with which sites must comply. “Of the 1,100 broad ambulatory elements of performance, 20% are related to CMS standards for imaging,” Kulczycki says. Only three elements of performance were added for MIPPA accreditation, he adds, all in the area of the environment of care. In addition to reviewing performance, the Joint Commission’s accreditation for MIPPA involves the use of patient-

tracer techniques resembling those that the commission uses in its ambulatory accreditations, Kulczycki says. The patient is traced through the cycle of care, and all points of care are examined for quality, safety, and treatment. “We also have system tracers,” Kulczycki says, “so at the typical imaging center, the site surveyors might spend two or three days looking at how the site collects data, its performance improvement, and its infection prevention as well.” The commission also looks at staff competence, training, credentialing, and privileging, Kulczycki adds. All of the Joint Commission’s survey teams would include at least one physician. “We have also hired ADIS specialists, radiologists, and medical physicists or radiologic technologists who get assigned

do it now: it’s Later than you think All three of the accrediting bodies— the ACR®, the Intersocietal Accreditation Commission (IAC), and the Joint Commission—are adopting July 1, 2011, as the absolute deadline outpatient imaging providers should pencil in for beginning the MIPPA accreditation process. That deadline, however, might not be realistic. Six months is how long it takes to gain accreditation through some accreditation providers, even if everything proceeds optimally. Often, that is not the case. The failure and deficiency rates are higher than might be expected. The Joint Commission’s Michael Kulczycki, MBA, CAE, executive director of the Ambulatory Accreditation Program, says that its pass rate is high, at more than 95%, but Joint Commission applicants can self-correct as they go through site review. The same high pass rates do not hold for the IAC and the ACR. The IAC’s CEO, Sandra Katanick, RN, RVT, CAE, says that only a minority of applications succeed without a second effort. “Less than 50% succeed outright,” she says. “Almost all have deficiencies—poor reports, poor documentation, or insufficient protocols. We are very clear when we tell them that they don’t meet the requirements, and a majority correct their deficiencies within

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two or three months.” Krista Bush, the ACR’s director of diagnostic modality accreditation, says, “The average deficiency rate, the first time through for sites, is approximately 20% for CT, MRI, nuclear medicine, and PET. When a site gets a deficiency the first time through, it is able to repeat only the exam that received the deficiency. If, upon repeating, it gets a second deficiency, then that is considered a failure. After a site receives the second deficiency, then it has to submit everything again to the ACR. The majority of sites pass when they repeat.” Pamela Wilcox RN, MBA, assistant executive director for quality and safety for the ACR, says, “The rates vary by modality. If a site doesn’t pass on the first attempt, we consider it a deficiency. The deficiency rates are 23% for MRI, 36% for CT, 20% for nuclear medicine, and 11% for PET. Sites then have the opportunity to correct the deficiencies and reapply.” Beyond deficiencies and failures, other pitfalls loom. For example, there is a shortage of medical physicists, and physicists are necessary to the accreditation process. The take-home message: Don’t wait until 2011. Get accreditation under way at the earliest opportunity. —G. Wiley

Mandatory accreditation | Three Choices

We pursued the designation as an accreditation body to preserve service for our existing customers. We wanted to design our accreditation process so that it was better suited for multisite, multimodality facilities. That’s our sweet spot. —Michael Kulczycki, MBa, cae, executive director, ambulatory accreditation Program, Joint commission

to the team, in addition to the physician surveyor,” he says. If the applicant site is small, the physician surveyor might be on site for two days and the ADIS specialist, for one day, he adds. For larger imaging centers with multiple modalities at each site, the survey team might include more than one physician, along with specialists who would document at least one example of each modality, Kulczycki says. “The patient images will not be evaluated,” he says. “Our process is not a peer-review process. We want to know the machine-evaluation process that the facility has in place. We look at quality control. It’s the role of the ADIS specialist to assess whether the program of the provider is an effective one.” Kulczycki notes that the Joint Commission’s accreditation regimen doesn’t end with completion of the initial survey. Each year, accredited sites are required to conduct periodic performance reviews. These are done electronically and might also involve phone contact. Kulczycki says, “They must do the periodic performance reviews. None of the others have this.” Kulczycki says the need for MIPPA accreditations nationally probably affects 5,000 to 6,000 facilities, but he adds that the Joint Commission has not set a target for those that it might accredit. “We pursued the designation as an accreditation body to preserve service for our existing customers,” he says. “We wanted to design our accreditation process so that it was better suited for multisite, multimodality facilities. That’s our sweet spot.” accreditation costs Now that accreditation is mandatory under MIPPA, providers must build the fees for it into their budgets. Those fees aren’t small.

Roughly speaking, accreditation programs from the ACR and the IAC are comparable in cost (at $2,400 per modality accredited), with discounts for accrediting more than one machine at a site. These fees cover the three-year term of the accreditation. The Joint Commission uses a more complicated formula. According to Kulczycki, for facilities with up to 5,000 annual patient visits, the fee is $8,510; for up to 50,000 visits, the fee is $9,550; and for up to 120,000 visits, it is $12,640. At levels of more than 120,000 visits per year, contract pricing is used. Branch site fees are also imposed. According to the Joint Commission, for facilities with one to four branch sites, the fee for the on-site survey is $1,180. For five to eight branches, it is $2,335, and for nine to 12 branches, it is $3,510. Kulczycki notes that these fees are payable over the three-year span of the accreditation, with 60% paid the first year and 20% paid during each of the two following years. “If you’re a single center with a single modality, the others are more cost effective. For multimodality facilities, we’re at parity; for multisite, multimodality providers, our cost structure is less,” Kulczycki says. Even though facilities that don’t bill CMS under the MPFS don’t need MIPPAmandated accreditation, competitive pressures will probably force them to obtain it, some industry analysts predict. The MIPPA accreditation mandate for imaging centers might, therefore, impose quality standards on imaging providers more broadly than the law strictly requires. Higher quality, more broadly enacted, is unlikely to be a bad thing. George Wiley is a contributing writer for Radiology Business Journal.

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FinalREAD

What Imaging Leaders

Should Know About Teamwork In preparing for the battle for survival, radiology practices have no better example than the 82nd Airborne By Curtis Kauffman-Pickelle

he following is not a trick question: What does the US Army’s legendary 82nd Airborne Division have in common with today’s medicalimaging profession? On the surface, probably not a lot; beneath the surface, however, I’ve seen quite a bit that our profession can learn from the focus, precision, and ethos of one of the finest US organizations. This is especially true when one considers that in order to accomplish its national-security mission, this group requires supremely refined teamwork for even the most minute of its tasks. First, the backstory: I am fortunate enough to belong to an organization of like-minded executives who share the honor of visiting selected US Department of Defense facilities, inside and outside the country, for the purpose of understanding their respective missions, as they apply to today’s national-security interests. It’s pretty amazing, and it’s eye-opening on many levels. On a recent trip, we visited Fort Bragg, North Carolina, and spent some up-close-and-personal time with the 82nd Airborne, even flying in a C-130 with paratroopers to witness, at first hand, how they do what they do. What help can the 82nd Airborne provide medical-imaging executives engaged in a real battle for survival? It is no secret that forces have emerged that have challenged the resourcefulness and capabilities of many practitioners, whether they are operating in hospital settings, private practices, or outpatient centers. The profession is, quite literally, under siege. What, then, can we learn from how the 82nd Airborne does its job? In a word, teamwork: Everyone in the 82nd Airborne knows his or her role and how this role relates to the overall vision

and mission of the organization. Each individual is perfectly aligned with these goals, and each understands and shares the core values that drive the team toward perfection. It’s amazing that even the tasks that seem the simplest are checked and rechecked, and they are supported by an array of specialists whose skills combine to form a unit that is formidable in the face of adversity. Each team member knows how he or she fits within the mission, and each understands the contribution that he or she makes to the overall success of the

need to embrace lessons from professions familiar with the leadership and teamwork models that build excellence—and, in turn, success. The US corporate environment, developing since the industrial revolution, has reached a point where many of these lessons can be found, and in my opinion, today’s modern US military is a shining example of such excellence. How can you apply some of these lessons and prepare your practice, hospital, or center for the future? First, reach out and find those shining examples from industry and the military

Each team member knows how he or she fits within the mission, and each understands the contribution that he or she makes to the overall success of the task. task. The team members know that they rely on one another’s professionalism and focus—they are truly interdependent. Unfortunately, in many practices and hospitals that I’ve seen, such teamwork does not exist. In fact, the narcissismbreeding culture of the individual is a historical ethos within specialized medicine that works against the very notions of alliance, partnership, and teamwork. That is not to say that good teams do not exist in health care; there are certainly rolemodel organizations that set examples, but I believe that we have quite a long way to go before teamwork is a universally accepted and applied idea. This is especially true when one considers how specialists compete for patient interventions based on which body part or disease state is involved and which of many diagnostic/therapeutic options is most convincing (if not necessarily most efficacious). Nonetheless, it is crystal clear that in order to succeed in tomorrow’s medicalimaging profession, organizations will

58 Radiology Business JouRnal | august/september 2010 | www.imagingbiz.com

that you can apply to your enterprise. Second, align the stakeholders around this shared sense of purpose. Third, clearly articulate your vision so that everyone will understand how he or she can contribute to its realization. Fourth, bring clarity to the competitive posture and value proposition that you take to your customers. Fifth, hold everyone accountable (including yourself, as the leader) for the focused accomplishment of the goals and objectives that will ensure the success of your organization. Sixth, compete to win. Don’t expect anything to be handed to you on a platter, and build a team that will want to follow you—even to the point of being willing to parachute into harm’s way to fight the battle with you. Huah. Curtis Kauffman-Pickelle is publisher of imagingBiz and Radiology Business Journal, and is a 25-year veteran of the medicalimaging industry. He facilitates strategicplanning retreats for radiology groups.

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GE Healthcare

More than just service. A complete solution. Introducing AssurePointâ&#x201E;˘ Services from GE Healthcare. Thousands of clinical assets. Tens of thousands of patients. With numbers like that, you need simple maintenance solutions that deliver solid numbers of their own. Like one of the largest parts networks, 24/7 remote service availability, and a new portfolio of flexible service offerings. AssurePoint Services let you create a maintenance solution designed around your needs and budget, so you gain the confidence of assured system reliability, 365 days per year. To learn more about AssurePoint Services, visit www.gehealthcare.com/AssurePoint.

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