Radiology’s Nuclear Spring
Tilting toward RSNA and entering the home stretch of 2011, I haven’t had a lot of time to reflect on the year, but I know that I am not alone. Everywhere I go, I hear a common chorus (no time!) followed by a plaintive refrain (at least I still have a job). When I walked into my primary-care practitioner’s office recently, even he repeated that refrain—evidence that the atmosphere of uncertainty and change has permeated all strata of US society, and, specifically, medicine. He said that unemployment and loss of benefits have taken a toll on his employed multispecialty practice, which is providing significantly more uncompensated care. The news of the past few months has done nothing to dispel this atmosphere of uncertainty, but I am seeing signs that radiology is stepping beyond its fear of both the known and the unknown. This is a very good development because, as we all know, fear paralyzes. The assault on the professional component induced a great amount of dread. After threatening a 50% discount on the professional component for procedures that fall under the Multiple Procedure Payment Reduction (MPPR), CMS settled on a 25% figure in the final Medicare Physician Fee Schedule, issued in early November. It doesn’t matter whether two different radiologists read the multiple procedures: In its final rule, CMS has expanded the MPPR to include multiple providers in the same group practice. A technique generously applied in the rehabilitation field, this cost-cutting measure is relatively new to physician reimbursement, although CMS has used it in the surgical realm. Applying the discount to multiple procedures performed for the same patient in the same practice seems to have been invented expressly for radiology. It’s impossible to cast this in a positive light, but perhaps it will have a positive effect. To date, the profession has been somewhat divided on CMS reimbursement matters, with those who do not own imaging equipment remaining somewhat remote on the issue of cuts to the technical component. With this latest development, radiologists will feel the pain equally, and this could be a unifying moment for the profession. Dose, e-Dose In 2009, excess-radiation events were reported by a highly respected Southern California hospital, setting in motion a great deal of uncomfortable media attention (as well as a redoubling of the effort begun by pediatric radiologists, physicists, vendors, and organized radiology to manage radiation dose). Achievements since then include the establishment of the ACR® national Dose Index Registry, the endorsement by the National Quality Forum of a dose-tracking quality measure (Participation in a Systemic Dose Index Registry), the adoption by many radiography vendors of an international standard that could eliminate technologist confusion in the DR/CR suite, and the widening of the Image Gently campaign to encompass other modalities that emit ionizing radiation. What has lagged behind is a sense of individual responsibility on the part of radiologists, but that appears to be changing, too. Interviewed at the ACR’s First Annual Imaging Informatics Summit and Dose Monitoring Forum (held in Washington, DC, on November 3–4), Richard Morin, PhD, Mayo Clinic (Jacksonville, Florida), acknowledged that the radiology community still has work to do before a dose report can be issued to patients (as California law mandates, effective July 1, 2012). Individual radiologists must begin by looking at their protocols. “How much radiation are they using, and if they are using more than their colleagues, why are they doing that?” Morin asks. Also interviewed in Washington was Marilyn Goske, MD, a pediatric radiologist at Cincinnati Children’s Hospital in Ohio. She believes that the department has an obligation to parents and patients to be as informative as possible, but allows that radiology must still find a way to communicate complex concepts more simply. “Patients have to be told clearly [what the risk is] when they come in; when they leave the department, they should know more about the test than when they arrived,” she says. “We have to get our house in order first.” The Informatics Wrench If there is a task to be accomplished or a problem to be solved, radiologists are quick to reach for the informatics wrench, so it is somewhat ironic that practices are struggling with the decision of whether to attest to meaningful use of health IT (see articles beginning on pages 24, 45, and 49). The news from the Washington forum is that the ACR has successfully engaged with the Meaningful Use Workgroup and the Office of the National Coordinator on the need for specialty accommodations in subsequent stages of meaningful use. As one who has participated in that effort, Keith Dreyer, DO, PhD, vice chair of radiology computing and information sciences at Massachusetts General Hospital in Boston, says, “The meaningful-use pathway is really a health-care reform ascension path.” The path progresses from capturing and sharing data (in stage 1) to implementing decision support (in stage 2) to outcomes analysis (in stage 3). On the exhibit floor in Chicago, Illinois, look for signs of what many predict is an impending leap in innovation in informatics: dose-mitigation and dose-tracking solutions, meaningful-use attestation, practice-management tools, and decision-support advances. From the depths of the radiation-dose crisis to the assault on the professional component, radiology is emerging stronger, more focused, more unified, and better equipped to communicate its value to medicine.