Educational sessions offer practitioner insight, experience

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 Real-world cases, relevancy to practice, and real strategies for implementation—these are the takeaways from education sessions delivered at the annual RSNA conference. Some of the notable presentations from this year are summarized here. For full-length stories these presentations and more, visit RSNA360.HealthImaging.com.


Imaging informatics

Katherine Andriole, PhD, of Brigham and Women’s Hospital in Boston, foresees a bright future for CR and DR. She predicted the technology will get faster and smaller, decrease in cost, and offer value-added tools for image-intense specialties. However, its use in mammography poses challenges for PACS workflow due to image size and workstation interpretation requirements.

Khan Siddiqui, MD, from the VA Maryland Health Care System in Baltimore said repetitive use of conventional user input devices such as the mouse and keyboard are associated with musculoskeletal injuries. He noted that alternative input devices including trackballs, roller mice, tablets and game controllers show promise.   

Siddiqui’s colleague, Eliot Siegel, MD, said that ergonomics is a serious business from both productivity and health perspectives. As such, radiology departments must promote healthy, low-stress reading environments.

“PACS workstations aren’t keeping pace with the increase in imaging volume,” said Steven Horii, MD, from the Hospital of University of Pennsylvania in Philadelphia.

Horii encouraged a focus on integration, automation, task-appropriate controls and user interfaces, and environments conducive to task management.

Aldo Badano, MD, with the Laboratory for the Assessment of Medical Imaging Systems at the FDA, said that informatics professionals must accurately assess display systems to provide radiologists the optimal start point for their image interpretation.


Molecular imaging

Martin Pomper, MD, PhD, of Johns Hopkins University in Baltimore, said radiology is evolving from anatomic-based diagnostic imaging to functional and hybrid imaging technologies.

Current research is focused on three areas: new imaging probes and technologies; drug development, imaging gene delivery and expression; and understanding cellular processes.

King Li, MD, from the National Institutes of Health Clinical Center, cautioned that radiologists could be taken out of the diagnosis and treatment loops if molecular medicine proceeds without diagnostic imaging.

David Gilmore from Beth Israel Deaconess Hospital in Boston discussed technology on the hybrid imaging horizon, including MR/CT, PET/MR and PET/mammo.


Mammography

“We really are at the beginning of our learning curve in digital mammo,” said Margarita Zuley, MD, from the University of Pittsburgh Medical Center.

Factors that challenge the reading of digital mammograms are: high volume; short viewing time; complex image interpretation; extremely low cancer incidence at screening; and human factors such as interruptions and fatigue.

“Perception in digital mammography is influenced by factors, the most important of which is the patient changing over time,” said Zuley. “The second most important influence is us [the radiologist] and our goal to perceive those changes given all the different variables we are dealing with in digital mammography.”

Matthew Freedman, MD, from Georgetown University Medical Center in Washington, D.C., said that computer-aided detection (CAD) improved the detection of “things,” which are eventually deemed benign, malignant or actionable. He said that with the assistance of CAD, more benign and malignant things will be seen.

Michael Ulissey, MD, from the University of Texas Southwestern Medical Center in Dallas, said that: “We have to tell the good white from the bad white in mammograms for detecting breast cancer,” which is more complicated in denser breasts.

He encouraged his fellow radiologists to use the detection technology because “CAD can be our greatest ally.”


Quality improvement

James Borgstede, MD, of the University of Illinois College of Medicine in Chicago, said that “what is best for the patient is best for the physician and changing practice requires a healthcare team effort.”

He said that for project success, the entire healthcare team needs to be involved; physicians need to be involved in the project; and all team members must have specific topics.

Paul Nagy, PhD, from the University of Maryland Medical Center in Baltimore, suggested that accelerated pace and performance pressure have left quality control marginalized. PACS products make everyone more productive, but they also need to increase communication between radiologist and technologist as opposed to decreasing it.

Ramin Khorasani, MD, from Brigham and Women’s Hospital, noted that: “For change management [to promote quality], you must address people more than anything else.”

Paul Chang, MD, from the University of Chicago Medical Center, said radiology needs to shift from cranking out work to adding value and contributing quality. Currently, he said, quality is peripheral to the daily tasks of radiologists, but “it’s inevitable that we have to deal with quality and we should want to.”


Practice extenders

Paul Ellenbogen MD, chair of the American College of Radiology (ACR) Commission on Human Resources said he foresees the radiologist assistant (RA) and radiology practitioner assistant (RPA) converging into one position—the RA.

“We do not anticipate RAs to be a replacement for individual diagnostic practitioners, but merely an extender,” he said.

John Patti, MD, observed: “There is a need to meet the demand and workload driving us in one direction but fear is driving us in the other—fear that they will replace us.”

Ellenbogen said that the Inter-societal Commission on the RA has been formed to address issues related to the practice of radiologist extenders and to create a definition of their scope of practice.


P4P

When it comes to the 2007 Physicians Quality Reporting Initiative (PQRI) and pay for performance (P4P), “radiologists must play,” said Paul Larson, MD.  “We need more data for radiology,” he said. “Why not get paid for collecting it?”

Mark Bernardy, MD, said consumers will shop around for their medical care, forcing not just physicians, but radiologists, to offer more value and quality than before.

Susan Nedza, MD, of the Special Program Office of Value-Based Purchasing at the Centers for Medicare and Medicaid Services (CMS), said it needs input from radiologists to create effective measure sets, which will only be as good as the feedback CMS receives.

Partners Healthcare in Boston opted to move to a P4P model, said Thomas Lee, CEO. Physicians who achieve targets are rewarded with a greater net increase, while those who do not will receive their guaranteed increase, but will see a lower net.

The current reimbursement system doesn’t reward quality or punish poor performance, said Bruce Reiner, MD, of the VA Maryland Health Care System.

He recommended the standardization and integration of reference databases, tracking quality assurance (QA) performance from the patients’ point of view, tying malpractice rates to individual QA rates, and tying reimbursement to the practice of evidence-based medicine.


Reimbursement

“If you’re not at the table, then you’re on the menu,” warned Chris Ullrich, MD, chair of the ACR managed care committee and managed care network during a course on reimbursement issues.

Richard Duszak, MD, chair of the ACR committee on coding and nomenclature, said that radiologists can facilitate the payment process by encouraging radiology certification among coders.

The budget-neutral adjustment in the current CMS environment reduces the physician work component of Medicare payments, and radiology remains in the cross hairs for future cuts, said Bibb Allen, MD, vice chair of the ACR Commission on Economics.


Lung cancer screening

Caroline Chiles, MD, from Wake Forest University Baptist Medical Center in Winston-Salem, N.C., acknowledged that lung cancer screening is not always effective because “screening tends to detect slowly growing cancer rather than rapidly growing cancers.”

Chiles highlighted two on-going randomized controlled clinical trials that she thinks will eventually shed light on how helpful imaging is in the detection of lung cancer. The U.S.-based National Lung Screening Trial (NLST) and the Belgium-based NELSON Trial are long-term trials on lung cancer screening in high-risk subjects.

David Yankelevitz, MD, from New York-Presbyterian Medical Center and Weill Cornell Medical College in New York City, spoke about the need to standardize the terminology of the clinical trial.

Both Chiles and Yankelevitz reminded the audience that no radiological method or trial is currently considered the gold-standard in lung cancer detection.  


Cardiac imaging: CT and MR

Ricardo Cury, MD, from Massachusetts General Hospital in Boston, heralded the benefits of CT for cardiac imaging, while J. Paul Finn, MD, from the University of California at Los Angeles, supported the use of MR for cardiac imaging.

Cury believes that CT can be used for comprehensive cardiac acquisition, including the coronary arteries, left ventricular function, coronary valves, and for perfusion and viability.

Finn said that cardiac MR is a “very versatile and flexible modality to approach cardiac imaging.” He stressed the clear advantage of cardiac MR is the evaluation of viability and myocardial perfusion. 


Gadolinium and NSF

Radiologists need to be aware that mounting evidence suggests the use gadolinium-based contrast agents may lead to nephrogenic systemic fibrosis (NSF) in patients with chronic kidney disease.

“We have been relatively confident all along that increasing the administered dose of a gadolinium-based MR contrast agent (GBMCA) for patients with severe or end-stage chronic kidney disease increases the likelihood of a patient developing NSF,” said Emanuel Kanal, MD, from the University of Pittsburgh Medical Center.

“New data from several more recent articles in the peer-reviewed literature now strongly suggest that cumulative doses of administered GBMCA [over an as yet undefined time period, possibly even a lifetime] seems to play a role in determining not only the likelihood of developing NSF, but also the severity of the clinical case of NSF that will be developed/experienced,” he said.


Key Points from the Keynotes
Images, IT and inevitable change

 
  RSNA President Gilbert Jost, MD
The pace of change is accelerating, RSNA President Gilbert Jost, MD, told RSNA attendees in the President’s Address, “The Evolution of the Digital Age and Its Impact on Radiology’s Future.” Radiology must take advantage of the opportunities offered by the digital world. The first step is a new breed of imaging scientists. “We should capitalize on technology to build effective, interactive, electronic teaching tools,” he said.

James P. Borgstede, MD, an MR imaging fellow and assistant professor of radiology at the University of California, San Diego, addressed “With Worldwide Image Distribution, Will Radiology Become a Commodity?” in the opening session. To avoid commoditization, the radiology community needs: Awareness and recognition that a problem exists; Practice alliances; Internalization of after-hours service (the use of teleradiology has more than tripled since 2003); To develop specialty identification with patients; To embrace quality metrics, and pay for performance and safety standards.

Electronic-based technologies are critical enablers to increase the growing desire for real-time delivery, optimized, personalized service, echoed Paul Chang, MD, professor and vice chairman of radiology informatics and medical director of pathology informatics at the University of Chicago Pritzker School of Medicine, who spoke on “Leveraging Informatics to Enhance Radiology Relevance and Value.” Next-generation IT systems need to improve throughput and report turn-around times, as well as provide more intelligent, prioritized worklists.

Embrace molecular imaging

Elias A. Zerhouni, MD, director of the National Institutes of Health (NIH) encouraged his fellow radiologists to embrace and seek to understand the biological complexities of molecular medicine in his Eugene P. Pendergrass New Horizons lecture, “Major Trends in the Imaging Series.” The future of understanding biological data needs to be quantitative, non-destructive, multi-dimensional, have a high temporal resolution, be spatially resolved, high data density and have common standards. “Imaging is no longer going to be defined by the tools we have, but instead, by its larger impact on the medical industry,” he said. 

Kudos for breast imaging

After decades of controversy and challenges, breast imaging is now enjoying new accomplishments, said Lawrence Bassett, MD, breast imaging section head at David Geffen School of Medicine at the University of California Los Angeles during the Annual Oration in Diagnostic Radiology “Breast Imaging: Yesterday, Today, and Tomorrow.” Among them are practice guidelines, the American College of Radiology (ACR) Commission on Breast Imaging, standardized reporting and evidence-based medicine. Bassett foresees an expanding role for breast imagers in disease management, advances in digital mammography, ultrasound, CAD, breast MRI and breast tomosynthesis and renewed interest in breast imaging among residents.

Solving the healthcare cost crisis

Healthcare costs in the United States are quickly approaching unsustainable levels and require immediate action, said Allen Lichter, MD, executive vice president and CEO of the American Society of Clinical Oncology (ASCO), who delivered the annual oration in radiation oncology. What are the solutions? Investment in primary care, EMRs and clinical trials that show where imaging and therapy are effective. And physicians need to guide healthcare reform and be advocates for “a rational payment system.”