Sara Michael

Interest in clinical applications for PET/MR continues to mount, and now researchers at the University of North Carolina School of Medicine are studying its use for bladder cancer staging.

Researchers at UNC’s Lineberger Comprehensive Cancer Center, Department of Radiology, and Biomedical Research Imaging Center are conducting a pilot study to evaluate PET/MR for staging patients with muscle invasive bladder cancer, which represents about a quarter of bladder cancer patients.

“We are interested in understanding whether PET/MR may be a better modality for detecting lymph node involvement” in these patients, said Matthew Milowsky, MD, principal investigator of bladder cancer staging project and a medical oncologist and associate professor of medicine at UNC Chapel Hill.

Conventional MR and CT are the standard of care, but their accuracy is poor in these cases. The reported sensitivity for detection of lymph node metastases is 50 percent for MR and overall accuracy is 50 percent to 60 percent for CT, Milowsky said. PET/MR might offer better soft tissue characterization and anatomical information plus functional molecular imaging, he said.

Thirty patients with muscle invasive bladder cancer are enrolled in the study. Prior to surgery, each patient undergoes conventional imaging with CT and a PET/MR scan with the Biograph mMR PET/MR system from Siemens Healthcare. The pathology from the standard of care lymph node dissection is used as the gold standard to evaluate the accuracy of PET/MR. “We will be able to see whether or not we can predict the presence of lymph node involvement,” Milowsky said.

Although it’s too early in the study to speculate on whether PET/MR is a better modality, Milowsky said “that’s the hypothesis and we are excited.”

Arif Sheikh, MD, assistant professor of radiology, nuclear medicine, at UNC, noted a growing interest in understanding the molecular characteristics of cancer, as well as finding the extent of the cancer. Though PET and MR each have their shortcomings, the combined modality may offer enough information to improve sensitivity and specificity, he said. “This is a marriage of the best two strengths in imaging to stage the patient with bladder cancer.”

The Biograph mMR PET/MR system received FDA approval in 2011, and researchers and clinicians continue to build data to demonstrate PET/MR’s advantages. Because it’s a new technology, the benefits have yet to be fully proven in bladder cancer, Milowsky said.

The technology is being reimbursed for both the PET and MRI portions when each exam is medically necessary and clinically indicated. In the case of bladder cancer, this pertains to the use of PET and MR during pretreatment staging.

A challenge for UNC with the new modality is the lack of cross-trained technologists, according to Weili Lin, PhD, director of the Biomedical Research Imaging Center, who is leading the implementation and current research. Training for the PET and MR technologists - which includes adjusting the work flow and learning the software - took some time. For the interpreting physicians, new software must be used to view the studies due to  complexities that are not experienced with traditional PET/CT imaging or even with the fusion of PET and MRI studies. This training will continue to be refined once the needs become more clearly defined, researchers said.

Joseph K.T. Lee, MD, a radiology professor in abdominal imaging and former chair of the department of radiology at UNC, credited his institution’s organization and team approach for making the program run smoothly. Every research project is led either by a clinician or a radiologist, said Lee, “and we have nuclear medicine physicians and radiologists and technologists working together. Without this organized team approach, there would be no way we could advance a new modality like PET/MR systematically.”

Milowsky agreed. “Any good medicine we know these days is characterized by a multidisciplinary effort. I think UNC has done a tremendous job in fostering a culture of collaboration and collegiality.”

Articles

Could PET/MR be a better modality than conventional MR and CT for bladder cancer?

PET/MR for Bladder Cancer: UNC Investigates

The timely and reliable delivery of critical test results has become a major priority for radiologists. Without effective systems in place, delayed communication could threaten patient safety and physician efficiency.

Recognizing this, Maimonides Medical Center implemented a critical test result management (CTRM) system four years ago. The system, a Nuance product, has dramatically improved the radiology department’s workflow, said Mark Flyer, MD, CIIP.

“The concern was… getting these results to the right person and making sure patients don’t fall through the cracks,” Flyer said in an interview at this year’s 

 where he presented about their use of this system. “We saw an opportunity to improve on patient care and communication, making sure that critical results are communicated efficiently, quickly and to the right person.”

The facility learned quite a few lessons along the way - one major one being that physicians across the board preferred physician-to-physician communication of results. In a survey conducted by the hospital, physicians noted their concern with the automated system was that lack of direct interaction.

“We in radiology have tried to back track a little and always put out the call first to the doctor,” Flyer said.

But when that direct contact isn’t possible, this system allowed them to effectively relay that information, he noted. The system has improved productivity by making it easier to convey the results. Hospital officials also made tweaks to the system to make it more flexible and tailored to specific physicians’ schedules and preferred contact methods.

Above all, the system has brought physicians a heightened understanding of the need for communication, Flyer said.

“Our job is not done once we issue a report and make a finding,” he said. “Our job is half done. The other half entails making sure that information gets into the hands of the person that has to act on it, so the patient will be the ultimate beneficiary of this.”

Videos

VIDEO: Mark Flyer, MD, CIIP, of Maimonides Medical Center, shares the experiences and lessons learned when his facility implemented a critical test results management system.

Tips for Implementing a Critical Test Results System

Radiology services have been a target of federal reimbursement cuts for the last several years. And most of these cuts, said 

, president of the American College of Radiology, are not based in logic.

These reimbursement policies represent a common thread between radiologists and radiation oncologists, said Blumberg, himself a radiation oncologist at and a practicing radiation oncologist at Radiation Oncology HealthCare PA and vice chair of the Department of Radiation Oncology at Greater Baltimore Medical Center.

“Though some may think there is a world of difference between the practice of radiology and radiation oncology, the truth of the matter is, the biggest challenge facing both subspecialties is really the government and the reimbursement polices being instituted by CMS and their constant efforts to reduce expenditures,” he said.

Blumberg was elected to his new post in May and recently sat down with Diagnostic Imaging to discuss the challenges facing radiologists and radiation oncologists.

The industry’s greatest fight right now, he said is to encourage CMS to adopt a computerized decision support system. This would allow for more appropriate image ordering, Blumberg said, which would result in savings, rather than cutting from radiologist reimbursement.

When it comes to bridging the gap between radiologists and radiation oncologists, Blumberg noted that the challenges the two groups are facing have a lot more commonalities than differences.

“It’s time to circle the wagons,” he said. “There needs to be an agreement that this should be a major goal.”

VIDEO: ACR president Albert Blumberg, MD, discusses CMS’s reimbursement cuts and the shared challenges of radiologists and radiation oncologists.

ACR President Blumberg on Reimbursement Cuts, Industry Goals

The radiology department at Hackensack University Medical Center has always been committed to patient safety and quality of care. But now they have a unique distinction to prove it.

The Bergen County, NJ, facility was recently recognized by the American College of Radiology as one of the first two 

This distinction, also awarded to the Mount Desert Island Hospital in Bar Harbor, Maine, shows the medical center went above and beyond accreditation, proving high quality in areas such as personnel, equipment specifications, outcomes measurement and quality control systems, safety policies, utilization reviews, facility management and patient outcomes. The center was also evaluated in service, availability of imaging and radiologists, and image interpretation and quality.

[[{"type":"media","view_mode":"media_crop","fid":"14193","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_9222787725802","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"708","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right; margin: 5px;","title":"Harry Agress Jr., MD, FACR","typeof":"foaf:Image"}}]]“By being so stringent and so specific, it not only speaks to the elements of patient safety and care, but it also goes to the point that we take this job very, very seriously,” said Harry Agress Jr., MD, FACR, chairman emeritus of the Department of Radiology at Hackensack University Medical Center, speaking in a podcast interview with 

. “This says we feel a great deal of responsibility for that.”

Agress and Jason Kreitner, MHA, RT, (R)(T), FACHE, administrator of clinical services at Hackensack, convened a multidisciplinary team to review the ACR standards set in the application. Together, that team tackled each area to ensure they met the requirements, he said. It turned out the medical center was already following most of the standards, and a few areas needed attention.

For example, the team upgraded and formalized many of their policies and procedures, such as those documenting communication with referring physicians. They also clarified some job descriptions, and spent time formalizing their education and marketing of radiation safety to patients and referrers.

Agress noted a few elements that make Hackensack unique, including that they have 24-7 coverage by onsite attending physicians, rather than outsourced radiologists or residents and fellows. That makes the radiology department available for consultation at any time, he said, and allows for faster turnaround times.[[{"type":"media","view_mode":"media_crop","fid":"14194","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_1973456998479","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"709","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right; margin: 5px;","title":"Jason Kreitner, MHA, RT, (R)(T), FACHE","typeof":"foaf:Image"}}]]

Now, with this Center of Excellence distinction, the facility can show to patients and referring physicians that they are taking that extra step, Agress said. “We are really a high-level imaging center [and] we care a great deal about our patients and the quality of what we are doing.”

The 25-page application can be a bit overwhelming, officials said, but it’s worth the effort. And Kreitner has already received calls from other facilities asking how they achieved this recognition and what the process was like.

“This exemplifies to our patients and physicians in our community that quality is paramount,” he said, “and demonstrates that we made the investment in ensuring we deliver the highest possible care to our patients.”

Podcasts

Hackensack University Medical Center has earned ACR’s distinction as one of the first two Diagnostic Imaging Centers of Excellence. Here’s how they did it.

What It Takes To Be an Imaging Center of Excellence

Patients don’t fully understand radiology’s role in healthcare, and they might not have the right forum for asking questions about medical imaging.

The solution? Create a radiology-specific blog with content dedicated to medical imaging.

“We want a way to connect with our patients meaningfully rather than just at the check-in counter or with our blind piece of paper from our radiology report,” C. Matthew Hawkins, a pediatric radiology fellow at Cincinnati Children’s Hospital Medical Center, said in an interview.

pediatric radiology fellow at Cincinnati Children’s Hospital Medical Center. - See more at: http://www.diagnosticimaging.com/voice-recognition/podcast-improving-natural-language-processing-error-rates#sthash.Z0UoG7jt.dpufpediatric radiology fellow at Cincinnati Children’s Hospital Medical Center. - See more at: http://www.diagnosticimaging.com/voice-recognition/podcast-improving-natural-language-processing-error-rates#sthash.Z0UoG7jt.dpuf

Patients also have a ton of questions - particularly in a pediatric setting - so a blog can offer relevant information about major public health topics such as radiation dose.

“We feel like we need an outlet to inform the public to tell them what we are doing to lower dose,” Hawkins said.

Cincinnati Children’s is in the process of implementing this department-specific blog, which will be supplemented by posts to Facebook, Twitter, and YouTube. The department has spent months planning and preparing content, and officials will monitor readership data once it’s live this winter.

Regularly updated content is a critical requirement for a successful blog, 

officials said in a report on their efforts

 presented at SIIM 2013. So to prepare for the launch, the department took great pains to plan content before going live, with as much as month of content ready at the launch. For example, they are developing interviews about publications and meetings, posts about new technology, entries about their department programs and information about radiation safety and other subjects of special interest to patients and parents. They also set up a video production studio to shoot and edit video content, which will be a bulk of the blog’s content.

The department created a social media content committee with representatives across the department to plan content, while a governance committee will determine guidelines and processes for posting. A major challenge is making sure the blog is sustainable, Hawkins said, noting that often social media efforts fall flat without the proper buy-in and planning.

Hawkins and his team also wanted to make sure the blog was as easy as possible. Delivering content takes time, so they wanted the process to minimize the time spent on it. Hawkins noted that the department will monitor data from the site, such as page views, visitors and clicks from other social media platforms.

VIDEO: Cincinnati Children’s is creating a department-specific blog to connect with and educate patients. Matt Hawkins, MD, discusses the blog’s prep and planning.

Implementing a Radiology Department Blog

Taking research from a controlled laboratory to the real world can introduce some practical problems. The device or medication, for example, might not work in practice.

“It’s not as simple as taking what you have in the lab and having it work patients,” said Bradley Erickson, MD, PhD, FSIIM, a radiology professor at Mayo Clinic in Rochester. He delivered the 2013 Dwyer Lecture on translational research at the

 “You have to deal with the real world, and that’s true for radiology just as it is for others.”

That bench-to-bedside, or translational, research is a critical part of understanding diseases and new technologies. But it can seem that the two sides are opposing forces. Innovation usually involves one person with a great - and disruptive - idea. Translation requires some discipline and teamwork.

But, Erickson said in an interview, “It’s possible for both to exist.”

In this video, Erickson explains translational research in radiology and what it takes to bring innovation into practice.

VIDEO: Bradley Erickson, MD, PhD, FSIIM, explains translational research and the challenges facing innovative radiology organizations.

Translational Research in Radiology

GRAPEVINE, Texas - What’s the best way to make sure physicians will embrace a new enterprise imaging system?

Get as many docs as possible to help select it. That’s the tactic officials at The Johns Hopkins Hospital took with a recent implementation.

“We wanted them to be a part of the decision making process, as many doctors as possible,” said Paul Nagy, PhD, FSIIM, director of quality in the Department of Radiology at Johns Hopkins. He was speaking Friday at a SIIM 2013 session on strategies for managing medical images. “We got 300 physicians.”

Nagy and his colleagues knew they wouldn’t have much luck asking physicians to come to vendor demo at 9 a.m. on a Tuesday. Physicians are busy, their schedules aren’t their own, and sitting through an hour-long passive demonstration was probably the last thing they wanted to do.

Instead, Nagy and his team brought the demo to the doctors. After identifying the technical and business requirements of the enterprise viewer, they rigorously evaluated a dozen solutions based on their criteria. Once the selections were narrowed to three, they presented the options to the doctors.

 They developed a Web-based tool for the testing and evaluation of the options. Without a specific location or allotted time, Nagy said the physicians would be free to test the systems at their convenience. Further, they made the evaluations task-driven, rather than a passive demo, which would allow the physicians to really test drive the capabilities. They also added in a few incentives - raffling a few iPads - to entice participation.

They were also able to reach Johns Hopkins physicians as they were logging into the hospital system, giving them a notice to take part in the survey and be a part of the enterprise viewer selection process.

“This was a lot of fun,” Nagy said of the process.

Users evaluated the solutions and filled out short surveys. After about a month, they had more than 300 responses.

Nagy noted that had they asked 300 physicians to attend vendor demos, that would have eaten up more than 900 work hours. Instead, the Web-based evaluation system took only about 80 hours total, saving 10 times the physicians’ time.

It always seems that the number of physicians who show up to an in-person vendor demo is inversely proportionate to the number who complain about the system that’s selected, Nagy said. So few docs come to the demo, but they are lined up with gripes later. Nagy and his team wanted to avoid this, and giving physicians a direct and critical role in the selection was the solution, with the idea that they would have greater clinical adoption. He added, “We did a lot to get people involved.”

The best way to maximize clinical adoption of a new enterprise viewer would be to get physicians involved in the selection process, IT officials said at SIIM 2013.

How to Get Physician Buy-In with a New IT System

GRAPEVINE, Texas - The use of mobile technologies in healthcare continues to grow, and staff isn’t just accessing data on employer-provided devices.

In fact, the BYOD - bring your own device - movement is “here and it’s here to stay,” said Marc Kohli, MD, of Indiana University School of Medicine. Eighty-one percent of workers overall use a personal device to access work information. That rises to 84 percent among healthcare workers, he said, speaking at a SIIM 2013 session.

“This has really led to a culture shift to where [organizations] are no longer trying to secure systems, but secure the information in the systems,” Kohli said.

To address these security concerns, many organizations are developing mobile device security standards. And those that don’t yet, will soon, he added. These policies address items such as passcode standards (how many characters and how long the device is accessible once logged in), intrusion prevention (how many times someone can try the wrong passcode before getting locked out), and data encryption on the device.

The good news, he said, was there are quite a few third-party vendors helping standardize and control mobile access for organizations.

There’s no doubt mobile computing will “have a huge impact on our lives,” said George Shih, MD, MS, of Weill Cornell Medical College, also speaking at SIIM. In healthcare, about 62 percent of physicians are using tablets, and more than half of them are using them at the bedside.

Though iPhones and the Apple iOS platform seem to dominate with more medical apps, open source platforms like that of the Android devices will reign in the future. The open architecture of these systems allow for easier development of apps and sharing of health information, Shih said.

Mobile also holds promise in medical education, Kohli noted. For example, the University of Colorado purchased 34 

. The devices were preloaded with textbook content, videos and other apps aimed at supporting their study.

University officials evaluated their program and found residents spent more time doing educational activities than they did before the introduction of the iPads, Kohli said. They had an easier time finding and accessing the information they needed.

“Tablets,” he noted, “are amazing content consumption devices.”

The use of mobile technologies in healthcare continues to grow, with staff accessing data on their own devices.

BYOD: The Challenge and Promise of Mobile Tech in Medicine

Are you waiting to jump head-first into the federal government's 

 program? That might not be a bad idea, according to David Avrin, MD, PhD, FSIIM, of the University of California San Francisco.

Arvin advocated a strategy of "watchful waiting vs. making a square peg fit in a round hole," he said, speaking Friday at the annual meeting of SIIM 2013.

The meaningful use program for electronic health records was developed with primary care, family, and OB/GYN physicians in mind – not radiologists and other specialties. Therefore, Avrin explained, it doesn't quite for radiologists needs for the technology. It's especially hard for smaller, private practice radiologists, which represent the majority in the industry, as opposed to hospital-based departments.

"It isn't about imaging," he said of the program, noting meaningful use is more focused on the 750,000 internal and family practice docs in the country. And it's not about tailoring the program to fit different specialties.

This is in stark contrast of a "make it work" attitude taken by Arvin's colleague and well-known meaningful use expert Keith Dreyer, DO, PhD, FACR, FSIIM, of Massachusetts General Hospital. Dreyer has long said that a vast majority of radiologists quality for the program, and that it is 

 Radiologists should be gathering information and working out plans to comply, he has said.

However, Avrin said, instead radiologists should support their industry organization efforts to get the federal government to make it relevant to radiology.

For example, radiologists want to be able to exchange images among organizations and provide access to patients. The program should support clinical decision support for radiologists and ordering physicians. Radiologists want to measure and monitor clinical quality measures. These are just a few capabilities ranked as high importance by radiologists surveyed by KLAS in conjunction with RSNA in 2011.

"I would rather take this list and keep working on these guys rather than massage the situation," Avrin said.

What about the hardship exemption that says radiologists can claim they are unable to meet the requirements, and therefore avoid penalties in 2015? Also not a good idea to rely on, Avrin said. It's hard for such a tech-savvy industry to claim hardship on digitizing medical records, he noted. And there's a general perception that with or without the temptation of the exemption, the specialty is subject to penalties at some point.

So what can you do while watchful waiting?

Discuss meaningful use certification plans with your PACS and RIS vendors, if you haven't done so already, Avrin said. Second, evaluate your practice to determine how you might work to comply with the program.

What do you think? Are you taking a watchful waiting approach or diving into meaningful use?

Waiting to jump head-first into the federal government’s meaningful use program? That might not be a bad idea, David Avrin, MD, said at SIIM.

Watchful Waiting with Meaningful Use in Radiology?

GRAPEVINE, Texas - Imagine a scenario where no little clinical decision support was utilized: A 53-year-old female presents to the emergency department with a headache and VI nerve palsy.

The ordering physician requests a head CT to rule out a mass. The radiologist receives the order and has plenty of questions. He calls the referring doc, and a lengthy discussion results in the decision to instead order an MRI.

During acquisition, it becomes clear the patient has issues with her renal function, so there are concerns about the contrast agent. Another lengthy discussion, this time with the technologies, ensues. Later, once the images are interpreted, there’s confusion about what to do with the results. Are they critical? What’s the hospital’s policy for communication the findings?

And then even more obstacles present when the billing department finds issue with the report because a supervising physician didn’t sign off on a trainee’s report.

“We did a lot of work here basically for nothing,” said Luciano Prevedello, MD, MPH, of Brigham and Women’s Hospital and Harvard Medical School. He presented this scenario and all its pitfalls Thursday during a presentation at the SIIM annual meeting.

“CDS is the way to go,” he declared, because pressure is only increasing to find efficiencies in health care. A  lengthy, convoluted process like the one he first described isn’t ideal. Instead clinical decision support can provide the right information to the right person at the right time, he said.

Take for example that same case, but with CDS. When the ordering physician tried to request a head CT, the system would have let him know MRI is the preferred test, based on the patient data he entered. A series of rules running in the background of the electronic system based on ACR Appropriateness Criteria would guide the decision.

The proper protocol could then be selected from given options, and the radiologist can ensure he has the right clinical data for the patient. He can also do external searches to aid in interpretation. When it’s time to report the findings, the radiologist can select the level of notification, following the hospital’s policies.

“CDS can be in a lot of places in the process,” noted Katherine Andriole, PhD, FSIIM, also of Brigham and Women’s Hospital and Harvard Medical School, who chaired the session. Decision support can assist in ordering, optimizing protocols, interpretation, reporting, communication, and follow up, she said.

Decision support’s potential doesn’t stop there. That massive amount of data can be mined and utilized to improve efficiencies, according to Woojin Kim, MD, of the University of Pennsylvania School of Medicine.

For example, if an ordering physician regularly doesn’t follow the recommendations and bypasses the decision support, mining that data can help improve compliance. A handy bar chart showing how often this one doc ignores the guidelines, and how much he is an outlier in his organization, can effectively encourage compliance.

“That wouldn’t be possible unless you mine the [computerized physician order entry] data,” said Kim.

Similarly, providing a physician with a patient’s prior studies might change his ordering behavior. Data on imaging recommendations follow-up and radiation dose can also be researched and mined to benefit the organization, he said.

Clinical decision support can assist multiple times in the medical imaging chain to improve efficiency and patient care, according to experts at SIIM 2013.