Download ACR Bulletin January 2011 - American College of Radiology

JANUARY 2011
VOL. 66 ISSUE 1
ADVOCACY • ECONOMICS • EDUCATION • CLINICAL RESEARCH • QUALITY & SAFETY
URGENT
MATTERS
RADIOLOGY IN THE ER
in this issue
8
WWW.ACR.ORG
R esearch Results From
ACRIN®
11 Should You Communicate
Directly With Patients?
26 Financial Report
itation.
d
e
r
c
c
a
R
C
mitment
“I trust A
m
o
c
e
m
a
s
the
We share
d safety.”
n
a
y
t
i
l
a
to qu
diologist
ertified ra
, board-c
— Vaden
MD
Padgett,
The ACR advantage
• Image quality
review by radiologists
• Accredit your facility in 90 days or
less after image submission
• Multi-site pricing
• Easy online application;
flexible time frames
Your colleagues at ACR are the imaging experts – and
the only CMS-approved partner you’ll need to meet the 2012
accreditation deadline.
That’s peace of mind for you and your practice.
Apply for ACR accreditation today at acr.org or 1.800.770.0145.
• Dedicated team of experienced
technologists on call
Choose
Standard. Choose
ChooseACR.
ACR.
Choose the Gold Standard.
7639 1.11
ACR Board of Chancellors
John A. Patti, M.D., FACR (Chairman)
Bulletin
Paul H. Ellenbogen, M.D., FACR (Vice Chair)
James H. Thrall, M.D., FACR (President)
Contents Bulletin
JANUARY 2011 • VOL. 66 • ISSUE 1
Lawrence P. Davis, M.D., FACR
(Vice President)
Alan D. Kaye, M.D., FACR (Speaker)
Howard B. Fleishon, M.D., FACR
(Vice Speaker)
Executive Editor
Anne C. Roberts,
M.D., FACR
Lynn King,
M.P.S.
(Secretary-Treasurer)
features
Managing Editor, Editorial
Bibb Allen Jr., M.D., FACR
Cary Boshamer
Albert L. Blumberg, M.D., FACR (ASTRO)
Managing Editor, Production
James A. Brink,
M.D.,Colgan
FACR
Betsy
Manuel L. Brown, M.D., FACR
Senior Writer
Cheri L. Canon,
M.D. Keefer
Raina
Gerald D.D
Dodd
FACR
esignIII,
&M.D.,
Production
THE RIGHT TO SPEAK?
Radiologists are divided when it comes to
communicating directly with patients.
Find out the implications — whether
you give imaging results directly to
patients or not.
By Leah Lakins
www.touch3.com
Burton P. Drayer,
M.D., FACR (RSNA)
Cassandra S. Foens,
M.D.,
Contact
UFACR
s
a member
JamesTo
D.contact
Fraser, M.D.,
FACR of the
ACR Bulletin staff, e-mail
(CAR Observer)
TRAUMA
14 TACKLING
Emergency department
Donald P. Frush, M.D., FACR
radiologists are under pressure to provide
quick, accurate reads while practicing
triage and prioritizing the patient. How
do they keep up?
By Alyssa Martino
[email protected].
James H. Hevezi, Ph.D., FACR
Bruce J. Hillman, M.D., FACR (JACR)
Richard T. Hoppe, M.D., FACR (ARS)
David C. Kushner, M.D., FACR
Paul A. Larson, M.D., FACR
Carol H. Lee, M.D., FACR
Deborah Levine, M.D., FACR
Jonathan S. Lewin, M.D., FACR (ARRS)
Lawrence A. Liebscher, M.D., FACR
Carolyn C. Meltzer, M.D., FACR
AND CLEAR
17 LOUD
Speech-recognition software
has come a long way. But will this tool
revolutionize radiology reporting?
By James Brice
11
>>also inside
8
CLINICAL RESEARCH:
INNOVATION IN IMAGING
20 23
26
RESEARCH AND TOOLS
TESTING: THE ART OF THE
QUESTION
SCHOLARLY PUBLISHING:
TAPPING INTO RICH RESOURCES
FINANCIAL REPORT: ON SOLID
GROUND
Cynthia S. Sherry, M.D., FACR
Geoffrey G. Smith, M.D., FACR
departments
2
Executive Editor
Lynn King, M.P.S.
Senior Managing Editor
Betsy Colgan
Copywriter
Plug into the ACR. Be sure to visit us on:
Alyssa Martino
3
10
Leah Lakins, M.P.S.
www.touch3.com
Contact Us
To contact a member of the
ACR Bulletin staff, e-mail
[email protected].
RECAPTURING THE CENTER
DISPATCHES
NEWS FROM THE COUNCIL:
PRESERVING TRADITION,
Contributing Writer
Design & Production
FROM THE CHAIR:
Check out our new digital issue at:
www.nxtbook.com/nxtbooks/acr/
acrbulletin_201101/
24
25
EXPANDING OPPORTUNITY
RADLAW: PROTECTING YOUR
PEER-REVIEW RIGHTS
ECONOMIC CHAIRMAN’S REPORT:
THE CONGRESSIONAL FORECAST
www.acr.org
27
28
FOR RADIOLOGY
TRANSITIONS
FINAL READ
>> FROM THE CHAIR
By John A. Patti, M.D., FACR
Chair, Board of Chancellors
Recapturing
the Center
O
ver the past
115 years,
radiologists have
been blessed by the
technological advances
of our specialty. In each
new era of health-care delivery, some new
technology has captured the hearts and
minds of physicians and patients. Our
reliance on that technical propagation has,
in part, contributed to a sense that radiology and radiologists are in such a central
position because that is the natural order of
health-care evolution. In today’s world, no
one would argue that excellent health care
could be delivered without imaging.
However, storm clouds that were on
the horizon are now directly overhead.
Health-care expenditures have reached an
unsustainable percentage of the national
gross domestic product; new payment
systems are being implemented; the
National Cancer Institute is proposing a
consolidation of collaborative research
programs; and proof of competence,
proof of outcomes, and value-oriented
medicine are being demanded across the
board by society.
Despite this seemingly unfavorable
climate, there is little debate that imaging
will maintain a central and indispensable
role in future health-care delivery. Scientific progress will not abate, and future
generations will experience personalized
medicine, genomic molecular imaging,
and personal biomarkers to predict risk
of disease and response to treatment. The
future of radiology will be secured by
scientific and technological progress. The
future of radiologists, however, will not be
2|
Bulletin | January 2011
secure unless true added value is generated and proven.
Lest radiologists become marginalized,
we must think in new terms about our
place in health-care delivery systems. I
would advocate we create the concept of
“radiology-centric medicine” as a means
of recapturing and securing the center of
the enterprise. A necessary component of
radiology-centric medicine is “radiologistcentric medicine.”
The future of
radiology will be
secured by
scientific and
technological progress.
The future of
radiologists, however,
will not be secure
unless true added
value is generated
and proven.
If we continue to perpetuate behavior
and practice patterns through which we
are perceived as ancillary, we will never
achieve our goal. Leaders in radiology
have told us for decades that we need to
emerge from our darkened reading rooms.
That advice has never been more important than it is now.
With a grass-roots commitment to recapture the center, our collective, creative
storehouse will be able to produce a broad
array of concepts that can be applied to
the development of radiologist-centric
medicine. The spectrum of these concepts
should include practical applications of
a renewed commitment to service, good
citizenship, professionalism, introspection,
and innovation. Longstanding models of
practice business and staffing will need to
be re-evaluated and revised to accommodate the process of recapturing the center.
In this issue of the ACR Bulletin, three
such concepts are described. For decades, the traditional radiology reporting
system involved a radiologist dictating
a report, a report being transcribed,
the radiologist checking the report for
errors, and finally, a printed copy of the
report being sent to the medical record
and the referring physician. This process
was progressively streamlined to the
point where it became an extremely
efficient component of the radiologist’s
workflow. However, depending on
clerical resources, report distribution
could be unduly delayed. The article on
page 17, “Loud and Clear,” discusses the
advantages and challenges of voicerecognition reporting systems — a tool
that clearly can facilitate the enhancement of radiologist-centric medicine
by proclaiming that the interests of
the patient, through immediate report
availability, are of primary concern to the
radiologists central to their care.
The article on page 11, “Right to
Speak?” reinforces the radiologist-centric
concept by exploring the process of
radiologists delivering imaging results
directly to patients. This would have been
unacceptable to referring physicians
40 years ago, but their appreciation of
radiologists’ ability to interact directly
with patients has evolved through the
efforts of mammographers and interventional radiologists. Direct reporting to
patients is another opportunity to create
radiologist-centric medicine.
Imaging is also central and critical
to the diagnosis and management of
trauma. The article on page 14, “Tackling
Trauma,” discusses the need to effectively
manage trauma through streamlined
care. Here is another area in which the
personal involvement of radiologists can
solidify our role in radiologist-centric
medicine. Stepping up in our role as true
consultants and not mere followers of
orders will enhance our stature in the
minds of our medical colleagues and
our patients.
The opportunities to create a brighter
future for radiologists are there. It’s up to
each of us to use them. //
dispatches
NEWS BRIEFS FROM THE ACR
AND AROUND THE STATES.
IT’S NOT TOO LATE TO MEET CMS MANDATES
The deadline for MIPPA/CMS accreditation is approaching. Beginning Jan. 1, 2012, the CMS
will not reimburse facilities without full accreditation in CT, MRI, breast MRI, PET, and
nuclear medicine that bill the technical component under Medicare, Part B.
Additionally, the CMS will not recognize “under review” status.
As an ACR member, please help spread the word that your College is the
right choice for accreditation. Advantages of ACR accreditation include:
• No pre-accreditation on-site survey
• Multisite pricing
• Easy online application
• Flexible time frames
• Accreditation generally within 90 days of image submission
Apply now by calling 800-770-0145 or visiting www.acr.org. For ACR
breast-imaging accreditation, call the hotline at 800-227-6440.
PREPARE NOW FOR CHAPTER RECOGNITION AWARDS
The 2011 award cycle of the ACR
Chapter Recognition Program has
begun. Chapters can submit information on activities until Jan. 15, 2012,
for awards to be presented during
the 2012 AMCLC.
The recognition program began
in 2003 with two goals: to formally
recognize chapter successes and
to facilitate sharing ideas among
chapters. Since the program’s inception, more than
half of the ACR chapters have been recognized for
their efforts. Honors are provided in these categories:
communications, government relations, meetings and
education, and membership. In addition, a chapter
may receive an Overall Excellence Award for demonstrating exemplary activity in all categories.
Within each award category are
specific forms and types of information that chapters may submit to
participate. Most of these submissions
can be made online, and winning
chapters will be notified this spring.
Awards for the 2010 award
cycle will be presented during 2011
AMCLC, held May 14–18, at the
Washington Hilton in Washington,
D.C. Check for more information on the upcoming
meeting as it becomes available at http://bit.ly/aovlj5.
For award criteria and to view samples of submissions
from previous years, visit www.acr.org/chapterawards.
To learn more about the program, please contact
the Office of Chapter and Volunteer Development at
[email protected] or 800-227-5463, ext. 4496.
ACR Bulletin (ISSN 0098-6070) is published monthly, with combined issues for
July/August and November/December, by the American College of Radiology,
1891 Preston White Drive, Reston, VA 20191-4326.
Opinions expressed in the ACR Bulletin are those of the author(s); they do
not necessarily reflect the viewpoint or position of the editors, reviewers, or
publisher. No information contained in this issue should be construed as medical or legal advice or as an endorsement of a particular product or service.
From annual membership dues of $795, $12 is allocated to the ACR Bulletin
annual subscription price. The subscription price for nonmembers is $90. Application for periodical mailing privileges is pending at Reston, Va., and additional
mailing offices. POSTMASTER: Send address changes to ACR Bulletin, 1891
Preston White Drive, Reston, VA 20191-4326 or e-mail to [email protected].
Copyright ©2011 by the American College of Radiology. Printed in the U.S.A.
The ACR logo is a registered service mark of the American College of Radiology.
For information on how to join the College, visit www.acr.org, or contact staff
in membership services at [email protected] or 800-347-7748.
For comments, information on advertising, or to order reprints of the ACR
Bulletin, contact [email protected].
ACR Bulletin is published 10 times a year to keep radiologists informed on
current research, advocacy efforts, the latest technology,Advocacy
relevant education
• Economics • Education • Clinical Research • Quality & Safety
courses and programs, and ACR products and services.
| 3
dispatches
ANNOUNCING THE 2011 GOLD MEDALISTS AND HONORARY FELLOWS
At the September meeting of the Board of Chancellors (BOC),
board members cast their votes for the 2011 ACR Gold Medalists and
Honorary Fellows. Gold medals are awarded to individual members
for their distinguished service to the College and the field of radiology
through teaching, basic research, clinical investigation, or radiologic
statesmanship. Honorary fellows are elected by the BOC in recognition
of their contributions to radiology. Only individuals who are not eligible
for admission as members of the ACR can receive this honor.
The gold medalists and honorary fellows listed below will receive their
awards at the 2011 AMCLC in Washington, D.C. Look for more information
about each recipient’s service and commitment to the specialty in next
month’s edition of the ACR Bulletin.
Gold Medalists:
• Lawrence W. Bassett, M.D., FACR, Iris Cantor
professor of breast imaging, David Geffen School of
Medicine at UCLA in Los Angeles
• Leonard Berlin, M.D., FACR, professor of radiology
at Rush University in Chicago and vice chair of
radiology at Skokie Hospital in Skokie, Ill.
• Arl Van Moore Jr., M.D., FACR, president of Charlotte Radiology in Charlotte, N.C.
FRANCE TESTS NATIONWIDE
PACS INITIATIVE
According to a Sept.
2010 AuntMinnie.com
article, France may be the
next European nation to
pursue a large-scale initiative to increase the use
of PACS. Currently, the
country conducts more
than 61 million radiology
exams each year, yet only
20 percent of academic
institutions have PACS to
read these images. The
proposal would create a
national imaging archive,
save money, and streamline storage. Estimated
savings would total 70 million Euros per year.
France implemented a pilot program last May in
24 hospitals near Paris. The program will last five
years and test the “PACS software-as-service-model
on a large-scale basis, handling 1.3 million images
per year,” the article explains. Though the initiative
would not require all radiology facilities to join,
public funding would only be provided to those
practices that take part. To read the full article, visit
http://bit.ly/ccC5dG.
4|
Bulletin | January 2011
Isaac Sanders, M.D., FACR (right), accepts his
2010 ACR Gold Medal at AMCLC.
Honorary Fellows:
• Andreas Adam, M.B., B.S., professor of interventional radiology at St Thomas’ Hospital in London,
England
• Byung Ihn Choi, M.D., from Seoul National University in Seoul, Korea
• Lawrence Shu-Wing Lau, M.D., chair of the
International Radiology Quality Network from
Victoria, Australia
RENEW YOUR MEMBERSHIP ONLINE
ACR membership provides important benefits,
including subscriptions to the JACR and the ACR
Bulletin, discounts on educational products, and
invaluable online resources to help enhance your
practice. Don’t forget to renew your membership
for 2011, which is a snap with the online renewal
system. To complete your renewal, follow these
simple steps:
1.Go to www.acr.org.
2.Click on “My Profile” (located on the top blue
bar).
3.Log in using your username and password. Your
2011 dues order information will appear (for
reinstatement or payment of past dues, please
contact the ACR membership department using
the information below).
4.Follow the prompts to complete your renewal
and submit payment.
For login assistance or dues questions, contact
the ACR Membership Department at 800-347-7748
or [email protected]. Online renewal for 2011
closes July 1, 2011. For more information about
making the most of your ACR member benefits,
visit http://bit.ly/cvN4L1.
IMPROVE YOUR
BREAST-IMAGING SKILLS
If you’d like to hone your
breast-imaging skills, the ACR’s
Mammography Case Review Series
provides five CD-ROMs that can
help. You’ll receive immediate
feedback, rationales, and scoring,
as well as up to 43 AMA PRA
Category 1 Credits™ and 6 SAM
credits. You can order each CD
individually or the full set of five.
Each CD is independent from
the others and can be completed
in any sequence. The full set is
available to members for $475
($950 for nonmembers). For more
information, visit www.acr.org/mcr.
If you’re looking for other
opportunities to advance your
breast-imaging skills, consider the
ACR BI-RADS® Atlas — a comprehensive guide to standardized
breast-imaging terminology,
report organization, and assessment structure. The classification
system features mammography,
ultrasound, and breast MR, as
well as sample reports, illustrated
cases, statistical definitions, and
explanations for mammography
audits. The atlas is available
for $175 for members ($300 for
nonmembers). To order, visit
http://bit.ly/djciN9.
And don’t forget to check out
upcoming ACR Education Center
courses on breast imaging. Sign up
for Breast Imaging Boot Camp on
April 28–30, 2011, and Breast MR
With Guided Biopsy on May 9–10,
2011. Visit http://bit.ly/aGwqou for
course information or to register.
JACR AWARDS BEST ARTICLES OF 2010
The JACR’s Editorial Board annually recognizes four articles, one
in each of the journal’s areas of interest, for their lucidity of presentation and importance to the specialty. The winning articles for 2010,
selected by committees of the board members, are featured below:
Clinical Practice
• “Radiation Exposure From Medical Imaging in Patients With
Chronic and Recurrent Conditions,” by Evan G. Stein, M.D.,
Ph.D.; Linda B. Haramati, M.D., M.S., FACR; Eran Bellin, M.D.;
Lori Ashton, B.A.; Gus Mitsopoulos, M.D.; Alan Schoenfeld, M.S.;
and E. Stephen Amis Jr., M.D., FACR, published in May 2010,
available at http://bit.ly/9Z3lHz
Practice Management
• “Trend in the Utilization of CT for Adolescents
Admitted to an Adult Level I Trauma Center,”
by Bahman Roudsari, M.D., Ph.D.; Daniel S.
Moore, M.D.; and Jeffrey G. Jarvik, M.D.,
M.P.H., published in Oct. 2010, available at
http://bit.ly/d8QJ5x
Health Services Research and Policy
• “Analysis of Appropriateness of Outpatient
CT and MRI Referred From Primary Care
Clinics at an Academic Medical Center:
How Critical Is the Need for Improved
Decision Support?” by Bruce E. Lehnert,
M.D., and Robert L. Bree, M.D.,
M.H.S.A., FACR, published in March
2010, available at http://bit.ly/dg1FoW
Education
• “Resident Duty Hour Limits: Recommendations by the
IOM and the Response From the Radiology Community,” by
Martha B. Mainiero, M.D.; Lawrence P. Davis, M.D., FACR; and
Jocelyn D. Chertoff, M.D., M.S., FACR, published in Jan. 2010,
available at http://bit.ly/amN8FF
RADIOLOGYINFO.ORG RECEIVES 2010 WEBAWARD
The jointly run RSNA-ACR website, RadiologyInfo.org, received
a 2010 Web Marketing Association “WebAward” for Outstanding
Achievement in Web Development. Since 1997, these awards have set
the standard for excellence in site development. Judged by experts
from around the world, 96 industries are reviewed. RadiologyInfo.org
received recognition in the category, “Medical Standard of Excellence.”
The website is a resource hub about imaging for patients. Debuting a
new look for its 10-year anniversary in 2010, the site has been refreshed
and reorganized for viewers’ benefit. It also includes understandable
descriptions of complex radiology procedures, as well as information
about how to prepare for and what to expect from these tests.
RadiologyInfo.org averages 550,000 visits per month.
Advocacy • Economics • Education • Clinical Research • Quality & Safety | 5
dispatches
MEMBER RESPONDS TO NORWEGIAN MAMMOGRAPHY STUDY
In response to the New England Journal of Medicine article, “Effect of Screening Mammography on
Breast-Cancer Mortality in Norway,” published in the
September 2010 edition,1 Daniel B. Kopans, M.D.,
FACR, chair of breast imaging at Massachusetts
General Hospital and professor of radiology at
Harvard Medical School, writes, “It is time to accept
that screening, beginning at the age of 40, is saving
tens of thousands of lives.” The Norwegian study
asserts that mammography, along with comprehensive
treatment, only reduced the mortality rate in women
by 10 percent. The
article further reports
that mammograms
alone were shown to
reduce the rate by
as low as 2 percent,
whereas older studies cited reduced
mortality rates of up
to 25 percent.
In Kopans’ reply,
which was featured
//Calendar/
January
24 American Institute for Radiologic Pathology
(course begins), Silver Spring, Md.
on ACR’s website, he explains
that the number of noncompliant patients reduces the impact
of screening. Furthermore, he
indicates that the authors’ short
Daniel B. Kopans,
follow-up period likely swayed
M.D., FACR,
their results as well. Kopans
encourages annual
also writes, “The Norway
mammograms for
results are based on screening
women over 40.
women ages 50–69 every two
years. In the United States,
women are encouraged to be
screened every year.”
He continues, “Clearly more lives will be saved
by giving breast cancer less time to grow between
screens. Even the United States Preventive Services
Task Force agrees that screening every two years
results in deaths that could have been averted by
screening every year.”
ENDNOTE
1. Kalager M., et. al. “Effect of Screening Mammography on BreastCancer Mortality in Norway.” N Engl J Med 2010; 363:1203–1210.
Available at: http://bit.ly/93SeHj.
March
6–11 Radiology Resident Review,
San Francisco
28–30 Society for Pediatric Radiology: Advances 7 American Institute for Radiologic Pathology
in Fetal and Neonatal Imaging, Orlando, Fla.
(course begins), Silver Spring, Md.
29–30 Society of Breast Imaging: Practical
18–20 ACR-SPR Pediatric Cardiac MR,
Breast MRI, Miami
30–Feb. 4 Leadership Strategies for
Radiology: Taking Your Practice to the Next
Level, Vail, Colo.
February
4–6 North Carolina Radiological Society:
Vascular Ultrasound Weekend Review Course,
Charlotte, N.C.
7–8 Breast MR With Guided Biopsy, Reston, Va.
7–10 Emergency Radiology, Palm Beach, Fla.
6 |
Bulletin | January 2011
Reston, Va.
April
5–6 SPR’s ALARA — Advances in CT, Dallas
6–9 Society of Thoracic Radiology 2011 Annual
Meeting, Bonita Springs, Fla.
9 Texas Radiological Society Meeting,
Austin, Texas
// //
CLINICAL
EYEBROW
RESEARCH
Innovation in Imaging Research and Tools
ACRIN® PRESENTS RESEARCH RESULTS AND UNVEILS IMAGE-MARKUP TOOL
AT RSNA ANNUAL CONFERENCE.
By
By Nancy Fredericks
Lesion 1
Area: 6.052 cm2
Mean: 76.291 SDev: 33.108 Total: 97576
Min: -50.000 Max: 171.000
Length: 9.680 cm
In secondary analyses from this trial,
findings from the study’s participants
were identified and prospectively
recorded using standard BI-RADS® terminology. These statistics also included
an additional descriptor for multiple
bilateral masses to note similar benignappearing findings in both breasts.
Trial researchers also compared similar
masses detected with mammography and
whole-breast ultrasound with isolated,
unilateral lesions. Among the 2,662 at-risk
participants who underwent three rounds
of screening with mammography and
whole-breast ultrasound, no malignancies
were identified among multiple bilateral,
benign-appearing masses by either screening method. When using mammography
alone, rates of malignancy were higher for
isolated circumscribed or obscured masses
Courtesy ACR Clinical Research Center Imaging Core Laboratory
N
ew and emerging clinical research findings from ACRIN®
were well represented among
the 2,600 scientific paper
and poster presentations at RSNA’s 96th
Scientific Assembly and Annual meeting.
The conference also gave members of the
ACRIN Biomedical Imaging Informatics
Committee the opportunity to showcase
their newest initiative — a novel annotated
image-markup tool.
ACRIN investigators delivered two
presentations that featured data analysis
from the ACRIN trial, “Screening Breast
Ultrasound in High-Risk Women.”
Wendie A. Berg, M.D., Ph.D., led this
multicenter study that focused on
determining the role of using breast
ultrasound to screen for cancer and the
associated risk of an unnecessary biopsy.
In this image depicting the graphical interface of the image Physician Annotation Device
(iPAD),* the reader has circumscribed a lesion in an image of the liver (left) and is using the
reporting template to completely describe the visual features of that lesion (right). Each
imaging observation, including the lesion name, is automatically prompted by the iPAD tool.
8 |
Bulletin | January 2011
than for similar multiple bilateral masses.
When analyzing mammographic findings and determining management, trial
researchers discovered that morphology
and distribution of calcifications should
also be considered, as well as whether the
finding is multiple, bilateral, or similar.
When using ultrasound for screening, the
descriptive categories between round and
oval masses allowed for further refinement in the classification of benign and
benign-appearing masses.
Data from ACRIN’s “Digital Mammographic Imaging Screening Trial”
(DMIST) were used in a secondary
analysis led by Kathryn P. Lowry, B.S.
In the analysis, a Markov Monte Carlo
model was used to evaluate the comparative effectiveness of annual breast-cancer
screening in women with BRCA-1 gene
mutations when using mammography
alone, digital mammography (DM)
alone, or a combination of the two with
MRI. Additionally, clinical surveillance
without imaging was compared with six
screening-strategy variations that started
at four different ages (25, 30, 35, and 40)
with the goal of projecting outcome for
life expectancy. When mammographyinduced risk of breast cancer was
taken into account, the optimal strategy
involved MRI beginning at age 25 and
alternating DM/MRI at six-month
intervals beginning at age 30.
Data from the “National Lung Screening Trial” were also presented at the
annual conference by Randell L. Kruger,
Ph.D., which focused on the effectiveness
of radiation dose associated with chest Xray examinations. Retrospective data from
67,641 chest X-ray examinations were
included in the assessment. Acquisition
parameters at the 33 screening sites and
participant-specific characteristics were
considered in calculating the effective dose
for each chest X-ray examination. The
median participant effective dose (0.0344
NLST DATA SUPPORT LOW-DOSE CT USE
FOR LUNG-CANCER SCREENING
Lung cancer is the leading cause
of cancer-related deaths in the
United States. With more than 94
million current and former smokers
in the United States, lung cancer is
expected to claim 157,300 American
lives in 2010. The National Cancer
Institute (NCI) recently announced
that initial results of the “National
Lung Screening Trial (NLST)” — the
largest randomized study of
lung-cancer screening in high-risk
In this axial CT image of the lung
populations to date — have the
of an NLST participant (from the
potential to impact hundreds of
second of three screening visits),
thousands of individuals.
the arrow points to a tumor in the
posterior right lower lobe.
The trial, sponsored by the NCI
and conducted by ACRIN® and
the NCI’s Lung Screening Study
group, enrolled more than 53,000 current and former heavy smokers
between 55 and 74 beginning in August 2002 at 33 sites across the
country. Each participant was randomly assigned to receive three
annual screens with either low-dose helical CT or a chest X-ray.
In addition, 15 NLST ACRIN sites collected and banked specimens
of blood, sputum, and urine. Tissue of trial participants’ lung cancer
was also collected across most sites. These specimens will provide
a rich resource to validate molecular markers that may complement
imaging to detect early lung cancer.
The NCI’s decision to announce the initial findings from the NLST
was made after the trial’s independent Data and Safety Monitoring
Board notified NCI Director Harold E. Varmus, M.D., that the accumulated data now provide a statistically convincing answer to the study’s
primary question and that the trial should therefore be stopped.
Comparing the effects of lung-cancer screening with CT and X-ray, the
trial found that 20 percent fewer deaths occurred among participants
screened with low-dose helical CT. The study’s design and methods
were recently published online in Radiology.1
Courtesy Drew Torigian
mSv) was consistent with prior studies,
providing more detailed information
about the potential for increased risk of
cancer associated with CT or chest X-ray.
A third presentation shared data from
a central review of brain MRI scans.
This research was obtained during the
ACRIN 6677 clinical trial, with the aim
of addressing the difficulty associated
with the assessment of tumor progression
in patients treated with the anti-VEGF
antibody bevacizumab. Led by the trial’s
principal investigator A. Gregory Sorensen,
M.D., the central review involved two
readers and an adjudicator. They were
trained using a customized presentation
and tested for comprehension prior to
performing a WHO-style bidimensional
radiographic assessment of progression
and assessment of serial 3-D volume (both
on T1-weighted measures for post-contrast
images), as well as 3-D volume assessments
for T2-weighted images. Researchers concluded that training and testing improve
agreement in central radiologic review and
that the addition of T2 imaging increases
detection of progression rates in patients
with recurrent glioblastoma who are being
treated with anti-VEGF therapy.
Another innovative development
showcased in the RSNA Quantitative
Imaging Reading Room featured a
demonstration of the image Physician
Annotation Device (iPAD)* from ACRIN
in conjunction with Stanford University.
iPAD, an open-source tool that links the
semantic content of a radiologic image
with the image itself, enables physicians to
annotate images so that descriptions are
recorded into the computer in a machineaccessible way.
Currently, when radiologists annotate
the same images differently, it is difficult
to compare findings with different
readers. Because iPAD stores data in a
quantitative manner, it automatically
provides a standard annotation vocabulary across the image repository and
between readers. Readers are prompted
to annotate lesions consistently and to
use similar terms to describe the same
features. This tool was developed by the
Annotated and Image Markup Project,
directed by Daniel L. Rubin, M.D., M.S.,
and supported by Mark A. Rosen, M.D.,
ENDNOTE
1. Gatsonis C.A. “The National Lung Screening Trial: Overview and Design.”
Radiology 2010. Available at: http://bit.ly/dhAXx5.
Ph.D., with programming assistance
interns from the Princeton Internships in
Civic Service Program.
RSNA attendees were also presented with information about ACRIN’s
expanding clinical trials portfolio and
how they might participate in ACRIN
research that will likely be featured at
future meetings. //
*Editor’s Note: Rubin’s team coined the
term “iPAD” well before the introduction
of the Apple product; however, they are
currently considering new names for the
annotation tool.
Nancy Fredericks, M.B.A., (nfredericks@
acr.org) is communications director, ACR
Clinical Research Center.
Advocacy • Economics • Education • Clinical Research • Quality & Safety | 9
>> NEWS FROM
THE COUNCIL
By Alan D. Kaye, M.D., FACR
Speaker, ACR Council
Preserving
Tradition,
Expanding
Opportunity
SKETCHING THE
BLUEPRINTS FOR THIS
YEAR’S AMCLC.
T
he 2011
AMCLC
will provide
a unique
opportunity for ACR
members to influence the policy and
direction of the College. Preparations
have begun, deadlines have been set,
and the Council Steering Committee
(CSC) anticipates a vibrant meeting in
Washington, D.C., from May 14–18.
The conference brings together councilors and representatives from 54 state
chapters and 25 radiology subspecialty
societies with diverse demographics and
practice settings. These differing perspectives enhance the CSC’s discussions
and debates about the issues facing our
specialty in these turbulent times.
A goal of my tenure as speaker
is to empower the council to make
policy, which is mostly accomplished
by passage of resolutions at this
meeting. To that aim, the council has
approved a new document drafted by
CSC member Katie D. Lozano, M.D.,
which provides a primer on how to
introduce a resolution for the council’s
10 |
Bulletin | January 2011
consideration. The document, which
will be posted on the ACR AMCLC
web portal at http://amclc.acr.org,
will provide links to members of the
CSC and the Board of Chancellors
(BOC) as well as contact information
for chapters and subspecialty societies.
(Individuals can also visit http://amclc.
acr.org/ContactCSC.aspx for more
information about the CSC members.)
I recommend that you contact me or
any of these individuals or groups to
facilitate the consideration of issues
you think the ACR should address.
In addition, the orientation session
for new councilors will be expanded
and all interested councilors will be
invited. The orientation is designed to
tion on meeting meaningful use criteria
for electronic records so radiologists
can take advantage of potential federal
subsidies. Shay Pratt, managing director
of the Advisory Board Co. — a national
consulting group for hospitals — will
discuss the evolving nature of radiologisthospital relations.
With all of the challenges we face
as radiologists, members surely have
thoughts on where our specialty must
go and how the ACR can help us get
there. While I have not yet chosen
the topics for the open microphone
sessions, I have a few potential topics
in mind that will give you the chance to
listen to your fellow councilors and be
heard by the ACR leaders.
With all of the challenges we face
as radiologists, members surely have
thoughts on where our specialty must go
and how the ACR can help us get there.
... We want to hear your opinions.
improve awareness of the governance
processes of the ACR and the council,
and make the annual meeting less
daunting for new councilors and enhance the effectiveness of experienced
councilors. We want to hear
your opinions.
Meeting Plans Take Shape
Our regular program for the 2011
AMCLC is supplemented with important lectures and discussions about the
challenges our members and specialty
face. This year, we invited Donald M.
Berwick, M.D., CMS administrator, to
deliver Monday’s Robert D. Moreton
Lecture. Other featured speakers will
include informatics expert Keith J.
Dreyer, D.O., Ph.D., from Massachusetts General Hospital in Boston, who
will deliver the Tuesday lunch presenta-
Continuing our tradition of providing clinical education for attendees,
the pre-meeting educational symposia
on Saturday, May 14, “Radiation Dose
and CT Scanning: Perspectives on the
Problem and Potential Solutions,” will
be co-sponsored by the ACR and the
American Roentgen Ray Society.
The 2011 AMCLC promises to be
an outstanding opportunity for ACR
members to participate in the policymaking process, stellar educational
sessions, federal health-care advocacy,
and discussions of issues critical to
the future of the profession. For more
information about the conference, visit
http://amclc.acr.org. To learn about the
CSC, volunteerism, or ACR state chapters, contact Brad Short, senior director
of member services, at 800-227-5463,
ext. 4795, or [email protected]. //
THE RIGHT TO SPEAK?
EXPERTS WEIGH IN ON GIVING IMAGING RESULTS
DIRECTLY TO PATIENTS.
By Leah Lakins
R
adiologists have traditionally served as the “strong, silent type” in the health-care
arena. Although they are a critical bridge between the patient and the referring
physician, their voices were often unheard or deemed unnecessary. But in this
new era — where patients are educated, informed, and ready to litigate — radiologists can no longer afford to keep their silence. Today’s professionals must be willing
to stand in the gap between the patient and referring physician and, as needed, be an
active, vocal partner, ensuring patients receive superior care. So, how do radiologists
determine when they should speak up?
Advocacy • Economics • Education • Clinical Research • Quality & Safety | 11
The first step toward charting
the communication waters begins
with understanding one of the most
trusted documents on the issue: The ACR
Practice Guideline for Communication
of Diagnostic Imaging Findings. Now in
its fifth revision, the guideline has been
mentioned in legal cases for and against
radiologists and as a foundation for
communication standards throughout the
radiologic community.
The guideline remains a hotly contested
topic among radiologists, accruing 110
comments since its creation in 1991.
Despite garnering four times the feedback
for a typical ACR standard,1 this document continues to be beneficial for today’s
practicing professionals. “Overall, the
guidelines have more pluses than minuses,” says Leonard L. Lucey, J.D., LL.M.,
legal counsel and senior director for the
ACR Department of Quality and Safety.
While the federal Mammography
Quality Standards Act already mandates
that radiologists deliver mammography
results directly to patients, the revised
ACR standard recommends direct
communication to the referring physician for findings that require immediate
intervention. In the most extreme or
life-threatening cases, radiologists can
report results directly to the patient when
the patient’s physician cannot be reached.
These cases include urgent imaging
results from emergency and surgical
departments, second interpretations that
are significantly different from the first
and may change a course of treatment,
and any findings for which the imager
believes a delay in communication will be
seriously adverse to the patient’s health.
The guideline also states, “Regardless of
the source of the referral, the interpreting
physician has an ethical responsibility to
ensure communication of unexpected or
serious findings to the patient. Therefore, in
certain situations the interpreting physician
may feel it is appropriate to communicate
the findings directly to the patient.”2
While these new recommendations
gave radiologists more license to speak up
if needed, many were uncomfortable with
circumventing the traditional reporting systems and rapport with referring
physicians. “Not all radiologists are good
12 |
Bulletin | January 2011
at speaking to patients,” says Richard
N. Taxin, M.D., FACR, from Southeast
Radiology Ltd. in Chester, Pa., and vice
chairman of radiology at the Crozier
Chester Medical Center in Upland, Pa.
“[Also] patients may get things wrong
when they hear things, and they may
miss out on a lot. This can lead to all
kinds of complications.”
Armed Patients
Regardless of a medical professional’s
preference or comfort level, today’s
patients are demanding more from all
of their health-care professionals —
including radiologists. With the
increasing popularity of medical
websites like WebMD.com and
MedicineNet.com, patients have more
access to diagnostic information than
ever before. Gone are the days of simply
accepting a medical diagnosis without
question or explanation. Instead,
patients are well informed and want to
partner with their medical professionals.
“Historically, radiologists did not
communicate directly with patients,”
says Leonard Berlin, M.D., FACR,
vice chair of radiology at Northshore
University HealthSystem at Skokie
Hospital in Skokie, Ill., and radiology
professor at Rush University Medical
College in Chicago. “Radiologists would
make sure the X-ray was done, write up
a report for the referring physician, and
send it back,” Berlin continues. “Now,
we are beyond the age of ‘paternalism’
in medicine where the doctors are the
ultimate authority. We are now in an age
of ‘consumerism’ where patients are very
involved and want to know about their
treatment options.”
Empowering patients is an important
principle for Harley J. Hammerman,
M.D., CEO of Metro Imaging in St.
Louis. When local physicians in his
area began acquiring their own imaging
equipment, Hammerman made the decision to provide imaging results directly
to his patients. Although there was some
grumbling from his fellow physicians,
Hammerman believes that immediately
giving his patients their results provides
peace of mind and helps them make
better decisions.
Richard N. Taxin, M.D.,
FACR, states that
referring physicians
should deliver imaging
results to patients.
“I believe that patients are best
served by their referring physicians,
who can explain the intricacies of a
diagnosis with more detail.”
— Richard N. Taxin, M.D., FACR
Leonard Berlin,
M.D., FACR, says
that radiologists
have a legal and
moral obligation to
provide results to
patients in a timely
manner.
“Now, we are beyond the age of
‘paternalism’ in medicine where
the doctors are the ultimate
authority. We are now in an age of
‘consumerism,’ where patients are
very involved and want to know
about their treatment options.”
­— Leonard Berlin, M.D., FACR
Harley J.
Hammerman, M.D.,
delivers image
results to patients
as soon as possible.
“Patients don’t want to spend
weeks being worried or concerned. They would rather hear
and know [their results]. This
gives patients the time to do their
research and be better prepared
to have a discussion with their
physician.”
­­— Harley J. Hammerman, M.D.
PATIENT
RADIOLOGIST
REFERRING PHYSICIAN
PATIENT CARE
TRIANGLE
+
“Patients don’t want to spend weeks
being worried or concerned,” he says.
“They would rather hear and know [their
results]. This gives patients the time to do
their research and be better prepared to
have a discussion with their physician.”
Berlin similarly advocates for keeping
patients in the loop. He says, “If I saw
something on a patient’s film, I couldn’t
bring myself not to tell him or her about it.
[Delivering results] to my patients never
worked against me, and it helped me build
up a nice relationship with them.”
While Taxin believes direct communication is a great courtesy to extend to
patients, he argues that it takes a lot of
time. “Our practice reviews more than
365,000 examinations every year,” he says.
“While [we are required by law] to discuss
diagnostic mammography results with
every patient, we wouldn’t have time to
provide this service for every patient. I
believe that, in general, patients are best
served by their referring physicians, who
can explain the intricacies of a diagnosis
with more detail.”
When the Law Intervenes
The decision to cross the communication divide with patients is more than just
a professional preference; it also comes
with legal considerations. While the ACR
guideline states, “the ultimate judgment
… of any procedure or course of action
must be made by the physician or medical
physicist,” several prominent court cases,
including Phillips v. Good Samaritan
Hospital, Jenoff v. Gleason, Stanley v.
McCarver, and Williams v. Lee, have also
made radiologists equally responsible for
the patient’s ultimate well-being.
“Imagine having to stand before a jury
and defend why you didn’t tell a patient
that you saw a potential cancer in his
screening,” Berlin says. “If you were to
simply say, ‘It wasn’t my job to deliver
those results,’ and the patient dies because
they didn’t receive the news in a timely
manner, that’s a very hard thing to defend
legally and morally.”
If a radiologist has to stand on trial,
Hammerman believes that developing a
relationship with patients will be beneficial. He says, “Most of the physicians who
are sued don’t have a relationship with
their patients. When we take the time
to develop a relationship with them, if
something goes wrong, we are less likely
to be sued.”
Even if radiologists aren’t comfortable
delivering critical medical news to a
patient, they are still obligated to ensure
that image results get to the referring
physician quickly and efficiently. “Courts
generally hold radiologists responsible for
getting a report where it needs to be and
making sure that it is acted upon,” Lucey
notes. “Although, the communication
guideline does also emphasize that referring physicians share in the responsibility
of obtaining results of imaging studies
they order,” he adds.
While many radiologists are still
divided about communication, the next
cue may come from patients. “The trend
is moving in the direction of providing
[imaging] reports directly to patients,”
says Berlin. “It’s the right thing to do
and I believe it is eventually going to
happen.” Regardless of where you stand
on the issue of communication, the
ultimate responsibility is clear — every
radiologist must make decisions to
ensure the health, safety, and well-being
of patients. //
ENDNOTES
1. Lucey L et al. “The ACR Guideline on Communication: To Be or Not to Be, That Is the
Question.” Journal of the American College of
Radiology 2010;7:109−114.
2. ACR Practice Guideline for Communication of
Diagnostic Imaging Findings. American College of
Radiology, Reston, Va., 2005.
Advocacy • Economics • Education • Clinical Research • Quality & Safety | 13
TACKLING
TRAUMA
+
RADIOLOGISTS ACT FAST, THINK
SMART TO STREAMLINE CARE IN
THE EMERGENCY DEPARTMENT.
BY ALYSSA MARTINO
14 |
Bulletin | January 2011
+++++++++++++++++++++++++++++++++++++++++++++++++++++++
Susan D. John, M.D.,
chose emergency
department radiology
because she enjoys
the physician interaction and intimate
atmosphere.
As current president
of the American
Society of Emergency
Radiology, Stephen F.
Hatem, M.D., believes
standardizing image
transfer protocols
will help improve
emergency care.
A
ll hospitals maintain one department unlike all the rest: the
emergency department (ED). It’s a place where the pressure to provide fast, effective care is rivaled only by the
number of acute injuries and illnesses witnessed each day. In the
ED, radiologists play a vital role in saving lives.
As Marty Khatib, J.D., RT(R), writes in Radiology Today, “Although many service
lines support the ED, diagnostic imaging is arguably one of the most critical areas.”
Khatib adds that 44.2 percent of ED patients have imaging procedures ordered, as
found in a National Center for Health Statistics study.1
“Some individuals can train for this lifestyle and others have it built into their
personality and thus gravitate toward it,” explains Susan D. John, M.D., vice president
of the American Society of Emergency Radiology (ASER) and professor of radiology
at the University of Texas Medical School in Houston. Although this one-of-a-kind job
is extreme in tension levels and pace, emergency radiologists face many of the same
challenges as other subspecialists — from making decisions and triage to communication and patient safety.
Urgency, Efficiency, and Turf Issues
ED physicians — radiologists included — face at least one major variation in their
patient care: “There’s a sense of urgency,” says John. In general medicine, “treatment
is usually ongoing. In the ED, you’re dealing with problems that have to be handled
immediately.” John, who practices both pediatric and emergency radiology, prefers
the ED’s climate because it’s very interactive and close-knit and requires a team-like
atmosphere, she explains.
Stephen F. Hatem, M.D., 2010–2011 president of ASER and radiologist at the
Cleveland Clinic in Ohio, made the decision to become an emergency radiologist after
completing residency at a level 1 trauma center. “It’s an eye-opening experience,” he
says. “You feel integral to patient management. You have to be prepared to deal with
multiple organ systems and multiple imaging modalities.”
“You feel integral to patient management. You
have to be prepared to deal with multiple organ
systems and multiple imaging modalities.”
— Stephen F. Hatem, M.D.
Referring physicians in the ED also need diagnostic answers as soon as possible,
which amplifies the role radiologists play in imaging decisions. “I think that all
practices work differently,” says Hatem. “But in mine, [radiologists have] taken a fairly
active role in triaging the requests we receive.”
John agrees: “We see many more patients in a day, so we need to be very efficient with
processes. [ED radiologists] sometimes need to decide which patients take precedence
based on how life-threatening a situation may be. We use trauma codes 1, 2, 3, [etc.] to
help with this.”
Advocacy • Economics • Education • Clinical Research • Quality & Safety | 15
++++++++++++++++++++++++++++
Another issue radiologists face in the ED
is “turf wars.” For example, in the March
2005 JACR article, “Turf Wars in Radiology: Emergency Department Ultrasound
and Radiography,” co-authors David C.
Levin, M.D., and Vijay M. Rao, M.D.,
argued against physician imaging, writing
that “the training offered to emergency
medicine residents is far less rigorous than
that provided to radiology residents.”2
John believes that while some physicians
have taken on imaging responsibilities in
the ED, they still rely heavily on radiologists. “Some physicians and trauma
surgeons have begun to use ultrasound as a
bedside tool to obtain focused information
they really need, such as whether there’s
free fluid in the abdomen,” she says. John
adds that it’s challenging for radiologists to
provide this information rapidly because
often they’re in the reading room, not the
trauma room.
Bridges of Communication
Though imagers have stepped up in
the ED, they must still communicate
and work with referring physicians to
avoid duplicate studies and ensure the
smooth transfer of images — both notorious problems in emergency medicine.
In the past several years, technology,
including PACS, has sped up the overall
processes of communicating findings.
“In the old days, when we had hard copy
film, you had one copy [of an image]
that everybody needed to see,” says
John. “It was messy and horrible. Once
PACS came into existence, multiple
people could view images from various
places without running all over the
hospital. This has been the biggest step
toward improving efficiency.”
In other arenas, however, more
advances are necessary to ensure efficient
care. Currently, CD-ROMs with a patient’s radiologic images are transferred
from other hospitals, which can pose
further obstacles. “Unfortunately, there
aren’t really standards for these CDs,”
says Hatem. “You receive data in all
different formats, which can be cumbersome and frustrating.
“I definitely support standardization of
this process — which, I believe, the ACR
is working on.” ACR’s system for the
16 |
Bulletin | January 2011
Transfer of Images and Data is helping
fulfill this goal by tracking and managing
the collection and transfer of images,
scans, and more. (To learn more, visit
https://triad.acr.org.)
John notes that although PACS has
definitely improved image transfer, the
technology still needs refining. “The
ability to dictate is lagging,” she says.
“If a department uses a transcription
company, typists listen and type dictations — this is a moderately slow process.
Now, with voice recognition, radiologists
become the typists. However, this means
we also have to correct any mistakes the
system incorrectly hears.” (For more on
voice recognition software, read “Loud
and Clear” on page 17).
Communicating findings is also
challenging during off hours. Hatem
explains, “More frequent utilization of
teleradiology has increased access to
expert radiologic interpretations — both
in academic and private practice.”
John’s department is also at the helm
of implementing a new “critical value”
system to communicate the most vital
of findings — those needed to save lives
immediately. “We’re looking for pieces
of information that are very valuable in
the treatment and welfare of a patient,”
she says. “For those, we’ll have a special
way of contacting the referring physician immediately.”
Protecting Patients
In this fast-paced, high-stress environment, one question is not overlooked:
how do ED radiologists remain mindful
of patient safety? John believes there are
two ways to prioritize safety. “The first
facet is on the technical side — setting
up department protocols based on
patient size so we don’t use the same
dose when we image a 60-year-old to
image a 2-year-old,” she says. This, she
adds, includes making sure equipment is
current and that the appropriate parts of
the body are imaged.
John also notes that the Image
Gently™ and Image Wisely™ campaigns
are important efforts to oversee safer
imaging. For more information and
resources, visit www.imagegently.com
and www.imagewisely.com.
++++
+
“The tendency is to
want to do a lot of
imaging quickly. It’s
easy to over-image in
those circumstances.”
— Susan D. John, M.D.
The second piece of protecting ED
patients is related to physician responsibility. “We need to make sure we’re only
doing studies that are necessary based
on the clinical problem,” John explains.
“This is a difficult process because
clinicians are under a lot of pressure, and
many patients have potentially serious
conditions that could be life threatening,”
she continues. “The tendency is to want
to do a lot of imaging quickly. It’s easy to
over-image in those circumstances.”
Hatem also agrees that radiation dose
and safety are important priorities;
however, he doesn’t believe these issues
require a higher level of awareness and
commitment from ED radiologists
alone. “I think [radiation safety] should
be on the forefront of all radiologists’
minds,” he says. “We should all strive
to minimize radiation dose and ensure
appropriate utilization.” //
ENDNOTES
1. Khatib, M. “Improving Emergency Department and Imaging Throughput.” Radiology Today
Nov. 16, 2009. Available at: http://bit.ly/9iJ0t9.
2. Levin, D.C. et al. “Turf Wars in Radiology:
Emergency Department Ultrasound and Radiography.” JACR 2005;3:271–273.
+
Radiologists articulate the advantages and challenges
of speech-recognition software.
By James Brice
R
adiologists have adjusted to many new technologies, but few
have posed a bigger challenge than speech recognition (SR).
Using computers to aid in translating speech into text, SR strikes
at the heart of radiology practice and work routine. SR performs its
primary function precisely at the moment radiologists perform theirs.
Advocacy • Economics • Education • Clinical Research • Quality & Safety | 17
radiology department that continues to
rely mainly on traditional transcription,
notes Arun Krishnaraj, M.D., M.P.H.,
clinical fellow at Massachusetts General
Hospital and Harvard Medical School,
who studied SR practices at the University of North Carolina.
Medium-sized acute care hospitals are
adopting SR swiftly, and small hospitals
and freestanding imaging services have
much to gain. “I would suspect the
improvement in report turnaround that
you get with speech recognition would be
even greater with small practice groups
and hospitals,” Krishnaraj says.
Bountiful Experience
One group with a positive SR experience is Radiology Consultants of Iowa
(RCI) in Cedar Rapids, Iowa. RCI first
applied the concept in 2005 as part of a
wide-area network PACS/RIS implementation for 12 small, rural hospitals. The goal
was to view images and dictate reports any
time, any place, says RCI partner John L.
Floyd, M.D., FACR. In fact, senior partner
W. Jay Friesen, M.D., uses the system to
dictate reports during frequent visits to his
second home in Arizona.
The new configuration delivered on
RCI’s promise to its rural hospitals for
report turnaround times as short as those
at its large facilities in Cedar Rapids.
Courtesy Hoag Hospital Newport Beach
Many radiologists dislike SR and prefer
the reassuring backup of a medical transcriptionist. In fact, SR forces radiologists
to correct mistakes and edit their work,
which sometimes makes interpretation
more time-consuming.
They are also wary because of SR’s
tendency to make rare, but dangerous,
mistakes. Nonetheless, the service has
evolved, and the most recently released
software’s error rates have fallen to about
2.5 percent.
Although radiologists still debate SR’s
merits, many hospital administrators are
convinced it saves money — often hundreds of thousands of dollars annually in
reduced medical-transcription expenses.
Vendors typically promise a positive
return-on-investment in about a year.
SR also dramatically cuts imagingreport turnaround times, creating
goodwill among referring physicians
whose loyalty and patients are key to a
hospital’s financial success. Recent product
developments are designed to capitalize
on SR as a workflow tool to automatically
load information, boost productivity, and
draw data from the system for billing,
patient management, and quality control.
Despite the misgivings, SR is on
its way to becoming as ubiquitous as
digital workstations in reading rooms.
Indeed, it’s hard to find a U.S. academic
William J. Van Dalsem, M.D., demonstrates Hoag Hospital’s approach to radiology
dictation assisted with speech-recognition software.
18 |
Bulletin | January 2011
With the exception of emergency CT
transmitted via rudimentary teleradiology, the rural sites were accustomed to
turnaround times as long as five days.
After installation, however, most studies
were signed and transmitted back in less
than two hours.
RCI then took steps to collaborate on
proposed SR installations with its two
largest clients, Mercy Medical Center
and St. Luke’s Hospital, both in Cedar
Rapids. Software was installed at Mercy
after the group contracted to manage the
facility’s in-house transcription service
and promised to charge the hospital less
per report than it paid when operating the
service itself. The hospital continued to
manage its own PACS and RIS.
St. Luke’s came on board in January
2007 when Floyd showed its management
how SR was dramatically improving report
turnaround times for its nearby competitor. The change at St. Luke’s was impressive.
Previously, only 20 percent of reports had
been available to referring physicians in
less than two hours after imaging. After
implementation, 90 percent arrived in less
than two hours, says Dennis E. Winders
Jr., St. Luke’s director of imaging services.
Since mid-2008, mean turnaround time for
final reports for ER imaging has been less
than 15 minutes.
Improvements were especially evident
in the ICU. “Physicians who arrived in the
mornings to make rounds among ICU
patients found that their radiology reports
were waiting for them,” Floyd says. “When
they came in to make afternoon rounds,
imaging reports were sometimes showing
up in patients’ records before the patients
returned to their rooms.”
Referring physicians were especially
pleased with the improved performance,
notes Kathy Epley, RCI’s chief administrative officer. A Press-Ganey survey
conducted a year after implementation
found that St. Luke’s and Mercy scored
with the top 1 percent of U.S. hospitals
for referring-physician satisfaction with
report turnaround times.
Radiologists also benefitted professionally and financially from the new SR
system. Faster turnaround led to fewer
interruptions for wet reads, Floyd reports.
Attending radiologists were more likely
to be available to field questions when
referring physicians read the findings.
And RCI’s transcription services at both
hospitals made a profit.
Like many SR implementations, Floyd
notes that his group’s effort started acrimoniously. Deep divisions emerged from
initial discussions about RCI’s strategy.
“Now, you won’t find any radiologist in
our group who would prefer to return to
traditional transcription, mainly because
of the backend benefits of immediate
filing,” he says.
Dispelling Doubt
Michael N. Brant-Zawadzki, M.D.,
FACR, tells a similar story about his
group’s initial skepticism and eventual
acceptance of SR at Hoag Hospital in
Newport Beach, Calif., in 2005. To overcome resistance, Brant-Zawadzki argued
that self-editing improved on traditional
transcription methods. “Before SR, reports
at Hoag Hospital were dictated in a
stream-of-consciousness fashion without a
conscientious attempt by the radiologist to
structure them properly,” he says.
Most reports were accurately transcribed, but there was no guarantee that
the transcriptionist understood crucial
details, so errors could find their way
to the referring physician. Confirming
clinical results was nearly impossible
because of the way work was organized,
Brant-Zawadzki adds.
Now, about 80 percent of the reports are
self-edited after SR implementation. This
extra step forces radiologists to invest 10
to 20 percent more time into each report,
but it also delegates responsibility for correcting errors to the person most qualified
to find them, according to William J. Van
Dalsem, M.D., Hoag Hospital’s medical
director of radiology.
While Van Dalsem doubts that every
radiology group will embrace SR, he is
committed to the self-editing concept.
“The style and quality of our group’s
reports are generally much improved,”
he shares.
New Features Save Time
Despite some lingering skepticism,
labor-saving upgrades are encouraging
broader use of SR. Radiology reports
are now frequently prepopulated with
demographic and clinical history, as
well as imaging protocol data from RIS
and PACS. Other time-savers include
a growing library of report templates
providing shortcuts to reporting normal
findings, and dictation that can be limited
to exceptions only, such as the presence,
size, and location of abnormalities. And,
the source of all material in a report can
be color-coded before self-editing so
radiologists can focus on critical sections
where significant errors may reside.
Newer software also helps radiologists
more accurately structure reports, add
punctuation, and correct bad grammar,
which means less editing time. Another
key advantage is that SR users can be
guided by master work lists that alert them
of the status of studies awaiting interpretations at multiple hospitals and imaging
centers served by the practice.
New, computer-assisted coding
engines that draw data from the
final report for automatic coding and
insurance billing can provide additional
efficiencies. These tools can also mine
PACS, RIS, and electronic medical
records for data to assist administrative
management-by-exception reporting.
And, future enhancements may even
support structured reporting. Although
new features continue to improve SR, it
may take time for radiologists to fully
embrace it; in the meantime, case studies
such as those in Iowa and California can
help illuminate its value and future ways
to refine its implementation. //
James Brice (jamesbrice@medicalwrite.
net) is a freelance writer.
Advocacy • Economics • Education • Clinical Research • Quality & Safety | 19
//
TESTING
The Art of the Question
NEW REFORMS CREATE DEMAND FOR SKILLED ITEM WRITERS.
By James Brice
W
ell-prepared residents
fly through them in less
than a minute. They read
the question, consider
the options, choose an answer, and move
on. They are multiple-choice questions,
and there is nothing quick or easy about
writing good ones. The question writer —
called an item writer in the field of exam
writing — spends hours formulating just
Gary J. Becker, M.D.,
FACR, believes that
diplomates of the ABR
can rely on cognitive
exams to determine
who is qualified for
clinical practice.
20 |
Bulletin | January 2011
one question to measure the test taker’s
clinical knowledge and diagnostic skill.
But the effort is considered time
well spent. Under the guidance of the
National Board of Medical Examiners
(NBME), many professional medical
societies, including the American
College of Radiology and the American
Roentgen Ray Society, have become
increasingly involved in promoting
sound medical testing practices. “Valid
testing has a very important role to
play,” says Mark R. Raymond, Ph.D.,
NBME’s principal assessment scientist.
“If the tests are done right, the public is
well served. If the questions are not well
designed, they can allow people who
really don’t know the subject matter to
get a passing grade.”
Diplomates of the ABR also deserve to
know that cognitive exams are a reliable
way to determine who is qualified for
clinical practice, notes ABR Executive
Director Gary J. Becker, M.D., FACR.
“Most [diplomates] do not know that
the evidence base is solid and growing
behind the correlation between their
performance on certifying cognitive
examinations and performance in
practice,” he says.
Good questions, and the item writers required to create them, are in
demand — particularly in radiology
because its certification programs are
in a state of flux. New committees are
developing test questions for the ABR’s
new core and certification exams for
radiology residents. The question areas
Janette Collins, M.D.,
M.Ed., FCCP, FACR,
notes that anyone can
learn to become a
good item writer.
include medical physics, patient safety,
10 categories of organ systems, and six
imaging modalities.
The new core exam will have 600–700
questions, and the certifying exam will
have approximately 300. Each committee
member who is helping develop the new
computer-based exams has been asked
to submit 20 cases for each of the next
four years to create a sufficient pool of
items for the test. (See October 2010 ACR
Bulletin for related article, “Introducing
the New Boards.”) Each case has one or
more items.
So, what is promoting this emerging
market, and what does it take to become a
good item writer?
Jeffrey P. Kanne, M.D.,
says that question
ideas are drawn from
relevant subject
matter, personal
clinical experience,
and review articles.
Effect of MOC
The ABR’s Maintenance of Certification (MOC) program is one area fueling
demand for talented item writers.
Lifetime board certification was discontinued in 2002 in favor of a 10-year
certification cycle that requires ABR
diplomates, who were first certified after
2001, to pass a cognitive recertification
exam every 10 years.
ABR diplomates are also required
to earn 250 AMA PRA Category 1
Credits™ every 10 years and to complete
two self-assessment modules (SAMs)
annually. More than 200 SAMs, which
each include a multiple-choice exam
to test comprehension, are needed to
accommodate the diplomates’ varied
professional needs.
Continuous professional development
and MOC testing are necessary because
of published evidence showing that a
physician’s professional performance is
likely to deteriorate over time, according
to Becker. “The facts have tremendous
bearing on the mandate for continuous
professional development and on the
need for MOC as a framework to accomplish it,” he says.
radiology, radiation oncology, or medical
physics, as well as willingness to learn the
mechanics of good item writing are key
requirements, she says.
The process begins with framing an
objective, according to Jeffrey P. Kanne,
M.D., associate professor of radiology at
the University of Wisconsin, Madison,
and member of ABR’s Thoracic Certifying
Committee. For questions designed for
Good questions, and the item writers
required to create them, are in demand —
particularly in radiology.
Developing Good Questions
Though academic radiologists will
meet most of the demand for this field,
anyone can learn to become a good
item writer, says Janette Collins, M.D.,
M.Ed., FCCP, FACR, chair of radiology
at the University of Cincinnati College
of Medicine in Ohio. Mastery over a
particular dimension of diagnostic
the ABR, Kanne selects subject matter
that an individual seeking certification
is expected to know after completing
residency training. Question ideas are
also drawn from personal clinical experience and review articles.
“Skilled item writers overcome the
tendency [to only write] multiple-choice
questions that require test takers to
ANATOMY OF A GOOD QUESTION
A 62-year-old man presents with a 3.2-cm peripheral right
upper-lobe lung adenocarcinoma and bilateral mediastinal lymph
node metastases. What is the most appropriate treatment?
A. Surgery and chemotherapy
B. Surgery and radiation therapy
C. Radiation therapy and chemotherapy
D. Chemotherapy only
Correct answer: C. This patient has T2N3M0 lung cancer (Stage
III-b). Standard treatment is a combination of chemotherapy and
radiation therapy.
This question tests a single concept — lung-cancer treatment.
However, it requires a higher level of thinking because the examinee
has to know the current lung-cancer staging system and standard
treatment for each stage to arrive at the correct answer.
This is a good test question because it is linear, complete, and clear;
provides all the information needed to answer (i.e., a knowledgeable
person can answer the item before seeing the choices); focuses on a
single concept; is worded positively; and is clinically relevant but not
controversial.
(Source: J. Kanne)
Advocacy • Economics • Education • Clinical Research • Quality & Safety | 21
recall memorized material,” Collins
says. “Writers should draw from Bloom’s
taxonomy, a pyramid of increasingly
sophisticated intellectual behaviors
important in learning. Higher levels of
learning can be tested with properly
formed questions. For example, the item
writer could provide a mammogram
showing a cluster of calcifications and
ask about the next logical step for the
patient’s management.”
Raymond advises item writers to keep
the question format as simple as possible.
He prefers “single best answer” multiplechoice questions where a concise
question, often referred to as “the stem,”
precedes four or five possible options
with one correct answer.
Another critical element for item
writers to develop carefully is the lead-in.
This element is the last sentence of the
question’s stem. According to Steven A.
Haist, M.D., an internist and associate
vice president of test development at
NBME, item writers need to create a
focused lead-in, structuring it as a question to produce a better item.
Developing alternate responses is also
a vital skill for item writers. “Inventing
wrong multiple-choice answers, also
called distractors, [can be] the hardest
22 |
Bulletin | January 2011
“A distractor must be
plausible enough to
become the choice for
some test takers, but
it must be implausible
enough to lead wellinformed test takers
to still select the right
answer.”
— Jeffrey P. Kanne, M.D.
part of item writing,” Kanne says. “A
distractor must be plausible enough to
become the choice for some test takers,
but it must be implausible enough to lead
well-informed test takers to still select
the right answer.”
Other pitfalls for item writing include:
• Stating a question in the negative (e.g.,
“Which of the following is not … ”).
These statements are often harder
for test takers to understand than
questions stated in the positive.
• Using “always,” “never,” or “sometimes.” These terms rarely appear in
the correct answer.
• Writing correct answers that are
longer than the distractors.
• Repeating key words in the correct
answer that are used in the stem.
• Creating distractors that are grammatically inconsistent with the stem.
Overall, item-writing is both a
science and an art, Kanne notes.
Newcomers may assume that item
writing will be easy. However, the
challenge of preparing a good question
becomes apparent when an item writer
tries to write one. “That is where the art
comes in,” he says. //
James Brice (jamesbrice@medicalwrite.
net) is a freelance writer.
RESOURCES
Case S.M., Swanson D.B. Constructing Written
Test Questions for the Basic and Clinical Sciences.
National Board of Medical Examiners. 2001; third
edition (revised).
Raymond M., Neiers R.B., Reid J.B. “Test-Item
Development for Radiologic Technology.”
American Registry of Radiologic Technologists 2003.
Collins J. “Writing multiple choice questions for
continuing medical education activities and self-assessment modules.” RadioGraphics 2006; 26:543–551.
Frey G.D., Ibbott G., Morin R. et al. “The Life of
ABR Physics Examination Questions.” The Beam.
Available at: http://theabr.org/4beam/question.pdf.
Spring 2009.
//
SCHOLARLY PUBLISHING
Tapping Into Rich Resources
JACR LAUNCHES NEW WEBSITE, CONTINUES TO PROVIDE
INVALUABLE TOOLS AND CONTENT.
By Leah Lakins
W
hy should you take the
time to read the Journal
of the American College
of Radiology (JACR) every
month? What makes it so special? The
journal is an informative, trustworthy
resource for radiologists to use in
daily practice. Each issue is full of timely,
cutting-edge research and practice-management strategies that can help improve
your individual skills and general practice.
While JACR is a fairly new addition to
the gamut of radiology journals — it was
founded in 2004 — it provides equally indispensable content that directly influences
how radiologists approach their daily reads
and interactions with their patients.
Also known as the “blue journal,”
the JACR has carved a distinctive niche
among radiology journals with its mix of
research and opinion pieces. JACR readers
can find articles on specific topics like
coding for radiologic services and content
of a broader nature, such as cost-effective
strategies for building and maintaining
your practice.
For a fairly new
scholarly publication,
Bruce J. Hillman, M.D.,
FACR, editor-in-chief
of the JACR and chair
of radiology at the
University of Virginia
in Charlottesville, Va., is
Bruce J. Hillman, proud of the quality and
M.D., FACR
number of submissions
received. And the JACR
recently earned the distinction of being
ranked number one in readership among
radiology journals, according to the 2010
Kantar Media report.
“Every month, subscribers can expect
to see a wide range of articles on topics,
such as health services, education, policy,
and practice management,” Hillman
says. “They can also expect to hear from
regular columnists who speak about
their everyday, practical issues
and help keep the profession in
the forefront.”
However, the journal’s
value extends beyond practicing
radiologists to residents as well.
“The journals are often the only
contact that residents have with
the practice of radiology during
their training,” says Hillman.
“[The articles] give them insight
into some of the issues they will
be facing in the future.”
As you enjoy your issues of
JACR, you can also earn CME
credits. You can easily view and
keep track of your CME credits
through the journal’s CME web
page at http://bit.ly/b7BJQo. On the
site, members can find a list of available
CME articles, read the articles, take the
corresponding tests, record and track
their test scores, and print out certificates
of completion.
Same Content, New Website
In addition to its useful content every
month, JACR recently unveiled a new
website with user-friendly tools and
updates. The redesigned home page
features horizontal navigation bars with
easy-access and drop-down menus that
display more content, allowing for easier
browsing between articles. Readers can
also view the “JACR in the News” section,
which lists JACR articles cited in news
sources and links to those stories.
The new site also includes an updated
interface for each article that gives readers
more flexibility to easily switch among
different sections and images. The page
displays a fly-out reference box that
provides readers immediate access to an
article’s sources and the ability to add
articles to their personal reading lists.
Visitors can also use the revamped
site to read past issues of JACR, sign up
for the electronic alerts containing the
table of contents, subscribe to JACR’s
RSS feed, and check out the most-read
and most-viewed articles for each
quarter. Finally, the site allows readers to
instantaneously share and comment on
JACR articles via expanded bookmarking tools (including Digg, StumbleUpon,
and Reddit).
Readers can access the new JACR
website either via the ACR home page
or directly at www.jacr.org. If you
have trouble logging in to the new site,
visit http://bit.ly/bThnk4 for a quick,
one-page instructional overview. Whether
you’re new to the field of radiology or a
seasoned professional, the JACR delivers quality resources that will help you
improve your practice today and ensure
the health of the profession tomorrow. //
WEB EXCLUSIVE
To discover more about the JACR, check
out our video on ACR’s YouTube Channel
at http://bit.ly/bHdZHR.
Advocacy • Economics • Education • Clinical Research • Quality & Safety | 23
>> RADLAW
By Bill Shields, J.D., LL.M., CAE,
and Tom Hoffman, J.D., CAE
Protecting
Your PeerReview Rights
ACR’S COUNSEL ELABORATE
ON LEGAL ISSUES WITHIN
THE FEDERAL AND LOCAL
PEER-REVIEW PROCESSES.
Bill Shields
Tom Hoffman
T
he ACR General Counsel’s Office
and the Quality and Safety Department are often asked whether
RADPEER™ materials can be
subpoenaed or “discovered” in court. As
with most legal matters, the answer is more
complicated than a simple “yes” or “no.”
The American Medical Association
(AMA) and many other bodies take a
narrow view of the medical peer-review
process. The AMA defines it as “the
process by which a professional review
body considers whether a practitioner’s
clinical privileges or membership in a
professional society will be adversely
affected by a physician’s competence or
professional conduct.”1
While this definition may have sufficed
in the initial uses of peer review within a
hospital, the College and many states now
take a much broader view. Peer review
matters for the ACR because all sites
initially applying for or renewing their
accreditation must be active participants
in a physician peer-review program. Thus,
RADPEER, or an equivalent program,
24 |
Bulletin | January 2011
is required for accreditation (except
for mammography and image-guided
biopsy programs). And because Medicare
will require accreditation for advanced
diagnostic imaging as of Jan. 1, 2012, the
link between peer review and quality care
is even more critical.
Since the purpose of peer review is to
assess competency and promote quality
treatment and patient safety, logically, it
should be conducted on a regular basis
at lower levels and in many places other
than the traditional hospital setting. For
example, in radiology alone, freestanding
diagnostic imaging, interventional treatment, and radiation oncology centers now
provide many services that hospitals had
previously exclusively provided.
To ensure that participants in the
peer-review process can express their
opinions freely without fear that the
peer whom they are reviewing will be
able to retaliate against them or that a
patient may use their peers’ comments
or analysis for a claim or lawsuit against
them, medical professionals have sought
statutory protections against such uses of
peer-review materials. Unfortunately, the
key federal peer-review law, the Health
Care Quality Improvement Act of 1986,
only provides protection to members and
staff of professional review bodies that
meet certain requirements.
Reviewing State and Local Law
Protection for practice-level, peerreview activities is governed primarily
by state law. At that level, most attention
is properly focused on ensuring that
the process is confidential and that the
results are not subject to legal discovery
or admissible in court. The College and
its Virginia chapter were successful in
placing language in the state’s peer-review
law that specifically protects ACR peerreview programs and materials. The 2006
Virginia Code § 8.01-581.17 – Privileged
communications of certain committees
and entities, states that “… Additionally,
for the purposes of this section,
accreditation and peer-review records
of the American College of Radiology
and the Medical Society of Virginia are
considered privileged communications.”2
This statement means that a Virginia
court will normally not order disclosure
of such information during a lawsuit.
When a lawsuit is filed in another
state seeking ACR peer-reviewed materials, that plaintiff may obtain a court
order directing the College to disclose
the information but then must ask a
Virginia court to enforce that order. The
Virginia court applies Virginia law and
thus should refuse to enforce the other
state’s order.
We have succeeded with this strategy
both in lawsuits filed in Virginia and
those filed in other states’ courts that seek
to enforce their disclosure orders against
the College via the Virginia courts. However, with RADPEER, the ACR does not
retain any physician or patient identifiable
data, and once the plaintiffs’ attorneys
realize this fact, they almost always drop
their request for information.
The problem may arise when a plaintiff
files an action in your state seeking
RADPEER materials in your possession.
Depending on the wording of the law in
your state, the courts may be able to order
your practice to disclose such data. The
same is true for information produced
by other similar peer-review programs.
The key factor in most cases is usually the
scope of the state peer-review protection,
not the specific program.
The College has frequently championed peer review as a means of achieving
safe, high-quality patient care and
understands the necessity of protecting
participants in this process. Now that
many payers require participating physicians and practices to have peer-review
programs, and the federal government
will soon do so as well, the ACR is
working with its state radiology societies,
state medical societies, and the AMA to
strengthen and enforce state and federal
peer-review protections. //
Bill Shields, J.D., LL.M., CAE (bshields@
acr.org), is ACR general counsel.
Tom Hoffman, J.D., CAE (thoffman@acr.
org), is ACR associate general counsel.
ENDNOTES
1. American Medical Association. Medical Peer
Review. Available at: http://bit.ly/bWpTLh.
2. Code of Virginia § 8.01-581.17. Available at:
http://bit.ly/d52tem.
The Congressional
Forecast for Radiology
2
010 was another hectic year for
the Economics and Government
Relations Department. With the
election of Sen. Scott Brown,
R-Mass., to the U.S. Senate last January,
many believed that comprehensive healthcare reform legislation
could not be passed.
However, at the Obama
administration’s urging,
the Patient Protection
and Affordable Care Act,
H.R. 3590 (PPACA),
was enacted in March
through the use of
reconciliation, a legislative vehicle that
circumvented a cloture vote in the Senate.
Despite years of lobbying efforts,
radiology was the only physician specialty
targeted for reduced payments. Specifically,
the equipment-usage assumption changed
from 50 percent to 75 percent and the
multiple-procedure payment reduction
(MPPR) increased from 25 percent to 50
percent. Both of these reductions affect
how the technical-component payment is
calculated and will target physician-owned
outpatient imaging centers and independent
diagnostic testing facilities. The ACR worked
extensively with Senate leaders to achieve a
65-percent equipment-usage assumption in
its version of the bill, but, unfortunately, the
House language on this issue prevailed.
The health-care reform legislation failed
to achieve many of organized medicine’s
stated goals. Notably absent from the bill
was a permanent fix for the sustainable
growth-rate formula used to calculate
the Medicare conversion factor. This has
required a series of congressional “fixes”
to prevent as much as a 23-percent cut
in Medicare payments for all physicians.
Without another congressional fix, the
CMS projects an additional six-percent
decrease in the conversion factor for 2011.
Also absent from the legislation was
meaningful tort reform. As a result of
these issues, many state medical societies
and some specialty societies have openly
opposed the PPACA legislation.
Additionally, the PPACA creates the
Independent Payment Advisory Board
(IPAB), which is authorized to recommend reductions in Medicare payments
to providers. These recommendations
will go into effect unless 60 percent (in
Congress) vote to overturn the decision.
The PPACA also authorizes governmental agencies, such as the U.S. Preventive
Services Task Force (USPSTF), to create
“evidence-based” policies to cover medical
services. However, due to public and
congressional outrage, the USPSTF 2009
recommendations for limiting screening
mammography were excluded from the
mandate by subsequent legislation.
Due to the advocacy of government
relations staff on behalf of our specialty,
the final equipment-utilization assumption was less than both the White House’s
proposed 95 percent and the initial
House bill (75 percent). During the
process, proposals were also submitted
for a separate conversion factor for
radiology and for prior authorization by
radiology benefit management companies. However, as a result of our efforts,
these proposals did not make it into the
health-care legislation.
The attention given to self-referral as
part of the PPACA discussions prompted
several House committee chairs to ask
the Government Accountability Office to
study the issue in more detail. As a result,
the effect of self-referral on the growth
of imaging was an important part of the
Medicare Payment Advisory Commission’s September 2010 meeting.
The process of moving from legislation to regulation began in June with
ECONOMIC <<
CHAIRMAN’S
REPORT
By Bibb Allen Jr., M.D., FACR
the Notice of Proposed Rule Making for
the 2011 Physician Fee Schedule. In the
proposed rule, the CMS went beyond the
legislation and continues to specifically
target radiology for additional payment
reductions. The agency proposes applying
the MPPR to noncontiguous body parts
and across different modalities.
Furthermore, the CMS is considering
an MPPR for the professional component
despite the work of the Relative Value
Update Committee (RUC) and the Current Procedural Terminology® (CPT®)
Editorial Panel to develop and value new
CPT codes for bundled services. The
agency proposed a lengthy list of radiology services for the RUC to review based
on the legislative mandates.
Finally, will the 2010 elections and
the composition of the 112th Congress
provide an opportunity for substantive
legislative change? There will not be
enough votes to overturn health-care
reform; however, certain provisions,
including the IPAB, may be reconsidered.
In the absence of legislative backing,
the executive branch will likely expand
its use of regulatory processes to advance
its agenda; correspondingly, look for the
CMS to develop even more payment
policies beyond the scope of legislative
mandates. Simultaneously, Congress
(especially House members) will probably
use its oversight authority to potentially
reign in some executive policies.
We will continue to use our influence
on Capitol Hill to help direct some of
these oversight efforts to issues where the
CMS may have overstepped the legislative mandates. However, a change in the
balance of power will not be enough.
Continued education for congressional
members and more grassroots advocacy
from our members will be needed to help
advance our agenda in Congress. //
Advocacy • Economics • Education • Clinical Research • Quality & Safety | 25
//
FINANCIAL REPORT
On Solid Ground
THE COLLEGE MAINTAINS A STRONG POSITION DURING A TOUGH FINANCIAL YEAR.
By Leah Lakins
A
s the economy slowly but
surely climbs its way to higher
ground, the College’s finances
have also steadily improved.
According to the 2009–2010 financial report from ACR Secretary-Treasurer Anne
C. Roberts, M.D., FACR, in Fiscal Year
2010, the College maintained a strong
financial position. As of June 30, 2010,
the ACR had assets of $108.6 million and
liabilities of $45.6 million, with net assets
of $63 million. Net assets increased over-
well. ACR CEO Harvey L. Neiman,
M.D., FACR, and all the staff have been
working to keep expenses down as much
as possible and have succeeded admirably.
Since the stock market has improved in
the last year, our long-term investments
are in a much better position. Through
the leadership of Dr. Neiman and Ken
Korotky, ACR’s chief financial officer,
the College is in a good position, but we
continue to watch our expenses and our
income carefully.
“We will continue to ensure that our members
get value over and beyond what they pay for
College membership.”
— Anne C. Roberts, M.D., FACR
all by $10 million in Fiscal Year 2010, with
a positive bottom line from operations
and investment earnings for the year. This
surplus stemmed primarily from accreditation revenues, as it was a strong year for
accreditation renewals in CT, PET, MRI,
and nuclear medicine.
The ACR’s long-term investment
portfolio also produced an improved
annual return for Fiscal Year 2010
of 14.6 percent. This performance
exceeded the benchmark return of
12.37 percent for the year. The portfolio
remains invested in a number of equity
and fixed-income mutual funds with an
allocation to stocks and bonds that is
in line with the long-term objectives of
capital appreciation.
To get a more in-depth view of the
College’s finances, the ACR Bulletin asked
Roberts to elaborate on performance
during the past fiscal year, as well as
what’s to come.
Bulletin: How has the College fared
during the current economy?
Roberts: The College’s finances are doing
26 |
Bulletin | January 2011
Bulletin: How will the new healthcare reform act affect the ACR’s
finances?
Roberts: I don’t think we know yet. There
will certainly be costs associated with our
Capitol Hill efforts. We may have a better
idea when the new session of Congress
begins this month.
Bulletin: How will the new accreditation mandates affect the College’s
finances?
Roberts: The CMS has designated
three organizations for radiology
accreditation for compliance with the
Medicare Improvements for Patients
and Providers Act of 2008. One is the
ACR, which has the most well-developed accreditation system. The College’s
accreditation looks at all the aspects of a
radiology practice, including the images
that are obtained. The other two entities are the Intersocietal Accreditation Commission
(IAC) and The Joint Commission (TJC).
The IAC accreditation process is very
similar to the ACR model, whereas
the TJC process is different. TJC does
not have the emphasis on the imaging
that one finds with the ACR and IAC
processes. The cost of the TJC process
may be less for some centers compared
to the ACR. However, we have built a
reputation over a number of years as
having an outstanding program, and we
know that we offer the best accreditation
program for radiology practices and for
the public.
Bulletin: How do the College’s
results for Fiscal Year 2010 compare
to other medical societies?
Roberts: It’s a challenge to compare
the ACR to other medical societies,
as we have a few very unique business
lines, such as our own contract research
organization, Image Metrix™. That
being said, our 2010 results exceeded our
budgeted expectations. We experienced
a positive net from operations of $5.3
million plus an additional $4.7 million
from long-term investments. Our reserve
balance remains in line with industry
averages as well.
Bulletin: Are there any new fiscal
benefits that members can expect
for the next year?
Roberts: At this time, we do not have
anything concrete planned. We will
continue to ensure that our members get
value over and beyond what they pay for
College membership.
Bulletin: What are some of the ACR’s
fiscal goals during Fiscal Year 2011?
Roberts: The College’s most important
goal is to continue to support our
members and their practices. This will
require ACR expenditures to fund political advocacy, standards, accreditation,
education, and outreach. It’s important
that we control our expenses as much as
possible so that there are funds available
for all of these efforts. //
>>>> TRANSITIONS
ARIZONA - TUCSON - Breast Imaging Radiology Ltd. seeks an additional
fellowship-trained and/or experienced
radiologist with mammography, breast
biopsy, breast ultrasound, & breast MRI
proficiency. Part-time/full-time partnershiptrack position available. Contact: Jackie
Hand at 520-545-1966, by e-mail at jackie.
[email protected], or mail CV to Radiology
Ltd, Jackie Hand, Administration, 677 N.
Wilmot Road, Tucson, AZ 85711.
FLORIDA - HOLLYWOOD - Nighthawk
Radiologist - Private practice seeks in-house
BC radiologist for shift from 11 p.m. to
8 a.m.; CT, US, nuclear medicine, & plain
films. Subspecialists backup call nightly. No
mammo/interventional required. Contact:
Jill Avendano, Radiology Associates of
Hollywood at 954-437-4800, ext, 2148, by fax
at 954-437-6628, by e-mail at jill.avendano@
rahmail.net, or mail to 9050 Pines Blvd., Suite
200, Pembroke Pines, FL 33024.
CALIFORNIA - BISHOP - General
Radiologist - Exciting partnership opportunity for outside enthusiast at a 25-bed
critical access hospital. Enjoy the autonomy
& challenge of developing a hospitalbased practice with the full support of an
established radiology group with broad
IT & teleradiology experience. Contact:
Stephen Loos, M.D., at Stephen.loos@
greatbasinimaging.com.
FLORIDA - PALM BEACH GARDENS Interventional Radiologist - Busy hospitalbased private practice seeks interventional
radiologist or neuroradiologist comfortable
with interventional procedures. Candidate with
current training preferred. Must be willing to
practice all aspects of radiology. Very desirable
location. Contact: Dr. Singh at 561-625-5036
or by e-mail at [email protected].
CALIFORNIA - SAN MATEO - Women’s
Imager - Part-time/full-time in busy outpatient practice. Must have breast imaging &
US fellowship with OB-GYN US or equivalent
experience. MRI experience preferred.
Modalities include digital mammo, stereotactic biopsy, MRI, US, x-ray, & DEXA; 25,000
exams annually. ACR accredited for US &
mammo. Health benefits/401k/education
allowance/paid vacation. Contact: Send CV
to [email protected].
CONNECTICUT - NEW LONDON - General
Radiologist - 13-member group seeks BC
general radiologist to replace retiring partner.
Partnership-track position with comprehensive
benefits package. Hospital based with 4 PACS
integrated outpatient centers & state-of-theart equipment. Teleradiology night coverage.
Fellowship training a plus, neuroradiology
preferred. Contact: Tom Manning, M.D., by
e-mail at [email protected].
CONNECTICUT - NORWALK - Part-time
Breast Imager - ACR accredited Breast
Center of Excellence seeks part-time breast
imager. No call. State-of-the-art digital mammography, comprehensive breast biopsy
service. Additional subspecialty skills &
fellowship training a plus. Contact: Alan H.
Richman M.D., President, Norwalk Radiology
Consultants, P.C. at 203-852-2715 or by
e-mail at [email protected].
FLORIDA - HOLLYWOOD - General
Radiologist - Large radiology group seeks
BC radiologist. Fellowship training in PET/
CT & nuclear medicine to support PET/
CT & radiology practice. ABR certification required. Contact: Jill Avendano at
Radiology Associates of Hollywood at
954-437-4800, ext. 2148, by fax at
954-437-6628, by e-mail at jill.avendano@
rahmail.net, or mail to 9050 Pines Blvd.,
Suite 200, Pembroke Pines, FL 33024.
INDIANA - FORT WAYNE - Diagnostic
Radiologist - Outpatient imaging facility offering competitive salary/benefits,
including 26 weeks’ vacation to qualified,
experienced diagnostic radiologist willing
to relocate. Imaging modalities include CT,
MRI, mammography, US, & radiography.
Image-guided biopsies (particularly breast
biopsies), arthrography, & myelography
also performed. Contact: Chris Conner at
260-436-7770, by fax at 260-436-3570, by
e-mail at [email protected], or
visit http://www.theimagingctr.com.
MARYLAND - BALTIMORE Neuroradiologist - Academic practice seeks
experienced interventional neuroradiologist.
Weekly responsibilities: clinical coverage
of ~ 2 days in interventional & ~ 2 days in
diagnostic, with interventional call coverage
& 1 day of academic time. Contact: William
Regine, M.D., at 410-328-2326, by e-mail
at [email protected], or send CV to Dept.
of Diagnostic Radiology, University of
Maryland Medical Center, 22 S. Green Street,
Baltimore, MD 21201.
MISSOURI - JEFFERSON CITY - General
Radiologist - General radiologist position
in a stable group with a busy outpatient
imaging practice & hospital contract for over
40 years. First year $375,000; 10 weeks’
vacation; call 1/6; nighthawk at 7 p.m. Low
cost of living/near major recreational lake
area. Contact: Jeffrey Patrick, M.D., by
e-mail at [email protected].
NEBRASKA - OMAHA - Neuroradiologist The neuroradiology section at University of
Nebraska Medical Center seeks a candidate
that has completed a neuroradiology fellowship & is ABR certified. Clinical expertise in
head, neck, spine, & brain imaging is required.
Individuals from diverse backgrounds are
encouraged to apply. Contact: E-mail CV to
Vickie Wrobleski at [email protected].
CLASSIFIED ADS These job listings are paid advertisements. The
ACR offers a bundled advertising package entitling advertisers who
purchase an online and ACR Bulletin classified ad to a 15 percent
discount on a classified ad in the Journal of the American College of
Radiology. To learn more about this bundled offer, e-mail [email protected].
RATES: ACR members: $50 per ACR Bulletin ad. Nonmembers:
$125 per ACR Bulletin ad. These fees are in addition to online posting fees. Ad length is a maximum of 50 words.
Advertising instructions, rate information, and complete policies
are available at http://jobs.acr.org. Publication of a job listing does
not constitute a recommendation by the ACR. The ACR and the ACR
Career Center assume no responsibility for accuracy of information
or liability for any personnel decisions and selections made by the
employer. These job listings previously appeared on the ACR Career
Center Web site. Only jobs posted on the Web site are eligible to appear in the ACR Bulletin, on a space-available basis.
NORTH CAROLINA - GASTONIA Nightshift Radiologist - Charlotte metro
area, board-certified radiologist needed
to work nightshift in 435-bed hospital.
Competitive salary/partnership track with
full benefits. Contact: Rick Keener at
704-852-9759 or by e-mail at keenerr@
gastonradiology.com.
PENNSYLVANIA - CHAMBERSBURG General Radiologist - Subspecialized group
of 12 radiologists with centralized PACS
seeks new team member with complimentary
skill sets. Partnership/employee track available. All fellowships welcomed. Generous
salary/benefits. Close to both Washington
and Baltimore beltway. Experience/interest
with mammography & mammo-intervention
skills required. Contact: Robert Pyatt Jr.,
M.D., at 717-264-4169 or by e-mail at
[email protected].
TENNESSEE - NASHVILLE - Associate
Medical Director - MedSolutions (an
intelligent cost management company
specializing in managing radiology, cardiology, ultrasound, & oncology services) seeks
an associate medical director (radiation
therapist/oncologist) to join its professional
multidisciplinary medical management team.
Contact: Leslie Thornton by e-mail at leslie@
physicianexecutive.com.
Advocacy • Economics • Education • Clinical Research • Quality & Safety | 27
final read
Rebecca E. Gerber, M.D.
Diagnostic Radiology, PGY-3 Resident
University of Virginia, Charlottesville, Va.
TELL US ABOUT YOUR
INTERNATIONAL ROTATION
EXPERIENCE.
D
Courtesy Rebecca E. Gerber
>>
Rebecca E. Gerber, M.D., relaxes with some of the children during Friday activities at GAIA
Vaccine Foundation’s Hope Center Clinic in Sikoro, Mali.
uring my medical school and
internship years at Brown
University, I collaborated with
my mentor Anne S. DeGroot,
M.D., from the Global Alliance to Vaccinate Against AIDS, to identify, raise funds
­— Rebecca E. Gerber,
for, and train medical professionals to use
an ultrasound machine for a communitybased clinic in Sikoro, a slum of Bamako,
Mali. In Mali, pregnancy and childbirth
complications are responsible for one-third
of the deaths of women aged 15 to 49. The goal was to use imaging to reduce pre- and perinatal
morbidity and mortality.
The ultrasound machine unexpectedly monopolized all the power in the village. I collaborated with the
local engineer, electrician, pediatrician, medical director, and executive director to solve the issue, which
was difficult because we all spoke different languages. After three weeks, we succeeded, demonstrating that
“it takes a village.” It was a wonderful moment when we plugged in the machine and it finally worked.
I also trained the local sonographer and pediatricians how to use the ultrasound machine to estimate
delivery date and identify potential complications. Now, the village women have access to imaging as a
routine part of their obstetric care, which is rare in Mali and Africa in general.
This imaging tool, seemingly obsolete in the United States, may be an incredible boon in a more
Rebecca E. Gerber, M.D.
resource-poor community. Previously collecting dust in the hospital basement, it was viewed as a “gift
from above” by the village chief. I humbly think that we all should value imaging’s role to such a degree.
This project further solidified my commitment to coupling international health with radiology. //
28 |
“Previously collecting dust in the hospital basement, it [ultrasound machine] was viewed as a ‘gift
from above’ by the village chief.”
Bulletin | January 2011
M.D.
ACR 2011
CME Calendar of Events
1.800.373.2204
www.acr.org/educenter
Education Center
Complete 2011 schedule now available at acr.org.
Neuroradiology coming in May 2011.
Cardiac and Peripheral Vascular MR
CT Colonography
This course is designed to optimize clinical practice skills by providing intense
training in interpreting cardiac MR examinations.
Jan. 10–11
ACR Education Center, Reston, VA
March 4–6
ACR Education Center, Reston, VA
CME: 30.75 AMA PRA Category 1 Credits and 4 SAM Credits
TM
Learn the technique, performance and interpretation of CTC through the
supervised review of a minimum of 50 cases.
CME: 21.5 AMA PRA Category 1 Credits and 4 SAM Credits
TM
Body and Pelvic MR – New for 2011 – Pelvic module added
Jan. 14–16
ACR Education Center, Reston, VA
This intensive, practical course on abdominal and pelvic MR image
interpretation focuses on the most common current indications for abdominal
and pelvic MRI.
CME: 35 AMA PRA Category 1 Credits and 4 SAM Credits
TM
Musculoskeletal MR
ACR-SPR Pediatric Cardiac MR
March 18–20
ACR Education Center, Reston, VA
Optimize clinical practice skills with intense training in interpreting pediatric
cardiac MR examinations under expert supervision.
CME: 33.25 AMA PRA Category 1 Credits
TM
ACR-Dartmouth PET/CT Course
March 29–31
ACR Education Center, Reston, VA
In this course you’ll interpret in a frontline fashion more than 150 PET/CT
scans covering all clinical applications.
CME: 34 AMA PRA Category 1 Credits and 4 SAM Credits
Jan. 28–30
ACR Education Center, Reston, VA
TM
This 100-case course provides intensive experience in the technique and
interpretation of MR imaging of the knee, shoulder, ankle, foot and hip.
CME: 34.75 AMA PRA Category 1 Credits and 4 SAM Credits
Education On the Go
TM
88th ACR Annual Meeting and Chapter Leadership
Conference
Breast Imaging Boot Camp
Feb. 3–5
ACR Education Center, Reston, VA
Develop your expertise in interpreting mammography studies through hands-on
interpretation of more than 240 digital screening and diagnostic mammograms.
CME: 34.25 AMA PRA Category 1 Credits
May 14–18
Hilton Washington Hotel, Washington, DC
Save the date for the ACR annual meeting to attend educational sessions,
participate in ACR elections and discuss the future of radiology.
TM
Breast MR With Guided Biopsy
Feb. 7–8
ACR Education Center, Reston, VA
s
Meet MR
st ion
Bread
at
it
Accreirements
Requ
This 100-case course provides practicing radiologists with intensive,
hands-on experience reading breast MRI under expert supervision.
CME: 21 AMA PRA Category 1 Credits and 4 SAM Credits
TM
5th Annual Body MRI Update Course
June 9–11
Hyatt Regency Atlanta, Atlanta, GA
Save the date for this state-of-the-art update and review of advanced methods
for disease detection.
Learn more at acr.org, “Meetings and Events”.
Coronary CT Angiography
Feb. 18–20
ACR Education Center, Reston, VA
Optimize your clinical practice skills in this intensive training course
interpreting coronary CTA exams.
CME: 33.25 AMA PRA Category 1 Credits and 4 SAM Credits
TM
Accreditation Statement: The American College of Radiology is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
Designation Statement: The American College of Radiology designates these educational activities for AMA PRA Category 1 Credits™ and SAM Credits. Physicians should only claim credit commensurate with the extent of their participation
in the activity.
The ACR Education Center courses were qualified by the American Board of Radiology in meeting the criteria for self-assessment toward the purpose of fulfilling requirements in the ABR Maintenance of Certification Program. Breast MR
includes 4 SAM Credits approved July 13, 2009; CT Colonography and PET/CT include 4 SAM Credits approved Aug. 6, 2009; Coronary CT Angiography includes 4 SAM Credits approved Nov. 5, 2009; Body MR includes 4 SAM Credits approved
Dec. 8, 2009; MSK MR includes 4 SAM Credits approved Dec. 17, 2009; Cardiac and Peripheral Vascular MR includes 4 SAM Credits approved April 27, 2010.
MKT CODE: CAL0111BUL
7639 01.11
PERIODICALS
ACR BULLETIN
1891 Preston White Drive
Reston, VA 20191-4326
ARRS Annual Scholarship Program
®
now accepting nominations
Investing in the Future of Radiology
The American Roentgen Ray Society (ARRS) and The Roentgen Fund®
invite medical schools, affiliated hospitals and clinical research
institutions to nominate one candidate for the 2011 ARRS Annual
Scholarship Program.
CPT Codes
Got You Down?
ACR makes it easier for you and your staff to comply with Current Procedural Terminology (CPT®) coding.
Starting January 2011, radiology practices will be required to report valid codes at the time of service. There is
Each year, up to two $140,000 scholarships are awarded to
no grace period to implement new codes ...
young investigators, educators and/or administrators to
support
studies
willACR
prepare
them resources
for leadershiptoday!
positions
… So
get that
your
coding
in academic radiology.
FREE 2011 CPT® Code Update
Scholarships
through a generousACR
grantRadiology
from
Find it inare
thefunded
September–October
Coding Source.™ Bookmark it! Visit www.acr.org/rcs.
®
The Roentgen Fund .
The 2011 Online Coding Update for Interventional Radiology is also FREE to members (nonmembers – $199)
Theand
general
requirements
forchanges
candidates
includes
significant
to are:
the lower extremity revascularization and atherectomy family of codes.
■ MD or DO from an accredited institution
■ InCompletion
all new
required
residency, fellowship
or equivalent
ASTRO-ACR
Guide totraining
Radiation
Oncology Coding 2011 (online-only version) is available to
addition,ofthe
■ ACR
Certification
by
the
American
Board
of
Radiology
or
equivalent
members ($75) and nonmembers ($225).
■ Full-time faculty appointment as a lecturer, instructor, assistant professor or equivalent for no more than five years beyond
Radiology
edAppointment
Coders —must
EarnbeCEU
Credits of radiology, nuclear medicine, or an associated department in
completion ofCertifi
training;
in a department
the radiological sciences of a medical school teaching hospital in the U.S. or Canada
■ Candidate must be a member of the ARRS at the time the application is submitted and for the duration of the award
To order your ACR coding resources, visit www.acr.org/coding.
For more information about the scholarship program and application procedures,
visit www.arrs.org or call 1-800-227-5463 or 703-648-8900.
2010 Nuclear Medicine Coding User’s Guide — Promo-code: NUCMED10
2010
Coding
User’s Guide
Promo-code: ULTRASOUND10
The deadline for submission
of Ultrasound
applications
is November
19,—
2010.
10% off!
7639.3 01.11
No 2011
Updates