August 2014 - American College of Radiology

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AUGUST 2014 VOL. 69 ISSUE 8 ADVOCACY • ECONOMICS • EDUCATION • CLINICAL RESEARCH • QUALITY & SAFETY

STORY BEHIND the SGR FIX

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ACR Board of Chancellors Bibb Allen Jr., MD, FACR (Chair) James A. Brink, MD, FACR (Vice Chair) Paul H. Ellenbogen, MD, FACR (President) Deborah Levine, MD, FACR (Vice President) Kimberly E. Applegate, MD, MS, FACR (Speaker) William T. Herrington, MD, FACR (Vice Speaker) Anne C. Roberts, MD, FACR (Secretary-Treasurer) Lincoln L. Berland, MD, FACR Edward I. Bluth, MD, FACR Cheri L. Canon, MD, FACR Beverly G. Coleman, MD, FACR Philip S. Cook, MD, FACR Gerald D. Dodd III, MD, FACR Burton P. Drayer, MD, FACR (RSNA) Keith J. Dreyer, DO, PhD, FACR Howard B. Fleishon, MD, MMM, FACR Richard A. Geise, PhD, FACR Marta Hernanz-Schulman, MD, FACR Bruce J. Hillman, MD, FACR (JACR) Peter A. S. Johnstone, MD, FACR (ARS) Alan D. Kaye, MD, FACR David C. Kushner, MD, FACR Lawrence A. Liebscher, MD, FACR Katarzyna J. Macura, MD, PhD, FACR Geraldine B. McGinty, MD, FACR Carolyn C. Meltzer, MD, FACR William D. Miller, MD (CAR) Barbara S. Monsees, MD, FACR Debra L. Monticciolo, MD, FACR Alexander M. Norbash, MD, FACR (ARRS) M. Elizabeth Oates, MD Seth A. Rosenthal, MD, FACR Cynthia S. Sherry, MD, FACR

ACR Bulletin Advisory Group Kay Spong Lozano, MD (Chair) James Y. Chen, MD Beverly G. Coleman, MD, FACR Rebecca E. Gerber, MD Lawrence A. Liebscher, MD, FACR Nathaniel E. Margolis, MD James V. Rawson, MD, FACR

ACR Bulletin Staff G. Rebecca Haines, CAE Publisher Paul Wiegmann Director of Publications Brett Hansen Senior Managing Editor Lyndsee Cordes Managing Editor Chris Hobson Associate Editor Meghan Edwards Copywriter Alyssa Martino, Jenny Jones, James Brice Contributing Editors www.touch3.com Design & Production

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To contact a member of the ACR Bulletin staff, email [email protected]. ACR Bulletin (ISSN 0098-6070) is published monthly by the American College of Radiology, 1891 Preston White Drive, Reston, VA 20191-4326. From annual membership dues of $850, $15 is allocated to the ACR Bulletin annual subscription price. The subscription price for nonmembers is $90. Periodical postage paid 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 ©2013 by the American College of Radiology. Printed in the U.S.A. ACR Bulletin is published 12 times a year to keep radiologists informed on current research, advocacy efforts, the latest technology, relevant education courses and programs, and ACR products and services. 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.

Bulletin

AUGUST 2014 • VOL. 69 • ISSUE 8

18 features

also inside

10 THE STORY BEHIND THE SGR FIX

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How did the ACR influence policy and protect its members and patients in a deeply divided Congress?

14 MED SCHOOL REBOOT

Realizing radiology’s importance to health care, some medical schools are overhauling their curriculum.

18 WELL TRAVELED

Checking in with six years of Goldberg-Reeder awardees.

SURVEY SAYS FRONT AND CENTER ONE SPECIALTY, TWO APPROACHES

departments 4

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FROM THE CHAIR OF THE BOARD OF CHANCELLORS DISPATCHES FROM THE CHAIR OF THE COMMISSION ON ECONOMICS

NEWS FROM THE BOARD OF CHANCELLORS

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NEWS FROM THE COUNCIL STEERING COMMITTEE RADLAW JOB LISTINGS FINAL READ

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 reprints of the ACR Bulletin, contact [email protected].

Get the ACR Bulletin App on your iPad. Scan the QR code to download the app.

Advocacy • Economics • Education • Clinical Research • Quality & Safety | 3

FROM THE CHAIR OF THE BOARD OF CHANCELLORS By Paul H. Ellenbogen, By Bibb Allen M.D.,Jr.,FACR, MD, FACR Chair

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n March of this year, I had the pleasure of attending the Oklahoma Radiological Society Meeting. We had a great discussion with radiologists about issues facing their practices and how the College was advocating in Washington on their behalf. At the time, Congress was considering the Protecting Access to Medicare Act of 2014 (H.R. 4302), the latest in a series of patches to the Sustainable Growth Rate (SGR) formula. The goal was to prevent deep cuts in Medicare physician payments. Needless to say, our conversation focused largely on the politics of health care reform, including such topics as our political leaders’ inability to reform the SGR formula and the possibility of enacting legislation that promotes improvements in patient care. Policy-makers in both Congress and the Obama administration believe that many of the current financial difficulties in Medicare are due to increases in the volume of services being provided to Medicare beneficiaries. While it is easy for decision-makers in Washington to say we need to provide more value and efficiency in health care instead of more volume, the current strategy of repeated cuts to fee-for-service payments creates a perverse incentive to continually increase volume. This brings to mind a quote attributed to Russian leader Nikita Khrushchev: “Call it what you will, incentives are what get people to work harder.” The value proposition of health care reform — better health at a lower cost — will be difficult to achieve until policy-makers recognize that the key is to align physicians’ incentives with those of the payers and health systems. To begin that process, on April 3, 2013, when the House of Representatives Energy and

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Aligning Incentives in Health Care THE RECENT SGR LEGISLATION BRINGS US ONE STEP CLOSER TO A BLUEPRINT THAT WORKS FOR STAKEHOLDERS THROUGHOUT THE HEALTH CARE SYSTEM.

It’s up to us as radiologists to develop and promote innovative solutions. Commerce Committee and Committee on Ways and Means first released their plan for Medicare payment reform, one of the tenets of SGR reform was to include incentives based on adhering to physiciandeveloped performance measures. Back in 1890, in The Picture of Dorian Gray, Oscar Wilde wrote, “Nowadays people know the price of everything and the value of nothing.” That timeless statement resonates with me. Despite all of the technological advances and clinical capabilities we have achieved in imaging, the increase in the use of imaging because of these capabilities has resulted in payers reducing the payments for individual imaging services. Unfortunately, at this point, the policy-makers believe the only way to increase value is to lower the unit costs for imaging. It’s like Henry Ford said, “If I had asked my customers what they wanted, they would have said faster horses.” And so in order to prevent Congress from taking the path of faster horses instead of true innovation, it’s up to us as radiologists to develop and promote innovative solutions. Otherwise, we are likely to see continued unit cost reductions. So with Congress now suggesting that physicians step up and create value-based initiatives for quality metrics for their specialty, I’m reminded of what Steve Jobs once said, “A lot of times people don’t know what they want until you show it to them.” Translation: in dealing with members of Congress, the burden lies upon us to show what works, not necessarily what they are expecting to see. As part of the Imaging 3.0™ strategy, the ACR wants to show policy-makers radiologist-led initiatives and tools that

improve the value of imaging to patients and health systems. In moving to valuebased care, it is imperative that we assure patients, payers, and policy-makers that the care radiologists provide is beneficial, safe, and appropriate. One way we can do that is to promote the use of appropriate use criteria, such as the ACR Appropriateness Criteria®, to policy-makers as an alternative to call-in prior-authorization programs. During the legislative process for SGR reform, the College was successful in getting Congress to agree to language that mandates physicians ordering advanced imaging consult physiciandeveloped appropriate use criteria. (For more about the SGR legislation, see page 10.) We were able to get this language included in the legislation because the ACR Appropriateness Criteria are well respected and constantly updated based on the best available evidence. Another key was the ACR informatics effort that has made the appropriateness criteria a clinically consumable product, called ACR Select™. And, finally, we were able to successfully influence this legislation thanks to the unending and doggedly persistent efforts of the ACR government relations team, who ensured that the language made it through all the iterations of the legislation. As a result of this legislation, our specialty has planted a flag in the sand as a leader in providing value-based medical care. Thanks to everyone who made this possible, including the tireless ACR staff and physician volunteer leaders in quality and safety, informatics, and government relations. This was truly a win for radiology and for our patients. //

dispatches NEWS FROM THE ACR AND BEYOND

CALL FOR NOMINATIONS The 2014–2015 College Nominating Committee (CNC) will recommend candidates soon to fill open positions within the College’s governance structure. Additionally, the CNC will select a private practice representative to attend the 2015 and 2016 ISC meetings. Any ACR member may submit recommendations for elected or selected positions to the CNC in care of the ACR Governance Office on or before December 15, 2014. Nomination information is available at http://bit.ly/NominationsACR or through the ACR Governance Office. For further information, contact Kathy Bentley and Katie Kuhn via email ([email protected]). Board of Chancellors For 2015, there is a second three-year term member eligible for chair of the Commission on Interventional and Cardiovascular Radiology. In addition, the chairs of the Commissions on Medical Physics and Pediatric Radiology are each eligible for a second three-year term. One at-large board member is also eligible for a first threeyear term on the BOC. Candidates for the BOC positions should be qualified radiologists who have been actively involved in the College and have leadership qualities beneficial in addressing critical issues brought to the BOC. Council Speaker and Vice Speaker For 2015, there will be openings for council speaker and council vice speaker. To be eligible, candidates must have served a minimum of two years on the CSC prior to election. Both of these positions are to serve a single two-year term. Council Steering Committee For 2015, five or more eligible candidates, who must have at least one year remaining as councilors for the terms for which they are nominated, will run for four two-year positions on the CSC. A candidate with only one year remaining as a councilor who wins election or re-election will serve the final year as a councilor-at-large. No member may serve more than six consecutive years on the CSC without a lapse of at least one year.

College Nominating Committee For 2015, five or more eligible councilors or alternate councilors, who must be councilors or alternate councilors through May 2017, will run for three two-year positions on the CNC. Members elected to the CNC by the council cannot simultaneously serve on the CSC. Members-in-Training Chapters are asked to submit to the CNC the names of interested, involved members-in-training to attend the Intersociety Committee (ISC) in 2015. The committee will nominate no more than four members-in-training, two of whom will be elected by the council. Private-Practice Representative The CNC will also select a physician who has a private office that is not affiliated with a hospital practice or who practices in a hospital without radiology residents. This representative will participate in the 2015 and 2016 ISCs.

Advocacy • Economics • Education • Clinical Research • Quality & Safety | 5

dispatches SIX MORE WAYS TO MAKE YOUR PRACTICE MORE INCLUSIVE, DIVERSE, AND WELCOMING By Johnson B. Lightfoote, MD, FACR

As the American population becomes increasingly diverse, we’re appreciating more and more the importance of a culturally competent health care workforce. Radiology and radiation oncology have become central to health care services over the past half century. However, we have not attended as well to the diversity in our specialty. Groups underrepresented in medicine are even more underrepresented in radiology. Improving diversity, representation, and inclusiveness in radiology and radiation oncology will make us all the more effective in service to our society and communities. From the ACR Commission on Women and General Diversity, here are six more ways you can boost diversity in your practice. Check out last month’s dispatches for the first six at http://bit.ly/12WaysJuly and visit the commission page at http://bit.ly/ACRDiversity. Walk a mile in their shoes. Empathy is one of a physician’s greatest assets. Take a look at an interaction (either contentious or compassionate) that includes underrepresented minority (URM) professionals or patients. Imagine how you’d react if you were either of those participants. Take your show on the road. Visit civic groups, churches, your local city council, or volunteer organizations, and let them know not just about your high technology, but about the diversity and service commitment of the people in your practice. Mind the gap. Is there a disparity in the care your female, LGBT, or minority patients receive? Is there a gap between your practice’s aspirations for inclusiveness and the actual representation of URMs and women in your group? Finding and addressing this gap will invite solutions. Take your own pulse. How do people in your practice appreciate the inclusiveness and diversity of the work environment? Invite frequent meetings of your group to discover how your most important assets — your team — think about how welcoming your practice really is. Move on up. Professional advancement is a great way to enhance an atmosphere of diversity and inclusion. Make sure you’re offering leadership and development opportunities to everyone in your organization. Leverage diversity. Unique talents and diverse needs can be used to great advantage in areas such as hours, work locations, fractional employment, specialty differentiation, and customer service. Welcome and creatively utilize the diverse professional capacities of your team. Enjoy the resulting effects on your bottom line.

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GEN. COLIN POWELL AT THE CROSSROADS OF RADIOLOGY The leader renown among leaders — General Colin Powell, USA (Ret.) — will be giving the keynote address, “Leadership: Taking Charge,” to open ACR 2015 on May 17. One of several nationally recognized speakers scheduled to appear at ACR 2015, Powell’s long history of leadership and effective diplomacy will provide annual meeting attendees with practical insights to navigate the new health care environment. Powell served in the United States Army for 35 years, rising to the rank of a four-star general. He also served as national security advisor, chairman of the Joint Chiefs of Staff, and Secretary of State. For more information, visit acr.org/acr2015. Don’t miss this special event!

CME Opportunity Visit http://bit.ly/ JACRdiversity to read a companion piece in the JACR and receive CME credit.

dispatches MEET THE 2014 ACR BOARD OF CHANCELLORS EXECUTIVE COMMITTEE

Front row: Anne C. Roberts, MD, FACR (secretary-treasurer), James A. Brink, MD, FACR (vice chair), Bibb Allen Jr., MD, FACR (chair), Paul H. Ellenbogen, MD, FACR (president), Cynthia S. Sherry, MD, FACR (chair, Commission on Leadership & Practice Development). Back row: Kimberly E. Applegate, MD, MS, FACR (council speaker), Burton P. Drayer, MD, FACR (RSNA representative), Geraldine B. McGinty, MD, MBA, FACR (chair, Commission on Economics), William T. Herrington, MD, FACR (council vice speaker), Deborah Levine, MD, FACR (vice president).

ACR STAFF MEMBER AWARDED RBMA PRESIDENT’S AWARD ACR staff member Pam Kassing, senior economics advisor in ACR’s department of Economics and Health Policy, was awarded the Radiology Business Management Association (RBMA) President’s Award in May during the 2014 RBMA Radiology Summit in Charlotte, N.C. Kassing received the award for her service to RBMA, which noted that Kassing went “above and Click here beyond to promote an atmosphere that enhances to take networking and ‘progress through sharing.’” the poll.

NRDR™ EXPANDS REACH The ACR National Radiology Data Registry (NRDR™) has been recognized by CMS as a Qualified Clinical Data Registry (QCDR). This means radiologists can now participate in NRDR to meet Physician Quality Reporting System (PQRS) requirements. Additionally, NRDR participants have the potential to gain maintenance of certification credit from the ABR for meaningful practice quality improvement activities. “This is an important announcement for ACR members,” says Ezequiel Silva III, MD, FACR, vice-chair of the ACR Commission on Economics. “This change could allow the ACR to serve as a one stop shop for multiple quality initiatives, including the PQRS, PQI MOC, and the Value-based Modifier Program (VBM).” For more information, visit ACR’s PQRS information page at http://bit.ly/ACRPQRSRep or the NRDR page at http://bit.ly/ NRDRACR.

TELL US WHAT YOU THINK When looking for a new job, what have you found to be the most effective interview strategies?

Advocacy • Economics • Education • Clinical Research • Quality & Safety | 7

dispatches THE SRU WANTS YOU

Calendar SEPTEMBER

Make your plans now to attend the Society for Radiologists in Ultrasound (SRU) Annual Meeting, which will be held October 24–26 in Denver, Colo. Physicians will not want to miss the keynote address this year, given by SRU fellow Dolores Pretorius. Her presentation will focus on practical clinical applications of 3-D ultrasound in obstetrics and gynecology using a case-based approach. To find out more, visit www.sru.org.

11–13 Neuroradiology, ACR Education Center, Reston, Va.

15–17 Dartmouth PET/CT, ACR Education Center, Reston, Va.

20–23 North American Society for Cardiovascular Imaging Annual Meeting, New Orleans

22–24 Breast Imaging Boot Camp with Tomosynthesis, ACR Education Center, Reston, Va.

OCTOBER

THE SPARK Kick off discussion with these notes and quotes from the field.

10–12 Body and Pelvic MR, ACR Education Center, Reston, Va.

16–18 High Resolution CT of the Chest, ACR Education Center, Reston, Va.

17–18 ACR-RBMA Annual Forum, Seattle, Wash.

The patient’s time may be even more important than a provider’s. Without the patient, there is no need for a provider. — Andrew DeLaO, in “Patient Experience: The Value of Time in Health Care.” Read more at http://bit.ly/CancerGeekSpark.

24–26 Cardiac and Peripheral Vascular MR, ACR Education Center, Reston, Va.

NOVEMBER 4–5 Breast MR with Guided Biopsy, ACR Education Center, Reston, Va.

20–22 Breast Imaging Boot Camp with Tomosynthesis, ACR Education Center, Reston, Va.

22–24 Emergency Imaging for the General Radiologist, ACR Education Center, Reston, Va.

We need to be proactive leaders — not a passive participant in health care. — Kristina Hoque, MD, PhD (@KristinaHoque), in the March

No matter what the task, today people want to do it faster. Medical imaging is no exception.

JACR Tweet chat. Read more at http://bit.ly/Mar14Tchat.

— Stewart C. Bushong, ScD, FACR, in Radiologic Science for Technologists, 10th ed. (Elsevier, 2013)

SCAN THE QR CODE TO SEE THE MOST RECENT VERSION OF THE ACR MEETING AND COURSE CALENDAR.

Bundling up…in August? THE ACR ECONOMICS TEAM IS FOCUSED ON POSITIONING RADIOLOGISTS TO THRIVE IN BOTH EXISTING AND EMERGING PAYMENT MODELS.

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ou might wonder why I am talking about bundling up when I hope this column finds you enjoying the warm summer weather. Well, “bundling” is quite a buzz word in health care payment policy these days. Its impact on radiologists will be far reaching and, in fact, has already been significant. First, a little background. Bundling initially appeared on our radiology radar screens when CMS began mandating a shift from the component coding system, with which we were all familiar, to bundled codes. (Read about coding in the Imaging 3.0™ toolkit at http://bit. ly/Img3Coding.) The initial targets were services commonly performed together, such as the surgical codes and guidance codes for many interventional procedures. CMS believed that component coding had inherent inefficiencies and duplication of effort. Our arguments that the component codes had been expressly developed to avoid any duplication fell on deaf ears. The initial threshold for bundled code development was 95 percent, which netted the codes for CT of the abdomen and pelvis. The result was the painful approximately 25 percent reimbursement reduction that went into effect in 2012. Inevitably, with CMS seeing the “success” of the bundling effort, reimbursement for valuable services was again significantly cut. The threshold dropped, and the most recent bundled codes were developed from codes performed together 75 percent of the time, including the codes for image-guided breast biopsy. CMS might feel satisfied with its accomplishment, but with the breast biopsy codes in particular, it might want to think a little harder about what success means. Image-guided breast biopsy represents an

advance in clinical care, with women no longer undergoing surgical procedures to either diagnose breast cancer or confirm a benign finding. Coming on top of so many other cuts in payment, some practices may be forced to reduce access to this valuable procedure or even stop performing it. Patients may have no other choice than surgical biopsy. While our specialty’s experience of bundling has been mostly at the individual-code level, that is not what most of the bundling buzz is about. Whether this is for a defined clinical episode, like a joint replacement surgery, or for the health of a population over time, as with the concept of accountable care organizations, bundled payments are touted as the panacea for aligning incentives and improving outcomes. But think about some of the misaligned incentives in our current system, particularly the focus on volume over value. It’s clear that there is room for improvement. Are bundled payments the answer to all these problems? Probably not, but they are a primary vehicle for the delivery of health care reform. And because of this, your economics team is focused on ensuring that radiologists’ value is recognized and reimbursed in existing and emerging payment systems. Since bundled payments are going to be a big part of our future reimbursement schema, does it seem shortsighted for us to spend a significant amount of time and energy on maintaining our feefor-service reimbursements? Not at all. Ezequiel Silva III, MD, FACR, vice chair of the ACR Commission on Economics, articulated this very clearly at AMCLC this year (see the presentation at http:// bit.ly/UpdateRUC). As we make the transition from volume to value, most of us receive the bulk of our reimbursement under the fee-for-service system. The current value-based incentives and penalties, such as Physician Quality Report-

FROM THE CHAIR OF THE COMMISSION ON ECONOMICS By Geraldine B. McGinty, MD, MBA, FACR, Chair ing Systems, are paid as a percentage on top of the fee-for-service structure. Even in a fully integrated payment system, fee-for-service will still play a role. Read more about the relative value unit system at http://bit.ly/RVUBulletin. So while we are keeping a close eye on the fee-for-service system, we would be remiss if we did not also develop strategies for reimbursement of radiology services within the bundling concept. We also realize that when it comes to bundling, the RBRVS has a glaring omission: It does not recognize the value of a service in terms of the outcome it delivers, and this is where we have some great opportunities as radiologists. We have multiple concurrent efforts ongoing to carve out a place for radiology in this model. I’m excited about the Neiman Health Policy Institute’s research into screening payment models that capture not only the initial event but also any downstream imaging over a defined time period. This type of bundled payment could provide not only an opportunity to advocate for a no-cost-sharing payment for our patients (which may improve compliance) but also a way to capture and reimburse the types of Imaging 3.0™ activities that are essential to good care. We continue to collaborate with outside stakeholders, such as the Brookings Institution, so that our voice is heard on how specialists should be recognized in new payment models. After a day-long meeting at ACR headquarters this spring, we concluded that compared to other specialties we are actually ahead of the process. While there is no magic bullet, we are on the right track with our focus on the patients and our clear stance on appropriate imaging. As always, I’d love to hear your feedback at [email protected] and encourage you to follow me on Twitter at @DrGMcGinty. //

Advocacy • Economics • Education • Clinical Research • Quality & Safety | 9

STORY BEHIND the SGR FIX

By Lyndsee Cordes

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ou already know how this story ends. But in a lot of ways, it starts on New Year’s Eve 2012. The country was about to plunge over the fiscal cliff when a small group of influential leaders, headed by Vice President Joe Biden and Senate Minority Leader Mitch McConnell (R-KY), ducked into a room at the last minute and negotiated a deal. Unfortunately, the deal contained an SGR extension that significantly slashed technical component reimbursements to radiology. “It was a mess,” says Rebecca Spangler, director of congressional affairs. “It was one of those deals where everything happened really fast behind closed doors and there was nothing you could do about it.” As the government relations team formed their strategy for the coming year, the dramatic cuts were never far from their minds. “That served as the motivation, at least for me, to make sure that our language would stay in the next SGR short-term patch,” says Spangler.

Pushing for Repeal In late 2013, Congress was moving toward repealing the SGR. The government relations team pushed to include three provisions: 1) to mandate that

referring physicians consult clinical appropriateness criteria for medical imaging prior to ordering advanced imaging services for Medicare patients, 2) to pass MPPR legislation to stop a 25 percent cut to the professional component of radiology reimbursement and to require CMS to release the data used to calculate the MPPR, and 3) to implement CMS dampening/code capping policy. Repeal of the SGR falls under the jurisdiction of three congressional committees: the Senate Finance Committee and the House of Representatives Energy and Commerce and Ways and Means committees. Each committee would put together a bill to address the flawed SGR. In July 2013, the House Energy and Commerce Committee passed its bill (H.R. 2810) unanimously. With aggressive lobbying from radiology leaders and the government relations team, the bill contained appropriateness criteria and MPPR provisions. The dampening policy was not present. In early December, the House Ways and Means Committee and Senate Finance Committee released their own proposals to repeal the SGR. Both contained appropriateness criteria and dampening provisions but nothing about MPPR. While all of this was happening, a clock was ticking down the days

• Sustainable growth rate (SGR): A formula designed to limit growth of

• Multiple procedure payment reduction (MPPR): A formula used to

HOW ACR ADVOCACY INFLUENCED POLICY AND PROTECTED MEMBERS AND PATIENTS IN THE MOST DIVISIVE CONGRESS IN DECADES

calculate reimbursement reductions based on estimated efficiencies for procedures performed for the same patient during a single episode of care. For years, the ACR has requested access to the CMS data used to calculate the resulting reductions. • Dampening policy (also called code capping policy): Legislation that

would require CMS to phase in any single-year cuts of more than 20 percent over a two-year period.

Advocacy • Economics • Education • Clinical Research • Quality & Safety | 11

QUICK GLOSSARY

Medicare spending by linking changes in reimbursement to the growth (or lack thereof) of the U.S. economy as a whole. Within a few years of the SGR’s implementation, health care spending had ballooned while economic growth had slowed, resulting in the SGR stipulating drastic cuts to reimbursement. Since the SGR was implemented in 1997, these cuts have been delayed 17 times by “doc fix” bills.

until March 31, 2014, when the previous patch would expire, triggering a 24 percent drop in payments for physicians treating Medicare patients.

A Looming Deadline It’s never been easy to get policy through, but it’s rarely been harder than it is in the current polarized Congress. “It used to be common to have hundreds of bills pass both the House and the Senate. Now it’s down to a fraction of that,” says Cindy Moran, executive vice president of government relations, economics, and health policy. To make things happen in this environment, the government relations team has honed a process that includes three key elements: grassroots (widespread advocacy efforts from membership), “grasstops” (efforts from constituents with close ties to their legislators), and relationships formed with members of Congress and their staff through lobbying. However, none of these strategies will be effective without good policy. “We developed a policy that was non-partisan, a policy that was hard to argue against. It was also a forward-thinking policy that works to improve the current Medicare program,” says Moran. Spangler agrees: “It falls right into line with where Congress is trying to go as far as health care delivery reform. We’re offering to be part of the solution.” “There were many, many times throughout this process that this whole effort could have just ground to a halt,” says Moran. “We don’t control the process — nobody does from the outside — but we felt that we had such a strong argument to make on why these policies were good. People realized that we were trying to get ahead of the curve and our policies were a way of putting some kind of sanity to the madness of inappropriate utilization.”

Reality Check As the March 31 deadline neared, the three congressional committees agreed to

work together during the holiday recess to combine their three respective SGR reform bills into one. On February 6, the committees released a final proposal. “We were fairly confident that dampening and CDS would be in there, but we literally turned to the end of the last page and there was a miscellaneous section and MPPR was in there too,” says Josh Cooper, senior director of government relations. While the legislation stopped short of eliminating the MPPR, it stipulated that CMS release the data behind the policy, which the government relations team had been requesting for years. “It was as if the MPPR transparency fell out of the sky,” says Ted Burnes, director of RADPAC. “I mean, we really worked on it, but if you had asked us with truth serum, ‘Hey, is it gonna happen?’ we would have given it maybe a 30 or 40 percent chance.” With a policy on the table, Congress began the debate on how to pay for the repeal, which is estimated to cost between $121 and $175 billion over 10 years. “While they had an agreement on the policy, it’s considerably more difficult to get an agreement on funding,” says Spangler. As Congress debated the various proposals, it became clear that there was a real possibility the repeal would not pass. “Once we’d made it into the legislation, we enjoyed being at the top of the rollercoaster. But now we were starting our plunge downward, realizing that Congress may not pull it off and get the legislation passed,” says Cooper. Without a repeal, the only option would be another short-term patch, a stop-gap solution that would delay the cuts without doing away with the SGR. The previous patch would expire in two weeks. Many medical societies opposed another patch, refusing to settle for anything less than full repeal. “Our feeling was that if it’s a patch, we wanted to be included, and if it’s a permanent fix, we wanted to be included. We decided to break with the rest of the house of medicine and support the patch,” says Spangler.

Click to watch the passage of the bill with play-by-play from Josh Cooper, senior director of government relations.

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Patching It Up The government relations team contacted staff on both sides of the aisle, in both the House and Senate, to make the case that its provisions should be in the patch. These provisions were noncontroversial and appeared in the full-repeal legislation (which was losing considerable momentum in Congress by this point). Another plus was that they didn’t cost anything. While it seems simple, the government relations team faced opposition to adding anything at all to the patch. “The more you put into a patch, the more you can potentially scare someone off,” says Burnes. One key was the relationships the team had formed on Capitol Hill, which led to calls from congressional staffers looking for opportunities to work together on the patch. “Usually when they reach out to us it’s either really, really good or really, really bad. Fortunately it was the former this time,” says Burnes. “And without the relationships we have, this would not have happened.” During this time, the Radiology Advocacy Network was actively supporting the government relations team’s efforts, with responses to calls to action sometimes reaching four times their normal rates. “Membership played a significant role in making sure Congress knew this was something that they were very interested in and wanted to have included,” says Cooper. As the patch came together, Congress included all of the imaging provisions. On March 25, 2014, the patch came up for debate in the House. The government relations team gathered to watch on CSPAN. (“We’re among the few people who actually watch CSPAN,” says Cooper.) During the debate, something unusual happened. “All of a sudden we noticed that debate was suspended. We’re scrambling to figure out what was going on. Rumors were running rampant that the House didn’t have enough votes to pass the patch because practically all of the other physician groups were mounting a charge in opposition,” says Cooper. The leaders of the House left the floor to consult. The team was stunned. “Then in one of the quickest votes I’ve ever seen,” says Cooper, “the House

Click to hear Rebecca Spangler, director of congressional affairs, describe the drama as the patch made its way through Congress.

came back into session and called for an immediate voice vote on passage of the SGR patch bill. No sooner than the words requesting the vote been spoken, the vote was gaveled down and the legislation declared passed.” Passing a piece of legislation is typically an hours-long process and usually includes further debate. “We were looking at each other going, ‘Did that just happen? Did we win?’” says Cooper. The patch had passed in 29 seconds. Six days later, the Senate passed the patch. The team watched as the vote tally climbed closer and closer to the 60 votes needed to pass. “When that 60th vote was cast, it was a great feeling,” says Chris Sherin, director of congressional affairs. On April 1, President Barack Obama signed into law H.R. 4302. Instead of the 24 percent drop, Medicare physician payments will increase by 0.5 percent through December 2014 and then remain steady through March 31, 2015. The bill contained three more pieces of good news for radiologists. First, referring physicians will be required to consult, but not adhere to, appropriateness criteria at the time of ordering. This is the first time this type of provision has been included in any form of Medicare legislation. “It’s shifting the direction of radiology toward what the government and the policy-makers see as the next frontier for health care, which is moving away from fee-for-service and toward value-based care,” says Sherin. “It’s designed not only to preserve radiologists’ role in the health care system but to elevate their role and increase their involvement.” The second piece of good news relates to the MPPR. CMS will now be required to reveal the data it used to justify the policy. The third victory affects the dampening policy. Starting in 2017, CMS will be required to phase in any single year cuts of more than 20 percent over a two-year period. This level of stability is crucial to

TIMELINE physicians, especially radiologists, who have faced the uncertainty associated with pending SGR cuts on a near annual basis.

Next Steps Now that it has passed, the legislation has to be made into law. “We have to make sure that it is implemented in a way that will have real impact,” says Burnes. The majority of the regulations pertaining to this policy will most likely be issued by CMS over a series of years. First and foremost, by no later than November 2015, CMS must deem various sets of appropriateness criteria as acceptable for consultation by ordering physicians. These guidelines must be developed by national medical specialty societies, such as the ACR. By April 2016, CMS will choose a clinical decision support system to administer the appropriateness criteria. ACR Select will be among the choices and contains the most comprehensive evidence-based guidelines for diagnostic imaging selection. Starting on January 1, 2017, ordering physicians will be required to consult the imaging appropriateness criteria through a clinical decision support tool. The details and timeline for CMS to release its MPPR data have yet to be decided upon, but once this information is available, radiology and other specialties can analyze (and potentially dispute) the statistics behind damaging cuts to reimbursement. “We’re hoping that it will then become clear to Congress that there was no justification for this MPPR reduction. At that point, we will pursue a legislative remedy or look to the courts to remedy this policy,” says Moran. “As we run our advocacy program, we look at radiology-specific issues, but we also look at broader reforms that we think would improve the Medicare program,” says Moran. “The dampening policy, appropriateness criteria, MPPR — all of these issues contribute to Medicare as a whole, benefiting not only radiologists but also patients and other physicians.” Meanwhile, this latest SGR patch is a temporary fix to a systemic problem. In the coming months, it will be up to Congress to determine whether to repeal the SGR or resort to another short-term solution. The current patch expires March 31, 2015. //

1997: The Balanced Budget Act, which includes the SGR formula, is signed into law. 2002: For the first time, the SGR formula results in cuts to physician payments. 2003: The first SGR patch is signed into law, stopping cuts without repealing the SGR. It will be followed by 16 subsequent patches over the next 11 years. 2013: The House Energy and Commerce Committee, House Ways and Means Committee, and Senate Finance Committee begin work on reforming the SGR system. This is the latest in a string of attempts to provide a long-term fix. DECEMBER 18, 2013: Congress passes a three-month extension on the previous patch (which would have expired on January 1, 2014), allowing more time to work on repealing the SGR. JULY 2013: The Energy and Commerce Committee unanimously passes a proposal to repeal the SGR. The bill also contains language about appropriateness criteria and MPPR. DECEMBER 2013: The Ways and Means Committee and Finance Committee release separate proposals for repealing the SGR. Both contain appropriateness criteria and dampening language. FEBRUARY 6, 2013: The three committees release a joint bill to repeal the SGR. It includes language on appropriateness criteria, dampening, and MPPR. Congress begins debate on how to pay for the repeal. MID-MARCH 2014: Discussions break down on financing the full repeal. Another patch becomes the only viable way to avert cuts when the previous patch expires. MARCH 25, 2014: The House passes the patch. MARCH 31, 2014: The Senate passes the patch. APRIL 1, 2014: President Obama signs the patch into law.

MED SCHOOL

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REBOOT

MANY MEDICAL SCHOOLS TAKE AN ANTIQUATED APPROACH TO RADIOLOGY EDUCATION, BUT AS IMAGING AWARENESS INCREASES, SOME SCHOOLS ARE OVERHAULING THEIR PROGRAMS.

Click to watch a video of ACR members discussing the current state of medical education.

By Jenny Jones

ome things are meant to go together: peanut butter and jelly, peas and carrots, milk and cookies, and radiology and the continuum of patient care. While that last couplet may not be a household phrase, radiology is undoubtedly an integral part of medicine. Whether a patient needs an X-ray of a simple bone fracture, a mammogram to screen for breast cancer, or an MRI to investigate a life-threatening brain tumor, imaging is intertwined with nearly all aspects of health care. As medical students learn to care for their patients, appropriate use of imaging is key. For the more than 90 percent of medical students who are not planning on a career in radiology specialties, it is vital to understand imaging’s impact on patients, says David M. Naeger, MD, assistant professor of clinical radiology and co-director of the Henry I. Goldberg Center for Advanced Imaging Education at the University of California, San Francisco. “Radiology is such a massive part of health care that if providers do not understand imaging, they cannot be good doctors.” Yet most medical schools do not emphasize radiology education. A 2012 study of U.S. medical schools reveals that just 25 percent require radiology as a clinical rotation.1 Instead, most medical students receive dedicated imaging training only as elective clinical rotations, according to another 2012 survey of medical school deans and radiology department chairs.2 Otherwise, the survey shows, imaging is integrated into preclinical courses, most notably anatomy, and later into core clinical rotations such as internal medicine, surgery, and obstetrics and gynecology.

Vague Requirements The use of diagnostic imaging has increased rapidly in recent years. Between 1996 and 2010, the number of CTs performed tripled and MRIs quadrupled

among six large integrated health systems alone.3 Naeger says radiology has become increasingly important in health care. But as imaging has advanced, he says, medical school “curricula have changed at a much more deliberate pace, so it’s a lot easier for old habits in medical schools’ approach to radiology education to persist.” Many medical schools follow an antiquated approach to radiology education, where students can elect to take a radiology rotation only during the fourth year. Waiting until the fourth year may make students less likely to become radiologists because they have already been exposed to and declared their interest in other medical specialties by that time. Caroline W.T. Carrico, MD, associate professor of radiology and director of medical student education in the department of radiology at Duke University, also notes, “By waiting until the final year of medical school to introduce students to diagnostic and interventional radiology, it significantly limits the time that students have to integrate good imaging utilization practices as they learn about and begin to practice patient care.” She hopes that moving radiology education into the preclinical and core clerkship year will help students learn basic imaging principles that will help them better use imaging in the care of their patients. “In order to be granted valuable time in the medical school curriculum calendar, academic radiology departments

will need to create and sustain highquality instructional courses and learning opportunities for medical students,” she says. Vasantha D. Aaron, MD, assistant professor of clinical radiology and imaging sciences at Indiana University School of Medicine, says schools need new curricula that get students involved in radiology rather than just having them observe radiologists at work. “It’s hard to be engaged if you’re just watching other people work without any participation yourself,” she says. One reason that approach has endured is because the Liaison Committee on Medical Education simply says that schools must offer “educational opportunities” in radiology, without specifying what those opportunities should entail. Emily M. Webb, MD, associate professor of clinical radiology and co-director of the Henry I. Goldberg Center for Advanced Imaging Education at the University of California, San Francisco, says radiologists should petition the Association of American Medical Colleges and the Liaison Committee on Medical Education for explicit radiology training guidelines. “We need more radiologists to advocate on a national level to get established standards and competencies on the books,” she says.

Lesson Plan Radiologists agree that new curricula should focus less on image interpretation and more on other aspects of imaging. “Historically, people were taught in medical school that everybody needed to know how to interpret images, but as imaging has become more complex and medicine more specialized, it’s important that images be interpreted by the people

Advocacy • Economics • Education • Clinical Research • Quality & Safety | 15

who received dedicated training in it,” Naeger says. Instead, medical school training should focus on such aspects of imaging as appropriateness, radiologists’ roles as consultants in patient care, how to use and understand radiology reports, and the importance of radiologists’ interpretations of images. “We don’t really care about medical students learning to interpret a CT scan, for instance,” Webb says. “We want them to know when to order a CT scan and for what type of indication and when they should be ordering an ultrasound instead.” Radiology education is gaining increasing attention in medical schools today, with some schools overhauling their programs. For instance, Duke University recently expanded its radiology elective into a required clerkship. As part of that transition the course went from a predominantly observational approach to a more interactive format. Under the new format, students participate in activities that are geared to help them better understand the complexity of imaging exams. They observe and help with patients during imaging exams and image-guided procedures to develop patient empathy, hear lectures by radiologists and radiology residents, and, when time permits, help interpret imaging studies. Carrico says the curriculum is tailored so that students learn the value of radiology. “I want them to appreciate how useful a radiology consult can be, as opposed to ordering numerous different exams that may or may not be suited to answer the clinical question,” she says. “They need to know that they can simply consult their radiologists to help guide imaging utilization.” One key to establishing a successful radiology program is having radiologists as teachers. The 2012 survey of medical school deans and radiology department chairs indicates that nonradiologists frequently teach imaging in both preclinical and clinical settings. “As radiologists, we created that problem by not making ourselves available and instead staying in the reading rooms and expecting students to come to us,” Webb says. “As the curricula started changing and we hadn’t shown up in the classroom yet, other providers took the reins, which is obviously a suboptimal

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RADIOLOGY IS SUCH A MASSIVE PART OF HEALTH CARE THAT IF PROVIDERS DO NOT UNDERSTAND IMAGING, THEY CANNOT BE GOOD DOCTORS.” —David M. Naeger, MD

assistant professor of clinical radiology and imaging sciences and program director of nuclear medicine at the Indiana School of Medicine, notes that providers often request imaging exams that are not ideal for the problems they want to solve, leading to challenges down the line. “If an inappropriate exam is done, a patient’s insurance may not want to pay for it, which could saddle them with a pretty big bill,” Westphal explains. “And from a radiologist’s perspective, it’s frustrating because we have to take time away from looking at scans to call the referring physicians and ask them whether they would prefer another exam.” If providers learn about appropriate imaging during medical school, those challenges should diminish. Comprehensive radiology education may also have a positive impact on the industry as a whole because providers will learn to see radiologists as consultants in health care — a goal of ACR’s Imaging 3.0™ initiative. Aaron says medical schools must stress that radiologists are available to collaborate with providers to ensure high-quality care. “They need to know that they can always call the radiologist or go by the reading room to consult with them just like they would a surgeon or anyone else,” she explains. If these concepts are taught early, they will become second-nature to providers. “The goal is to introduce these concepts at the medical-student level so that from the first day, the students see radiologists as partners in patient care,” Carrico says. “Hopefully, for the next generation, this will be a routine mindset.” // Jenny Jones (jenny@jennyjoneswriter. com) is a freelance writer.

situation because they don’t know exactly what these students should be learning.” Now that radiologists are showing interest in teaching, Webb says, they are being welcomed into the educational environment. “The other providers are happy to have us take it over,” she says.

Teach Them Well Teaching medical students how to use imaging appropriately will help them improve patient care throughout their careers. Steven M. Westphal, MD,

ENDNOTES 1. Poot JD, et al. “Understanding the US Medical School Requirements and Medical Students’ Attitudes About Radiology Rotations.” Acad Radiol 2012;19(3):369–73. 2. Straus C, et al. “Medical Student Radiology Education: Summary and Recommendations From a National Survey of Medical School and Radiology Department Leadership.” JACR 2014;11(6):606–10. 3. Smith-Bindman R, et al. “Use of Diagnostic Imaging Studies and Associated Radiation Exposure for Patients Enrolled in Large Integrated Health Care Systems, 1996-2010.” JAMA 2012;307(22):2400–09.

AN ACR TASK FORCE INVESTIGATES RADIOLOGY’S ROLE IN MEDICAL EDUCATION. By Alyssa Martino The ACR Task Force on Medical Student Education in Radiology, in partnership with the Alliance of Medical Student Educators in Radiology, surveyed academic radiology department chairs and medical school deans in late 2012 to understand how medical imaging is currently taught and how physician education can adapt going forward.1

Who should teach imaging? Nonradiologists cannot adequately teach imaging skills

98% 25%

radiology program chairs

medical school deans

What obstacles exist to implementing these changes? Radiology faculty time and availability

18.2% radiology program chairs 18.2% medical school deans Available curriculum time

16.4% radiology program chairs 22.7% medical school deans Resistance from other departments

16.4% 13.6%

radiology program chairs medical school deans

Financial reasons

12.7% 13.6%

radiology programchairs medical school deans

How can the ACR and the Alliance of Medical Student Educators in Radiology help? Support advocacy efforts

26.9% 7.1%

radiology program chairs medical school deans

Establish a national standard curriculum

13.5% 21.4%

What should change in the next ten years? More imaging education across all four years of medical school

44.1% 25.6%

medical school deans

More involvement of radiologists in teaching imaging to medical students

18.6%

radiology program chairs medical school deans

radiology program chairs

20.6%

radiology program chairs

medical school deans

Provide curricular resources

25% 53.6%

radiology program chairs medical school deans

How is radiology usually taught in medical school? During a radiology elective

89%

radiology program chairs

Integrated into other courses, such as anatomy

81%

radiology program chairs

Radiology interest group

67%

radiology program chairs

Didactic clinical lectures

54%

radiology program chairs

What Does All of This Mean? Christopher M. Straus, MD, associate professor of radiology and director of medical student education at the University of Chicago and a member of the ACR task force, says this survey highlights the surprising disparity between academic radiology chairs and medical school deans on such issues as who should teach imaging. He believes the task force summary demonstrates the “need to promote greater involvement through minimizing the effort required. This can be achieved through the deployment of a nationally available curriculum that each program can adopt and integrate in parts or in its entirety to best fit its specific needs.” Straus says, “We need to increase the availability and involvement of radiologists in the education of our future referring physicians.” ENDNOTE 1. Straus CM, et al. “Medical Student Radiology Education: Summary and Recommendations From a National Survey of Medical School and Radiology Department Leadership.” JACR 2014;11(6):606–10. http://bit.ly/JACRMedSchool.

RADIOLOGISTS LOOK BACK ON THEIR EXPERIENCES WITH THE ACR’S GOLDBERG-REEDER TRAVEL GRANT. By Meghan Edwards

ou’ve just transferred to a new hospital, and things are looking rough. At best, you have an ultrasound machine at your disposal, but no sonographer. Patients come to you clutching their films, sometimes walking for miles to get to your door. The power goes out from any time between noon and six o’clock, flooding the reading room in darkness, effectively halting your progress on the work you wanted to finish. Despite this seemingly unending chaos, however, you are surrounded by a flood of residents eager to learn, patients and referring physicians in need of your help, and a host of opportunities ahead. This is a snapshot of what the world of a resident traveling under the Goldberg-Reeder grant might look like. Each year for the past six years, the ACR Goldberg-Reeder Travel Grant has funded several residents to volunteer in impoverished areas overseas. The Bulletin caught up with several alumni to find out what they’re up to now and what lessons they carried with them beyond the plane ride home.

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Looking Back Sihanouk Hospital in Cambodia specifically caters to the poor. During my first day, I was on rounds with other medical teams and noticed a patient in the corner of the room. He was intubated and was surrounded by family, with one member squeezing the manual resuscitator. At first I thought the family members were employees, but then I realized that each of the members were taking turns “breathing” for the patient. I kept waiting for someone to connect the endotracheal tube to a machine, but it never happened. They only had one machine and it was already being used. Going on rounds with other teams is different, but then we get to see things like this — it’s nice to see the faces of the patients that go with our images and learn their stories. — Morlie L. Wang, MD

0.28 physicians

0.03 physicians

CAMBODIA ETHIOPIA 61 years 64 years

0.9 beds

0.24 beds

TANZANIA

0.01 physicians 61 years

0.34 physicians

0.6 beds

Life expectancy Physician density per 1,000 people

BOTSWANA

Hospital availability per 1,000 people

1.8 beds 54 years

The women that I worked with in Botswana constantly blessed me. They think that what doctors do is incredible — that we will immediately make the cancer go away. Because of that, they would go around petting me and giving me all the blessings in the world. By the end of my trip, not only were the women trying to get me married off, but the patients and everyone else was in on the act too. — Surbhi Grover, MD

attention to us. So we would go on clinical radiology rounds and try to interact with the general surgery teams and the clinical teams. We’d see their patients and interact with them as well. By taking a patientcentered approach, we were able to create relationships and share information. — Daniel L. Cooke, MD

One of the things that we encountered at first was a difficulty creating professional relationships. The doctors at Kilimanjaro Christian Medical Center were very busy, and it would be arrogant to expect them to simply set their work aside and solely pay

Be prepared for things to move slowly. Don’t expect everything to fall on a timetable, says Cooke. Adhering to a strict schedule is helpful in the U.S., where we have the capabilities to do things quickly. But in places where you have regular

Words from the Wise

power outages and no internet, things will slow down fast, so you have to be flexible. Don’t let anxieties stop you from going. When Wang applied for the grant, she was hesitant to tell people. Wang was afraid of the opposition she might face because many of her friends and family believed she had too much on her plate already, and that she shouldn’t leave her two young children. With the support of her attending physicians, she went anyway. The experience paid off, and Wang discovered a love of teaching in Cambodia. “My children are proud of the work their mother did when they were younger,” Wang says. Your time and knowledge are your best resources. The old adage about teaching

Thinking of where you should go? Take a look at the past grant recipients and their destinations.

2008 Daniel L. Cooke, MD — Tanzania Matthew J. Kogut, MD — Tanzania

2009 Aarti K. Sekhar, MD, works with a faculty member from Addis Ababa University in Ethiopia.

Morlie L. Wang, MD, teaches residents at Sianhouk Hospital Center of Hope in Cambodia.

Aarti K. Sekhar, MD — Tanzania Sonia J. Bobra, MD — Tanzania

2010 Morlie L. Wang, MD — Cambodia Rebecca Gerber, MD — Rwanda

2011

Helmut Diefenthal, MD, director of the program at Kilimanjaro Christian Medical College in Tanzania, teaches radiologists around the light box.

a man to fish is true; nearly every GoldbergReeder alumnus noted that what residents already possess are the best things that they can donate. While many physicians and hospitals find it prudent to donate equipment, often these donations are only good until the machines need service, as many places do not have the resources to maintain the equipment. It’s important to teach the residents about procedures that they can do with the resources they have readily available. Understand the needs of your host country. This is another piece of advice that nearly all Goldberg-Reeder alumni gave. The hospitals you travel to will be completely different from the settings you are used to — power outages are often frequent, and physicians there will have different priorities from your own. For example, Aarti K. Sekhar, MD, noted that, in Ethiopia, the volume of imaging is not as high as in the United States, and the radiologists there spend a great deal of time directly interacting with patients and even going on rounds with the referring clinicians. It’s also a good idea to try and find out about your host site’s priorities before you travel, although sometimes that isn’t possible.

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Daniel L. Cooke, MD, and Helmut Diefenthal, MD, prepare a demonstration using a bovine liver.

Beyond Borders I’ve become much more efficient. In Botswana, things tend to happen at their own pace, so you really have to step up and make things happen. If there’s an emergency, people may take it lightly, so you have to jump on it and be a true advocate for your patient. — Surbhi Grover, MD My time abroad cemented how much I love to teach. In Cambodia, I noticed that every single student was passionate about learning. Even the secretary would ask me to come over and show her what I was showing the residents. Now, in addition to my fellowship, I do online teaching at a local hospital. The students in Cambodia made me realize I like teaching and that, in return for my efforts, I helped cultivate students who were smarter and more capable than they were before. And that’s the best reward for a teacher. — Morlie L. Wang, MD (continued on page 29)

Barbara J. Nickel, MD — Kenya Ginger Merry, MD — Kenya Ryan P. Lokken, MD — Bangladesh Nnenna Agoucha, MD — Nigeria

2012 Mary F. Wood, MD — Chile Ifeanyi C. Onyeacholem, MD — Mozambique Surbhi Grover, MD — Botswana Robin N. Sobolewski, MD — Cape Verde

2013 Kara-Lee Pool, MD — South Africa Kosj Yamoah, MD, PhD — Ghana Claire Alleyne, MD — Kenya Maud M. Morshedi, MD, PhD — Mozambique

Looking to apply for the Goldberg-Reeder grant? The 2014–15 deadline has closed, but check out how to apply for travel in 2015–2016 at http://bit. ly/ACRGoldbergReeder, or contact Brad Short at [email protected]. Applications are due by June 30, 2015.

SOCIAL MEDIA

Front and Center TWITTER-SAVVY RADIOLOGISTS USE SOCIAL MEDIA TO UNCOVER PRO-PATIENT SOLUTIONS. By Meghan Edwards

P

roviding valuable care to patients has always been a tenet of medicine. Because value means something different to everyone in health care — patient, doctor, and administrator — physicians must strive to create patient-based care that adheres to everyone’s needs. In February, the #JACR tweet chat discussed design thinking, featuring noted health design thinker Joyce Lee, MD, MPH, a pediatric endocrinologist and associate professor of pediatrics at the University of Michigan. Design thinking, a methodological approach to innovation that is both creative and human-centered, can help with that. To help come up with these creative solutions, individuals and organizations often use social media as a forum for exchanging ideas. @joyclee to me #designthinking is design at any level that is centered on the most impt person in #hc, the patient #JACR @KristinaHoque #Jacr design thinking must be a partnership between dr and patient- and thinking must be translated to “design doing”

Read some of the highlights throughout the article to understand what problems radiologists face in incorporating design thinking and how radiologists can start incorporating patient participation in their practice. @Ruthcarlosmd as radiologists, we tend to minister to the referring clinician not the patient. Needs to change. #jacr @TirathPatelMD Many times, the patient only receives secondhand information about the report, filtered via the referring clinician #JACR

Communication is an issue often cited in value-based care; unsurprisingly, it is integral to the concept of design thinking in medicine as well. Participants in the chat noted that the radiologist does not always factor in the patient experience and instead remains a distant face in the dark room. This is an issue for incorporating design thinking as radiologists must seek to understand what it is that patients value before they can begin incorporating value-based tasks. Additionally, the specialty often does not primarily interact with patients and instead speaks with the referring clinician. Communicating well with the clinician is still a vital part of value-based health care. However, patients often do not understand the findings in their images, or what those findings mean for their health.

Want to get in on the #JACR tweetchat? Join us the fourth Thursday of every month at 12 p.m. EDT. For more information or to view past chat transcripts, visit http://bit. ly/JACRTChat.

@RogueRad With current regulatory burden, designing is like expecting Da Vinci to paint Mona Lisa with his nose, blindfolded #JACR @TirathPatelMD Not just regulatory. Much of radiology driven by RVUs, TAT, & performance metrics. Hard to “design” in such climate #JACR

Design thinking can also relate to the burden of regulations that physicians have to follow. HIPAA, Meaningful Use, RVUs, the Patient Protection and Affordable Care Act — radiologists must follow and satisfy all these requirements and more. A deluge of requirements to satisfy and procedures to follow often stifles any ability to think beyond the borders of current workflows. Additionally, although many of these regulations are designed to provide quality care, it is easy to lose sight of the patient’s needs in the process. @Jim_Rawson_MD #JACR Patients are great partners. Have had patient advisors on design team on equip projects for over a decade @Dleerad #jacr 1. Commuicate results 2 patients face-to-face with rad, clinician, & patient all present. 2. Embed rad n clinic @NateMargolisMD #JACR need focus groups w pts to solve design issues, can use social media, #epatients input welcome

How can you combat these obstacles and find creative solutions to help patients? Perhaps it means using “baby steps,” as @TirathPatelMD said during the chat. First, it is important to identify what problems you may be facing: do you want to have more face-to-face time? Have you considered what patients might desire as they progress from the waiting room to the imaging suite? From there, identify a solution and a strategy to tackle the problem. These can also be small steps. Above all, participants suggested getting input from patients. Patients know their obstacles best, so they are the best ones to consult. Consider using social media such as Facebook and Twitter to ask patients what they would like improved, and what you can do to help. You could also try creating a focus group of patients. By including patients in your design thinking process, you also show them that you are not just a specialist sitting in the dark, but a physician who is committed to being a central piece of the health care process. //

Advocacy • Economics • Education • Clinical Research • Quality & Safety | 21

NEWS FROM THE BOARD OF CHANCELLORS By Paul H. Ellenbogen, MD, FACR

Your Board in Action THE BOC GATHERED AT AMCLC TO REVIEW THE YEAR’S ACTIVITIES AND CHART A COURSE FOR THE COMING YEAR.

Patient safety remains an important part of everything we do.

Paul E. Ellenbogen, MD, FACR, immediate past chair, comments during the Saturday BOC meeting at AMCLC.

T

he ACR Board of Chancellors (BOC) held its spring meeting at AMCLC in May. The meeting focused on multiple initiatives that the College had undertaken in the previous six to twelve months and included a strategic planning exercise in forecasting environmental trends and future assumptions. At my final meeting as chair of the BOC, I highlighted accomplishments within both the legislative and decisionsupport areas. Of particular note were the ACR-backed policies and the provisions for imaging clinical decision support that are now incorporated into federal law. The board heard updates on the growing use of ACR Select™ and the transition to electronic health records, emphasizing that although there will be continued challenges ahead, clinical decision support will be an

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integral diagnostic imaging tool to assist our members and patients in the changing health care system. Patient safety remains an important part of everything we do, particularly the use of ACR Appropriateness Criteria® for determining appropriate imaging services. I also reported on the United States Preventative Services Task Force (USPSTF) positive grading of CT lung cancer screening, which provides coverage under the Affordable Care Act for high-risk patients aged 55–80 covered by private payers. The College continues to work to have Medicare provide coverage for high-risk enrollees as well. I then reported on the launch and growing recognition of Imaging 3.0™. In closing, I thanked my wife, Macki, members of the BOC and College Steering Committee, and ACR staff for their ongoing support. I look forward to serving the College in my new role as ACR president. William T. Thorwarth Jr., MD, FACR, presented the CEO report, thanking the Search Committee, BOC, and ACR staff for a smooth transition into his role as CEO. A special thank you was extended to Harvey L. Neiman, MD, FACR, for his vision and leadership. Thorwarth described ACR program areas, highlighting the significant legislative success in getting our highest priorities enacted into law despite the ongoing challenges presented by significant changes in health care payment and delivery systems. Thorwarth reported that the College’s investments, membership, and net assets continue to grow. Clinical research restructuring continues.

In addition, Thorwarth reported that the ACR’s Education Center received a generous in-kind gift of hardware and software from General Electric. He further noted that IT and informatics continue to focus on a common Imaging 3.0 informatics framework by meeting with key industry partners. ACR Select continues to grow and is currently implemented in 30 sites in 17 states. The Head Injury Institute™ is collaborating with the Department of Defense on defining several significant funding opportunities. Thorwarth thanked the ACR staff, who continue to work tirelessly on these and other endeavors in support of the membership and the patients they serve. Anne C. Roberts, MD, FACR, ACR secretary-treasurer, provided a financial report and proposed budget for the upcoming fiscal year, from July 1, 2014, through June 30, 2015. The College remains financially strong, and the proposed College budgets for fiscal year 2015 were approved as submitted. Bibb Allen Jr., MD, FACR, vice chair of the BOC, provided an update on the strategic planning process, introducing Paul Meyer of Tecker International. Meyer reviewed the strategic planning process and timeline of activities for the College. He then facilitated a planned “Environmental Scan” exercise. The BOC, CSC, and staff members were divided into eight small groups, each tasked with brainstorming, documenting, and reporting the most significant assumptions about the future of radiology. The five categories of discussion included professional competition and structure; economic factors and

Geoffrey G. Smith, MD, FACR, Alan D. Kaye, MD, FACR, Katarzyna J. Macura, MD, PhD, FACR, Cynthia S. Sherry, MD, FACR, and Marta H. Schulman, MD, FACR, participate in the BOC meeting.

global business; legislation and regulations; demographics and social values; and technology and science. Next steps will include collecting research with primary groups followed by strategic planning sessions this summer. Results will be presented at the fall board meeting. Kimberly E. Applegate, MD, FACR, ACR Council speaker, highlighted upcoming activities at the 2014 ACR AMCLC. Applegate reported that the council considered 19 policy resolutions for ten-year renewal, four new policy resolutions, two bylaws resolutions, and 29 practice guidelines and technical standards. An additional late resolution was determined as emergent and co-sponsored by the BOC and CSC for council consideration. Four ASTRO collaborative guidelines were reviewed and approved by the BOC and CSC. Cynthia S. Sherry, MD, FACR, chair of the ACR Commission on Leadership

and Practice Development, provided an update on achievements of the Radiology Leadership Institute® (RLI). To date there have been 1,700 enrollees in the RLI, with more than 125 online courses. Several resident programs have also expressed interest in incorporating RLI content into their non-clinical training. The 2014 RLI Leadership Summit will take place August 7–10, 2014, at Babson College, in Wellesley, Mass. The RLI campaign has exceeded its first-phase goal of $5 million in pledges. Soliciting and stewarding the support of key campaign donors, creating ongoing publicity, and reviewing campaign effectiveness are all key next steps. Debra L. Monticciolo, MD, FACR, reported on the ACR Commission on Quality & Safety, providing updates on lung cancer screening activities. The changes in practice guidelines criteria, established by the Institute of Medicine, were reviewed. To

ensure compliance, a late resolution seeking BOC sponsorship to change the name “practice guidelines” to “practice parameters” was approved by the board. A newly enhanced online ACR Fellowship application process was demonstrated by M. Elizabeth Oates, MD, FACR, and staff. Programs, trends, and final survey data on the adoption of the 16-month accelerated pathway to dual board certification in diagnostic radiology and nuclear radiology were reviewed. The latest work force survey results were reviewed by Edward I. Bluth, MD, FACR. This was the third annual survey illustrating trends in hiring and anticipated hiring practices. The survey results are to be published in the JACR®. Katarzyna J. Macura, MD, PhD, FACR, provided an update on the ACR Commission for Women and General Diversity, highlighting the commission’s vision, mission, and three-year plan. Utilizing a variety of communications strategies, the commission will continue to increase awareness of the value created by increased diversity. Macura reviewed the latest statistics for both women and minorities and made recommendations for improving institutional performance. At the end of the Saturday meeting, outgoing members of the BOC and officers were recognized and thanked for their outstanding service. On Tuesday afternoon, the newly installed officers of the BOC and CSC held a short meeting. Allen welcomed newly elected and appointed members to the BOC and CSC. Allen shared his vision for the board, emphasizing collective teamwork and the importance of thinking and acting strategically. The BOC and CSC will next meet in September 2014. The proceedings will be reported to the membership in the ACR Bulletin. //

Advocacy • Economics • Education • Clinical Research • Quality & Safety | 23

NEWS FROM THE COUNCIL STEERING COMMITTEE By Kimberly E. Applegate, MD, MS, FACR, Speaker of the Council, and William T. Herrington, MD, FACR, Vice Speaker of the Council

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embers of the Council Steering Committee (CSC) have embraced their role and responsibilities and lost no time in getting down to business following the annual meeting.

Work Group Progress The primary responsibility of Work Group I, chaired by Jacqueline A. Bello, MD, FACR, is to analyze evaluations from AMCLC 2014 attendees and make recommendations. While CSC work groups may change from year to year, this one has become a staple and its members’ Kimberly E. work will be especially Applegate important this year as we look forward to ACR 2015, the first annual meeting for all members — and all of radiology. Under Dr. Bello’s leadership, the work group will lead efforts to develop and provide orientation to the council meeting for attendees who have never attended, provide recommendations to ensure appropriate communication to our members about all aspects of the ACR 2015 program, and assist caucus chairs with optimizing their meetings in the context of the new format. Work Group II is chaired by Richard Strax, MD, FACR, and focuses on resolutions and policy development. The newly adopted CSC mission statement (see sidebar) outlines the CSC’s goal of facilitating and developing ACR policy, and this work group is focused solely on this. Members will work to identify issues through a number of sources and evaluate them for potential policy resolutions. The group will also work with the entire CSC, the BOC, and the ACR

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2014-2015 CSC Off to a Running Start WITH NEW MEMBERS IN PLACE, THE CSC IS FOCUSED ON THE YEAR AHEAD.

Council to promote and facilitate the development of necessary policy resolutions. Work Group III, chaired by Joseph G. Cernigliaro, MD, FACR, William T. is charged with reviewHerrington ing and better utilizing the CSC’s liaison role with chapters, subspecialty societies, and ACR commissions. Through the liaison program, CSC members provide ongoing communications to the chapters, societies, military branches, and federal agencies represented within our council. The group will seek to not only improve the mechanisms through which the CSC communicates but also the frequency with which they do so. The ultimate goal is to engage the council members and leaders year-round and develop more meaningful relationships. Work Group IV, chaired by Sanjay K. Shetty, MD, MBA, is charged with

enhancing the attendee experience at ACR 2015 through the use of information technology. Dr. Shetty chaired a similar work group this past year, which resulted in the use of an improved audience response system at AMCLC 2014, the continuation of the popular “Appy Hour” and the launch of a very well-received social media training session. Work group members this year will contribute significantly to the technology orientation for next year’s annual meeting and the continued improvement of features that have previously been implemented.

ACR Strategic Planning As you may know, the ACR is engaged in strategic planning for the future of the organization. In coordination with Bibb Allen Jr., MD, FACR, chair of the Board of Chancellors and chair of the ACR Strategic Planning Committee, we invited all councilors and alternate councilors to participate in the strategic planning

WHAT IS THE ROLE OF THE CSC? The mission of the Council Steering Committee (CSC) is to be the representative voice of the ACR membership, by facilitating and developing ACR policy. The College bylaws and current traditions hold that the roles of the CSC include the following: • Approve parameters and standards with input from its members • • • •

and the ACR Council Manage resolutions for the annual meeting Coordinate with the chapters and related societies Plan the governance pathway of the annual meeting Interact with the BOC and commissions

For more information about the CSC, including member pictures and bios, visit http://bit.ly/ACR-CSC.

process. We thank the council members who took advantage of this opportunity to provide input on ACR’s future direction via an electronic survey. The results will be aggregated with all the research that the committee is gathering and will contribute to the development of a new plan that members will see in the coming months.

CSC and AMA Resolutions In June, the AMA’s House of Delegates (HOD) approved a resolution for mandatory Medicare coverage of low-dose CT for lung cancer screening. The CSC was asked by Arl Van Moore Jr., MD, FACR, chair of the ACR’s delegation to the AMA HOD, to generate grassroots support through its liaison network, which members did very quickly and with positive response. In recent years, ACR delegation initiatives to garner AMA support at the

HOD meetings have been quite successful and have proven valuable assets to our government relations team, particularly on issues such as breast cancer screening and repealing the 25 percent multiple procedure payment reduction by CMS in 2012. The CSC will continue to use its liaison communications for similar efforts in the future.

Practice Parameters and Technical Standards One of the CSC’s primary roles (see sidebar on page 24) is to participate in the approval process for parameters and standards, which includes receiving input from members and facilitating council approval at the annual meeting. To that end, we are focused on improving the current processes and developing resources to ensure transparency and facilitate improved

participation by not only the council but the members that we represent. The result of our efforts will be shared via the Council News and in web-based councilor orientation materials.

The CSC Looks Forward Finally, the Moreton Lecturer for ACR 2015, James H. Thrall, MD, FACR, has been confirmed. We have also been busy reviewing the Digest of Council Actions, assessing policies up for their 10-year sunset review, and providing guidance for next year’s annual meeting as members of the ACR 2015 Planning and Program Committees. We are proud to have such an engaging, active, and supportive group to take on the issues that matter to ACR members and the specialty. Please keep in touch by contacting us at [email protected] or [email protected]. //

A CENTRAL ROLE FOR GOVERNANCE AT ACR 2015

ACR 2015 is fast approaching, and the CSC is working to ensure that College governance retains a central role within the expanded meeting program. As attendees navigate the nine knowledge pathways, they will have an opportunity to participate in the annual business meeting of the College by selecting the Governance Pathway. Members of the ACR Council will attend all governance sessions to ensure that the business of the College is conducted with representation from all chapters, qualified subspecialty societies, federal agencies, and military branches. All members are invited to join the Council meeting and participate in debates on pending resolutions that will establish policies, bylaw changes, and practice parameters and technical standards.

Highlights of the Governance Pathway include reports from ACR leadership, ACR elections, the consideration of resolutions, and lively discussion and debate providing critical insight into areas affecting medicine and radiology. Crossover programming for the Governance Pathway also includes the Economics Forum on Monday afternoon, the Moreton Lecture on Tuesday morning, and the Legislative Update and Capitol Hill Preparations on Tuesday afternoon. To see the complete ACR 2015 program, visit http://bit.ly/ACR2015Program. Meeting registration is now open. Go to http://bit.ly/ACR2015reg to get the discounted early registration price.

Advocacy • Economics • Education • Clinical Research • Quality & Safety | 25

SOCIETY CONNECTIONS

One Specialty, Two Approaches ACR AND RSNA PROGRAMS LEAD THE WAY IN PATIENT-CENTERED CARE. By Mary Henderson

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e’ve heard the clarion call: Health care’s new economics require all providers to transition from volumebased to value-based care. For radiologists, that means shifting our practice paradigm from transactional to consultative and focusing on both interpretation and outcomes. It’s imperative that radiologists become more patient-centered and integral to patient care. Chances are you’re aware of the Imaging 3.0™ initiative. These concrete steps and tools empower all radiologists to take a leadership role in shaping America’s future health care system. (Learn more at http://bit.ly/Imaging3Tools.) What you may not know is that RSNA sponsors a related initiative, Radiology Cares™. If you’re looking to make your practice more patient centered, a wide range of resources are available. Need a customizable PowerPoint presentation to share with hospital administrators or community groups or a powerful video on the importance of conveying empathy? Do you

want to quickly peruse media, trade, and scientific articles on patient-centeredness? It’s all part of Radiology Cares.

The Invisibility Factor By encouraging meaningful physician engagement in the patient experience, RSNA’s Radiology Cares campaign offers an effective solution to a common problem: invisibility. “Even though we actively participate in patient care, we’re relatively invisible to the eye of the patient,” says William T. Thorwarth Jr., MD, FACR, ACR CEO. “We need to be seen as we actually are: active participants in patient care.” RSNA launched the Radiology Cares: The Art of Patient-Centered Practice campaign at its 2012 annual meeting and scientific assembly, challenging radiologists to play a more visible and active role. To aid in that effort, RSNA’s Patient-Centered Radiology Steering Committee, which oversees the campaign, has put together a library of online tools at www.RadiologyCares.org. Online resources include professionally

produced videos, PowerPoint presentations that can be customized for specific audiences, and patient-centered care literature (see sidebar). Central to the campaign is the Radiology Cares pledge encouraging radiologists and other imaging professionals to commit to more meaningful engagement in the patient experience, with the goal of helping patients make better-informed decisions regarding their health care. Those taking the pledge at www.RadiologyCares.org receive notifications about campaign updates and new materials. Various market forces — from the growth of teleradiology to health care reform and changing reimbursement models — make it more critical than ever for radiologists to prioritize patient satisfaction and strengthen relationships with referring physicians, hospital administrators, and insurers. “The whole field will lose credibility and respect over time if all we do is read images and are not engaged in the process,” says Mary C. Mahoney, MD, FACR, director of breast imaging at the University of Cincinnati Medical Center’s Barrett Cancer Center and RSNA Board Liaison for Publications and Communications. “We need to bring more to the table or we’ll become less relevant to clinicians and patients.”

Self-Assessment

Hector Ferral, MD, interventional radiologist at Rush North Shore University Health System in Chicago, consults with a patient.

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Bulletin | August 2014

To become more patient-centered, Thorwarth suggests that radiology practices conduct self-assessments addressing the entire continuum of care. “We need to be continually asking, ‘What are we doing well? Where do we need to improve?’” he says. “Every radiologist knows the value of making the patient experience more positive, from convenient parking to a comfortable waiting area to easy and timely access to results.”

ON THE WEB RadiologyCares.org features access to a wide variety of resources related to patient-centered care.

Hector Ferral, MD, explains a set of images to a patient.

While the Radiology Cares campaign suggests increasing face-to-face interaction, Mahoney says talking to patients and sharing results is just one small piece of the overall patient experience. Specific initiatives undertaken to improve that experience — and keep up with the pace of change — will vary from practice to practice. “There’s no such thing as being perfectly centered on the patient,” says Brent J. Wagner, MD, president of West Reading Radiology Associates in Reading, Pa. “The fact that you are moving in the right direction is what really counts.” When it comes to talking to patients, Wagner advises radiologists to look for opportunities for interaction and then strive to get the most out of each exchange. “If we interact with just two or three patients a day, there’s no reason we can’t bring an emotional energy and investment to each of those interactions,” he says. For example, Wagner takes the opportunity to meet with the parents of children who have had normal ultrasound exams, patients who’ve undergone biopsies, and those asking to speak with a radiologist.

Patient Education Empathy for patients maneuvering through the health care system prompted Jennifer L. Kemp, MD, chair of RSNA’s Patient-Centered Radiology Steering Committee, and her colleagues to develop communication tools for their patients at Rose Medical Center in Denver, where she serves as chair of the radiology department. Those resources include patient education videos, a follow-up postcard, and thank-you letters that solicit feedback.

“I wanted to include information on radiologist training in these pieces because I think even my friends and family don’t have a clue as to what I do,” says Kemp, also a private practice radiologist with Diversified Radiology, a Denver-based radiology group. “In our current health care environment, people need to know the value we offer.” The postcard they give to patients directly addresses the invisibility issue and emphasizes quality: “While you might not have seen us, we know you are here; we know your physicians and what they are looking for. We work hard to assure that you are having the best and safest test to address your symptoms.” To improve accessibility to referring physicians, Kemp and colleagues list their direct phone number at the bottom of reports — a change she says has had a profound effect on both physician relationships and her work life. “Referring physicians call more often now,” she says. “They want to talk about appropriate follow up or ask for a second opinion. As a result, I find my work much more rewarding; I feel more connected with the patients. And it helps me to be a better radiologist.” Despite the interruptions, Kemp says the volume of exams read by the six radiologists at her hospital is among the highest in her 50-radiologist group. “I’d rather be part of a team caring for patients than just someone turning out a report,” she says. “I strongly believe that I’m building a trust among referring physicians and patients because they know their exams are being read by a radiologist who cares.” //

Education Toolkit Your index to literature about the movement to become patientcentered. Information comes from experts, scientific journals, medical trade publications, and mainstream media. Presentation Toolkit Customizable PowerPoint presentation decks will help you convey to your colleagues and communities the importance of radiologists being patient-centered. RadiologyInfo.org The award-winning www. RadiologyInfo.org website is an invaluable resource for patient education, offering comprehensive information on radiology procedures, treatments, and therapies. Video Library Access a growing library of videos produced by RSNA as well as other organizations. You’ll find a sample welcome video from a radiology practice as well as entertaining shorts on the power of empathy and how radiologists can impact the lives of their patients. Take the Pledge Commit to communicating more effectively with your patients and you’ll receive a certificate to display in your office.

Mary Henderson is a freelance writer.

Advocacy • Economics • Education • Clinical Research • Quality & Safety | 27

RADLAW By Bill Shields, JD, LLM, CAE, and Tom Hoffman, JD, CAE

I

n past columns, we outlined the history, authority, and structure of the Office of the Inspector General (OIG) of the federal Department of Health and Human Services (read more at http://bit.ly/ May12RADLAW) and explained the OIG Advisory Opinion process (read more at http://bit.ly/June12RADLAW). This month, we’ll delve into a little-known but critically important document called “the OIG Work Plan.” The work plan is an outline of the areas on which the OIG plans to focus during a particular fiscal year. The introduction to the 101-page fiscal year 2014 work plan states, Work planning is a dynamic process, and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues with the resources available. We assess relative risks in the programs for which we have oversight authority to identify the areas most in need of attention and, accordingly, to set priorities for the sequence and proportion of resources to be allocated.1

In other words, the OIG carefully selects the target areas for its work each year. They aren’t just saying they’re going hunting — that’s a given. They’re saying, this year, they’re hunting ducks, deer, and sometimes, radiologists. ACR committee members and staff spend a significant amount of time and effort parsing each annual work plan in an effort to assist members and practices that may fall into these target areas. For example, in the FY 2014 Work Plan, the OIG targets one area that will clearly impact radiologists and two other areas in which radiologists are either already or soon will be involved: Imaging services - Payments for practice expenses Billing and Payments. We will review Medicare Part B payments for imaging

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Bulletin | August 2014

The OIG Work Plan WHAT ARE THE HHS AREAS OF FOCUS THIS YEAR?

services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices. For selected imaging services, we will focus on the practice expense components, including the equipment utilization rate…. Security of portable devices containing personal health information Protected Health Information. We will review security controls implemented by Medicare and Medicaid contractors and at hospitals to prevent the loss of protected health information (PHI) stored on portable devices and media, such as laptops, jump drives, backup tapes, and equipment considered for disposal. Controls over networked medical devices at hospitals (new) Protected Health Information. We will determine whether hospitals’ security controls over networked medical devices are sufficient to effectively protect associated electronically protected health information (ePHI) and ensure beneficiary safety.

In the imaging practice expenses area, we anticipate the OIG will scrutinize to what extent radiology practices actually use imaging equipment. In 2009, the Medicare Payment Advisory Commission (MedPAC) issued a report on the assessment of payment adequacy. MedPAC opined that a 50 percent utilization rate (i.e., using equipment for 25 hours per week, when an imaging center is open for 50 hours per week) contributed to the rapid volume growth of advanced imaging services by mispricing those services. MedPAC asserted that health care entities that had a lower volume of services thereby might have incentive to purchase expensive machines. However, ACR and other organizations contended that the MedPAC data was too limited

because it only included six markets. ACR has discussed this audit with OIG officials and offered to assist the OIG in designing its parameters, especially as it relates to the equipment utilization rate. At press time, the OIG had not yet finalized its audit. When it comes to networked medical devices in hospitals, we anticipate the OIG will include RIS, PACS, and electronic medical records (EMRs) access as part of its review. In some hospitals, the facility controls all of these systems. In others, by contract or past practice, radiologists are responsible for the PACS and RIS. The OIG will undoubtedly examine access controls, access tracking, password use, encryption, antivirus protection, and reporting of any breaches or other violations. The same is true for EMRs. Although radiologists are unlikely to have direct control over a hospital EMR system, they are responsible for the actions of their physicians and other employees. In this regard, the OIG always looks at HIPAA training and enforcement. The OIG is still working on this audit. In the area highlighting security of portable devices, we anticipate that the OIG will examine which devices can be used to access patient data in the hospital systems and the system protections such as password use, encryption, antivirus software, HIPAA training, etc. Of particular relevance to radiologists is the use of various devices for remote interpretation and reporting. While a tablet may be very convenient for such work, a four-digit security code, such as those securing Apple’s mobile devices, may not be considered adequate for protection of PHI. Whether the radiologist loads the images in the hospital and carries them out on (continued on page 29)

JOB LISTINGS Well Traveled

The OIG Work Plan

Going to these countries makes you more empathetic and flexible. Any time you work with people who are in a very different situation from you, you have an opportunity to learn from that experience and make personal connections. Living in a place where there is limited access to hot water or electricity also has helped increase my flexibility and the range of what I can do with limited resources. — Aarti K. Sekhar, MD

the device or accesses them remotely on the PACS, the OIG will expect the same level of protection as is enforced within the hospital. Virtually all HIPAA breaches involving portable devices involve either lost tablets or laptops or unprotected devices that were accessed by someone who was not authorized to do so. This audit is also pending. //

continued from page 20

Passing the Torch Unsurprisingly, several of those who have participated in the Goldberg-Reeder grant have continued to do work in global health. Surbhi Grover, MD, who traveled to Botswana in 2012, will join the faculty at the University of Pennsylvania next September. From there, she will return to Botswana, dividing her time between countries. “I always wanted to work in international and clinical settings, where I can both treat patients and contribute to research,” she says. Cervical cancer in particular is prevalent in India and sub-Saharan Africa. “They need more oncologists there, and they welcomed me with open arms,” she notes. Aarti K. Sekhar, who traveled to Tanzania, is now an assistant professor at Emory University, in Georgia. After her experiences in Africa and because of her international background, she decided she wanted global health to be a significant part of her career. Now, Sekhar works as a faculty advisor in an Emory program that sends residents to Ethiopia for month-long rotations. She travels with the residents to Emory’s sister hospital in Ethiopia, where they train others to perform procedures such as CT and ultrasound-guided biopsies, go on rounds with residents from other specialties, and interact with patients at the bedside. “These experiences abroad are really formative and valuable,” Sekhar says. “The Goldberg-Reeder helped me decide what I wanted to do in my career, and now I want to help my residents have that experience.” //

continued from page 28

ENDNOTE 1. U.S. Department of Health and Human Services Office of Inspector General. “Work Plan for Fiscal Year 2014.” http://bit.ly/OIGworkplan. Accessed May 30, 2014.

DELAWARE - Lewes – Practice radiology at the beach. An eight-member group desires to add two diagnostic radiologists. Southern Delaware Imaging Associates serves a 120-bed hospital and three outpatient offices in a small beach town in southern coastal Delaware and the adjacent semi-rural Sussex County. Fellowship training preferred. Contact: Frances Esposito by phone at 302-228-8598 or by email at [email protected]. FLORIDA - Tampa Bay Area - Great opportunity with growing and dynamic multispeciality radiology group seeking a radiologist to join their group. Incoming physician will be reading all general modalities while covering outpatient imaging facilities in the extended Tampa Bay area. NO CALLS! High income potential. Contact: Email resume to gisrads@ gmail.com. ILLINOIS – A practice located approximately one hour northwest of Chicago is looking for a candidate with a fellowship in either neuro or MSK. Contact: Rebecca Stemm by phone at 815-519-2600 or by email at Rmstemm@ gmail.com. KANSAS - Kansas City - Large progressive radiology group in Kansas City is looking for a BC/BE radiologist with fellowship training in breast imaging to start around July 2015. The group covers 10 facilities, including an imaging center. Competitive salary/bonus package and benefits. Contact: Please email CV and three to five personal references to [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% discount on a classified ad in JACR. To learn more about this bundled offer, e-mail [email protected]. RATES: ACR members: $50; nonmembers: $125. 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 website. Only jobs posted on the website are eligible to appear in the ACR Bulletin, on a space-available basis.

NEW YORK - Join the premier radiologic group of New York’s Hudson Valley! Currently we are offering a part-time opportunity to cover weekday evenings and weekend evenings. This shift is from 4:00 p.m. to 12:00 a.m. and services both our hospitals and outpatient customers. The shift is performed onsite. We offer competative salary and malpractice benefits. Contact: Rita Cavaliere by phone at 845343-0616 or by email at [email protected]. PENNSYLVANIA – Hospital-based private practice in northeastern Pennsylvania is seeking a part-time, BC radiologist to supplement growing needs. Candidate will work mornings, perform minor procedures, and read all modalities as needed. Candidate must be onsite, a team player, and willing to speak with referring physicians. Contact: Send CVs to [email protected]. TEXAS - Houston - Seeking a breast imager to join our busy outpatient-based practice. Candidate must be board certified and fellowship trained in breast imaging with a current Texas license. Candidate should be able to cover general radiology cases. No overnight call and occasional weekend responsibilities. Contact: Tamara Richard by phone at 281-453-7463 or by email at [email protected].

Advocacy • Economics • Education • Clinical Research • Quality & Safety | 29

final read

>>

Roger S. Eng, MD, MPH, FACR, President, Golden Gate Radiology Medical Group, Orinda, Calif.

WHAT CAN RADIOLOGISTS DO TO BECOME VISIBLE MEMBERS OF THE CARE TEAM?

I

look forward to the day when our patients routinely view their radiologist in the same way they see their internist or cardiologist. As health care pivots to new delivery models, our specialty’s survival will depend on engaging patients more directly. Patients need to know that radiologists are doctors at the center of the care team, and it’s our job to help this happen. How can we achieve this? We need to change our practice patterns to place the patient at the center of our workflow, rather than the imaging report or our beloved technology. With increasing consumerism in health care and shifting payment practices, there has never been a better opportunity for us to occupy a chair at the patient care table. The good news is each of us has the capacity to better engage our patients. There are a host of opportunities for this, from face-to-face consulta-

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“We need to change our practice patterns to place the patient at the center of our workflow, rather than the imaging report or our beloved technology.” — Roger S. Eng, MD, MPH, FACR tions to imaging-centric patient portals and social media involvement. I know many groups in California have already begun this transition. The most successful have grown their practices despite a challenging environment. A shift to a more patientcentric specialty will not be easy, but we have the skills and expertise to contribute more visibly to patient care. Let’s use them to do just that. //

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Women’s Imaging & ARRS Annual Scholarship Program ARRS Annual Scholarship Program Breast Imaging now accepting nominations now accepting nominations with

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.

Investing in the Future in of the Radiology Investing Future of Radiology

October 9–11, 2014 | Silver Spring, MD

Tomosynthesis

Each year, to two $140,000 scholarships are awarded to Roentgen Fund® TheupAmerican Roentgen SocietyRoentgen (ARRS) and TheRay American RayThe Society (ARRS) and The Roentgen Fund® young investigators, educators and/or administrators to invite medical schools, affiliated hospitals and clinical research and clinical research invite medical schools, affiliated hospitals support institutions studies thattowill prepare one themcandidate for leadership positions nominate for the 2011 ARRS Annual institutions to nominate one candidate for the 2011 ARRS Annual in academic radiology. Scholarship Program.Scholarship Program.

Improve your diagnostic accuracy, limit differential Coronary CT Angiography oskeletal MR call backs Muscul Breast MR with Guided Biopsydiagnoses and reduce

ARRS Annual Scholarship Program now accepting nominations

Scholarships a generous grant from Each are year,funded up to through two $140,000 scholarships are awarded Join faculty for a to comprehensive rad-path review of women’s and breast imaging and Each year, upleading to two $140,000 scholarships are awarded to ® The Roentgen Fund . young investigators, educators and/or administrators to understand the underlying pathology of to topics spanning the breast and pelvis. young investigators, educators and/or administrators support studies that will prepare them for leadership positions support studies that will prepare them for leadership positions Investing in the Future of Radiology The general requirements for candidates are: in academic radiology. in academic radiology. Coronary CT Angiography ■ MD or DOBreast from an accredited institution Coronary CT Angiography oskeletal MR Musculoskeletal MR MR with Guided Biopsy ® Breast MR and withThe Guided Biopsy American Roentgen Ray Society (ARRS) Roentgen FundMuscul ■ TheCompletion of all required residency, fellowship training or equivalent Scholarships are funded through aare generous grant froma 15–16 Plus, attend the one-day tomosynthesis workshop 11 theOctober ACR Education Center is packed with CT Colonography August Scholarships funded through generous grant August from at on medical schools, affiliated hospitals and clinical research ■ invite Certification by the American Board of Radiology or equivalent ® ® The Roentgen Fund . dynamic, interactive mini-fellowships to help you improve andfor learn to pinpoint the size, shape and location of any Thecandidate Roentgen Fund . effectively to one theinstructor, 2011 ARRS Annual Coronary CTnominate Angiography August 19–21 ■ institutions Full-time faculty appointment as aabnormalities lecturer, assistant professor or equivalent for no more than five years your interpretation skills, scan protocolsbeyond and productivity — leading to better detection, fewer call backs and Scholarship Program. completion of training; Appointment must be in a department of radiology, nuclear medicine, or an associatedfocus. department in Investing in the Future of Radiology with a real-world Use Promo SUMMER1000BU UseThe Promo Code: SUMMER1000BU general Code: requirements for candidates are: Investing in the Future of Radiology greater peace of mind. The general requirements for candidates are: the ■ radiological sciences of a medical school teaching hospital in the U.S. or Canada MD or DO from an ■ accredited MD or DOinstitution from an accredited institution ® Each year, up to two $140,000 scholarships are awarded to Roentgen TheCompletion American Ray Society (ARRS) and The Fund ■ Candidate must be aRoentgen member of the ARRSRoentgen at fellowship the time the application isand submitted and forFund the ®duration of the award The American Ray Society (ARRS) Thewww.acr.org/educenter Roentgen ■ of all required residency, training orfellowship equivalent Register for Your Mini-Fellowship ■ and/or Completion of all required residency, or equivalent young investigators, educators administrators toclinical August at the ACR Education Center is packed with CT Colonography August 15–16at training CT Colonography August 15–16 invite medical schools, affiliated hospitals and research medical schools, affiliated hospitals and clinical research ■ studies Certification byprepare the American Board orBoard equivalent 1.800.373.2204. Register now atofairp.org/catcourse ■ invite Certification byoftheRadiology American Radiology or equivalent dynamic, interactive mini-fellowships to help you improve support that will them for leadership positions institutions to nominate one candidate for theone 2011 ARRS Annual For more information the scholarship program and application procedures, Coronary CTabout Angiography August 19–21 institutions to nominate candidate for the 2011August ARRS Annual ■ Full-time faculty appointment as a lecturer, instructor, assistant professor or equivalent for no more than years beyond Coronary CT Angiography 19–21 ■ Full-time faculty appointment as a lecturer, instructor, assistant professor or equivalent for no more five years beyond your interpretation skills, scanfive protocols and than productivity in academic radiology. Scholarship visit www.arrs.org orProgram. call 1-800-227-5463 or 703-648-8900. Scholarship Program. completion of training; Appointment must be in a department of radiology, nuclear medicine, or an associated department in completion of training; Appointment must be in a department of radiology, medicine, associatedfocus. department in with a nuclear real-world focus. Use SUMMER1000BU Use Promo Promo Code: Code: SUMMER1000BU withoraan real-world Use Promo Code: SUMMER1000BU Use Promo Code: SUMMER1000BU theare radiological sciences of a medical school teaching hospital in the U.S. orhospital Canada in the U.S. or Canada the radiological sciences of a medical school teaching Scholarships funded through a generous grant from Each year, tonot two $140,000 scholarships are awarded to application The deadline forupare submission of rates, applications is November 19, 2010. Each up to scholarships awarded to with PLEASE Savings valid on year, MIT ontwo already orare in combination otherfor discounts. ■NOTE: Candidate be a Candidate member the ARRS atpurchased the time the istime submitted and the duration of be$140,000 a member of courses, the ARRS at the application is submitted andtheforaward the duration of the award The Roentgen Fund®Register .must ■ forofmust Your Mini-Fellowship atthewww.acr.org/educenter

save $1,000

Tomosynthesis Workshop ARRS Annual Scholarship Program ARRS Annual Scholarship Program now accepting nominations now accepting nominations

save save $1,000 $1,000

airp.org | 1.800.373.2204 |

Register for Your Mini-Fellowship at www.acr.org/educenter