Society of Breast Imaging From The Editor: IHE 2007 ACR ® First Class 1891 Preston White Drive AIM To Improve Digital CPT Code Mammography U.S. Postage Reston, VA 20191-4397 Mammography Performance Breast Imaging Update Accreditation PAID Permit #144 2 3 5 9 Waldorf, MD

The Member Newsletter of the Society of Breast Imaging FALL 2006 Presidential Message: Maintenance of Certification, Maintenance of Confidence

government invited their participation their respective 24 Boards. Six core R. James Brenner, MD, JD in return for reconsidering drastic competencies are defined by the reimbursement cuts. Since the begin- ABMS for all specialties and include ost of us have heard of the ning of this Century, highlighted in an medical knowledge, patient care, in- Mupcoming Maintenance of IOM (Institute of Medicine) report, terpersonal and communication Certification, or MOC, the public and payers have been advo- skills, professionalism, practice based program, perhaps even read about it cating a process that would improve learning and self-improvement, and in one of the national journals. Some the quality of healthcare in a manner system based practice. Board certi- may have already participated in one that could be objectively measured. fication reflects all of these and until element leading to MOC, a SAMS Pointing to other industries where 2002, those who received certifica- exam where questions are answered certain metrics could be used to mea- tion were not required to demonstrate following a conference presentation, sure quality, such advocates have any further evidence of continuing that can be applied toward completion declined to accept the autonomy of competency beyond compliance with of the ten year process. But I suspect the American physician and insisted approved programs for continuing that both the rationale and even de- on developing systems that at least education. Since 2002, ABR certifica- tails of the program are not familiar. begin to incentivise improvement in tion is granted for diagnostic radiologists That will change and the purpose of care. This effort in fact dates back at for ten years, after which re-certification this column is to facilitate that least ten years; consider the HEDIS is mandatory. Otherwise, evidence of change. This is an issue that affects standards that were applied to pri- MOC is voluntary but, as will be dis- not just breast imagers or even radio- mary care physicians to encourage cussed below, external events may logists; it affects all of medicine. compliance with best practice patterns modify this condition. There are a number of terms that such as recommending screening This historic assumption that relate to this subject with one of the mammography. Of interest, this year those who are involved in approved more interesting terms being “pay for California will institute a trial program, continuing education activities are performance.” (PFP) This lightening rewarding primary care physicians helping to insure continuing compe- rod phrase is certain to capture the who fulfill certain medical recom- tency has been challenged. The answer attention of most practitioners and its mendations. to this challenge is unknown. Under significance is illustrated by the The American Board of Medical such circumstances, MOC programs changing attitude of the AMA Specialties (ABMS), which includes may be seen as the next step in trying (American Medical Association) the American Board of Radiology to provide the public and payers a basis which initially resisted any partici- (ABR), has left the task of establish- for encouraging, if not insuring that pation in a PFP initiative, until the ing parameters for MOC to each of Continued on page 11

1 The Member Newsletter of the Society of Breast Imaging

From The Editor: AIM To Improve Mammography Performance

Without knowing more of the which are available in CD-ROM for- Murray Rebner, MD fine details I would like to offer my mat. The AIM program will start by comments on the program. First, I do testing radiologists with community arla Kerlikowske’s article not think any breast imager would be practice representative screening K describes how the NCI’s opposed to the AIM concept. We are cases. Over time, perhaps the pro- Breast Cancer Surveillance all aware that mammography, albeit the gram could also select diagnostic Consortium (BCSC) will use a 2.5 mil- gold standard for breast cancer screen- cases to further sample the breast lion dollar award to improve mammo- ing, is far from perfect. For phase one, imager’s skills. Assessment and man- graphic interpretation. The AIM determining what, if any, minimum agement recommendations based on (Assessing and Improving Mammog- volumes of screening studies read per the diagnostic workup could also be raphy) project will attempt to do so by year are associated with better per- evaluated. It makes no sense to this writer a three phase effort. In phase one, formance is important. However, the to identify potential areas of improve- researchers will determine the effect timing of the interpretations may also ment to the breast imager if he/she of volume of mammography examina- be important. If radiologist A reads cannot easily follow up in these ar- tions interpreted per year on radiologists’ 480 cases per year and reads 40 cases eas by taking more training. The idea interpretive performance, independent each month, and radiologist B, a back of providing in-person, interactive of other variables such as patient, phy- up reader in a practice, reads 480 cases training with expert breast imagers sician, and facility factors. In phase over the last month of the year for two is an excellent way of doing this. two the investigators will create assess- years to comply with FDA regulations, CME credits could be obtained in the ment tests from community practices does radiologist A perform better than process and maybe over time, a ro- and determine whether cancer preva- radiologist B due to more frequent ex- tating group of expert radiologists lence or other mammographic findings posure to the modality? Also, is there a and technologists could travel to dif- influence performance. Finally, the daily interpretation volume above ferent parts of the country and offer researchers will develop in-person, inter- which performance declines? We are this service. This would be a differ- pretive training programs with expert all under pressure to do more with less. ent refreshing way of meeting CME breast imagers and see if these improve Certainly, experience and ancillary needs. Current topics such as CAD, performance. support tools such as physician ex- breast MRI and digital mammography tenders, checklists in lieu of dictation, etc. might also be integrated into the in- would factor into this determination. teractive sessions. However, at this time I agree that a lower Finally, as I said earlier, I do not volume limit is the place to begin. think any breast imager opposes the The second and third compo- concept of improving mammographic nents of the program, in my mind, will interpretation. However, some would essentially be linked. Anytime we oppose participating if the process hear about more test taking (SAMS, was not made extremely “user recertification, etc.) the natural reaction friendly”. I am sure that the investi- SBI News is published by the Society of Breast Imaging is to say “not again!” However, as Dr. gators have realized this and done To submit articles for publication, please Brenner points out in his presidential their best to minimize inconvenience send your material to the editors c/o: message, Maintenance of Certification to the participants. Those who wish SBI Headquarters likely will become linked to reimburse- to take part hopefully will be given 1891 Preston White Drive ment (pay for performance). Mammo- credit, in the form of time, by their Reston, VA 20191-4397 graphy assessment tests already exist and colleagues. Secondary benefits from For membership or provide good clinical and didactic the program such as fewer malprac- additional society information, call: (703) 715-4390 teaching for a variety of diagnostic tice suits are likely to result. If, as fax: (703) 716-4487 problems. Dr. Ed Sickles and colleagues Dr. Sickles says, the program has the website: www.sbi-online.org at the ACR have created three such self potential to substantially improve EDITOR assessment modules (Interpretive mammographic performance in clinical Murray Rebner, MD; email: [email protected] Skills Assessment) for mammography settings, why not support it? I do. ●

2 FALL 2006

IHE Digital Breast Imaging

Dianne Georgian-Smith, MD Massachusetts General Hospital Boston, MA

ince June 2005 when the Additional problems have Hinging on workflow problems S first meeting of users in digital stemmed from PACS systems now is the issue that technologists may imaging occured. The digital managing and storing large files have to push images to interpretation breast imaging, the IHE mammography which are approximately 30 MB per workstations and PACS. This prob- subcommittee has made amazing image from an area of radiology lem leads to human errors of forget- progress working with the vendors to where large volumes of patients pass ting to do so particularly if sending define electronic and information through daily. images to PACS is not integrated to systems’ standards within digital Workflow issues are paramount. the interpretation. Previous digital breast imaging. They can be broken down into acqui- images are not always immediately As many of you know first hand, sition, post-processing, and reporting available and may have to be pushed there are many problems currently components. Problems exist in which or pulled from the PACS system, but within digital breast imaging that images are poor quality at the acqui- one may not know on which vendor’s resulted from the fact that the FDA sition systems making it difficult for machine the previous ones were im- required mammography vendors to technologists to screen for motion or aged if there has been cross-over. develop complete systems from acqui- for radiologists to see some calcifi- These are some of the issues that sition to interpretation workstations. cations for needle localizations. Ad- have made the move from analogue to Consequently, manufacturers devel- ditionally, acquisition stations do not digital breast imaging very difficult. oped proprietary systems that poorly display images from other vendors. In the past year and a half, the integrated with other vendors. With regards to post-processing, Mammography IHE subcommittee A common scenario is a site with manufacturers use proprietary algo- has made significant progress to several manufacturers’ screen-film rithms to produce the “for presentation” achieve integration. The purpose of machines. Replacing these analogue images. Although a manufacturer IHE is to define basic standards for machines with each manufacturer’s will be able to show a different manufacturers so that they can be digital equivalents requires one to also manufacturer’s images, the format integrated into one seamless system. purchase the same manufacturer’s in- will not be in a format supported Vendors are not limited by these stan- terpretation workstation, albeit recent for interpretation. Therefore, follow- dards and can still develop unique advances in universal workstations. up images on patients must be per- functionality beyond the standards to This latter situation is still not ideal formed on the same manufacturers’ continue to strive for market share. since third party work stations may not machines time after time. Otherwise, Accomplished this year is the be able to post-process digital images a radiologist finds himself/herself Mammography Image Profile which is if that post-processing is performed moving from chair to chair to compare a supplement to the IHE Radiology Tech- outside of the acquisition station. In images, an impossible scenario. With nical Framework. The profile is available summary, one may have many addi- regards to reporting/interpretation on the at: http://www.ihe.net/Technical_ tional workstations reflecting the issues, due to different number of pixels Framework/upload/IHE_RAD- number of mammography manufac- per image per manufacturer, breasts TF_Suppl_MAMMO_TI_2006-04- turers at one’s site. Additionally an are displayed at different sizes 13.pdf). alternator adjacent to the interpretation when viewed on the same monitor Currently, the subcommittee is workstation is needed for comparison from two different manufacturers. working on the Workflow Profile films. Most mammography reading Management of patients’ work-lists (this effort being chaired by Gordon stations, designed for film-screen in- differs between manufacturers. One Smith, neither a vendor or a radiologist terpretation, are poorly designed to must also determine if the measure- but neutral party former director of handle the increased amount of ments on an acquired magnified MGH Radiology Informatics). The hardware needed for digital read- image is true size or also subject to subcommittee met in July/August to ing, as well as the heat output from magnification. Manufacturers handle define the issues and will be meeting the additional computers, and light this measurement step differently, in November and January to hammer pollution from the alternators on to and consequently this can markedly af- out line by line the Workflow Profile. the monitors. fect planning for needle localizations. Continued on page 8 www.SBI-online.org 3 The Member Newsletter of the Society of Breast Imaging

2007 CPT ® Code Update Relocates Mammography and Most Guidance Codes

Reprinted with the permission of the American College of Radiology.

ook for pertinent changes in (75998, 76003, 76005, 76006, 76355, stereotactic body radiation therapy, ster- L the CPT® 2007 code book 76360, 76362, 76370,76393, 76394); eotactic radiosurgery, and revision to the that will affect radiology prac- bone studies (76020, 76040, 76061, nuclear medicine genitourinary code tices and will require revision to computer 76062, 76065, 76066, 76070, 76071, section. In addition, a number of ad- systems and charge sheets. Significant 76075, 76076, 76077 76078, 76400); ditions and deletions will be made to the among the changes is the relocation of and vertebroplasty codes (76012, Category III (tracking) CPT code sec- a number of older codes to more specific 76013). Most of the codes will be re- tion. See the September/October 2006 sections within the CPT code book, numbered and relocated to the beginning ACR Radiology Coding SourceTM for an e.g., relocation of mammography and section of the 77000 series section of the update on the 2007 CPT code changes. most guidance codes to the 77000 series CPT codebook prior to the radiation on- Note: It is important that billing section. cology codes, while a few are being relo- systems be updated and the new 2007 The relocation of these codes within cated to other more appropriate sections. codes available for use when these the 2007 CPT codebook is part of an Because of the number of radiology codes codes become valid on January 1, AMA organizational restructuring (CPT that need to be relocated, the beginning 2007. The Health Insurance Portabil- 5 Data Model Project) to facilitate com- of the 77000 series of codes was the only ity and Accountability Act (HIPAA) puter processing and interoperability with choice. Click here for a crosswalk to the transaction and code set rules require various computer systems. Codes which revised code structure. (Link) the use of the medical code set that were previously listed under “Other” have Among the new codes for 2007 is valid at the time the service is pro- been relocated to more descriptive sec- are functional MRI, nuchal translu- vided. Physicians, carriers and inter- tions. This relocation will include a host cency measurements, percutaneous mediaries no longer provide a 90-day of codes with which many are familiar radiofrequency ablation of pulmonary grace period to implement new code and which include: mammography tumor(s), a unique all-inclusive code sets. Reference the ACR Web site at codes (76082, 76083, 76086, 76088, to describe uterine fibroid emboliza- http://www.acr.org/s_acrdoc.asp?CID 76090, 76091, 76092, 76093, 76094, tion, placement of interstitial device =3323 &DID=19843 for additional in- 76095, 76096); most guidance codes (e.g., fiducial marker) in the prostate, formation on this HIPAA requirement. ●

Mark Down Scholarships For Members In Training These Dates! The Society of Breast Imaging is offering scholarships for residents April 14-17, 2007 interested in breast imaging and individuals currently in breast SBI imaging fellowships to attend the SBI 8th Postgraduate Course, 8th Postgraduate Course April 14 – 17, 2007 in Hollywood, Florida. Westin Diplomat Interested individuals should submit an essay of no more than 250 Resort and Spa words along with a letter of support from a faculty member and a Hollywood, Florida letter from the department chair indicating the individual will be allowed the time off to attend the conference. May 8-10, 2008 The scholarship will cover travel expenses up to $2,000, within the 33rd guidelines of the Society reimbursement policy. National Conference on Breast Cancer Submit to: [email protected] JW Marriott Deadline: February 1, 2007 Grande Lakes Resorts Orlando, Florida Include: Name, address, telephone and email address

4 FALL 2006

2007 CPT® Code Updates NEW 20007 CODES CPT DESCRIPTOR

19105 (replaces 0120T Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma 22526 (replaces 0062T) Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level 22527 (replaces 0063T) Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; one or more additional levels (List separately in addition to code for primary procedure) 32998 Ablation therapy for reduction or eradication of one or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, radiofrequency, unilateral 37210 Uterine fibroid embolization (UFE, embolization of the uterine arteries to treat uterine fibroids, (leiomyomata), percutaneous approach inclusive of vascular access, vessel selection, embolization, and all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the procedure 55876 Placement of interstitial device(s) for radiation therapy guidance (e.g. fiducial markers, osimeter), prostate(via needle, any approach), single or multiple 70554 Magnetic resonance imaging , brain, functional MRI: including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration 70555 Requiring physician or psychologist administration of entire neurofunctional testing 76776 (replaces 76778) Ultrasound, transplanted kidney , real time and duplex Doppler with image documentation 76813 Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation 76814 Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation (List separately in addition to code for primary procedure) 77371 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment OF of cerebral lesion(s) consisting of 1 session; multi-source Cobalt 60 based 77372 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cerebral lesion(s) consisting of 1 session; linear accelerator based 77373 (replaces 0082T) Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions 77435 (replaces 0083T) Stereotactic body radiation therapy, treatment management, per treatment course, to one or more lesions, including image guidance, entire course not to exceed 5 fractions +0159 Computer-aided detection, including computer algorithm analysis of MRI image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretations, breast MRI (List Separately in addition to code for primary procedure) (Effective July 1, 2006) +0174T (replaces 0152T)* Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation (List separately in addition to code for primary procedure) (Effective January 1, 2007) 0175T (replaces 0152T)* Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed remote from primary interpretation (Effective January 1, 2007)

*Not listed in CPT code book, but effective 2007. Continued on page 6 www.SBI-online.org 5 The Member Newsletter of the Society of Breast Imaging

® 2007 CPT Code Updates (continued) NEW 20007 CODES CPT DESCRIPTOR

2007 Code Relocation 55875 (replaces 55859) Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy 72291 (replaces 76012) Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance 72292 (replaces 76013) Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under CT guidance 76998 (replaces 76986) Ultrasonic guidance, intraoperative 77001 (replaces 75998) Fluoroscopic guidance for central venous access device placement, replacement(catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision nd interpretation, and radiographic documentation of final catheter position) (List separately in additional to code for primary procedure) 77002 (replaces 76003) Fluoroscopic guidance for needle placement (e.g. biopsy, aspiration, injection, localization device) 77003 (replaces 76005) Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve, or sacroiliac joint), including neurolytic agent destruction 77011 (replaces 76355) Computed tomography guidance for stereotactic localization 77012 (replaces 76360) Computed tomography guidance for needle placement (e.g. biopsy, aspiration, injection, localization device), radiological supervision and interpretation. 77013 (replaces 76362) Computed tomography guidance for, and monitoring of , parenchymal tissue ablation 77014 (replaces 76370) Computed tomography guidance for placement of radiation therapy fields 77021 (replaces 76393) Magnetic resonance guidance for needle placement (e.g. for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation 77022 (replaces 76394) Magnetic resonance guidance for, and monitoring of parenchymal tissue ablation 77031 (replaces 76095) Stereotactic localization guidance for breast biopsy or needle placement (e.g. for wire localization or for injection) each lesion, radiological supervision and interpretation 77032 (replaces 76096) Mammographic guidance for needle placement, breast (e.g. for wire localization or for injection) each lesion, radiological supervision and interpretation 77051 (replaces 76082) Computer-aided detection(computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; diagnostic mammography (List separately in addition to code for primary procedure) 77052 (replaces 76083) Computer-aided detection(computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; Screening mammography (list separately in addition to code for primary procedure) 77053 (replaces 76086) Mammary ductogram or galactogram, single duct, radiological supervision and interpretation 77054 (replaces 76088) Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation 77055 (replaces 76090) Mammography; unilateral 77056 (replaces 76091) Mammography; bilateral 77057 (replaces 76092) Screening mammography, bilateral (2-view film study of each breast) 77058 (replaces 76093) Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral 77059 (replaces 76094) Magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral 77071 (replaces 76006) Manual application of stress performed by physician for joint radiography, including contralateral joint if indicated

6 FALL 2006

® 2007 CPT Code Updates (continued) NEW 20007 CODES CPT DESCRIPTOR

2007 Code Relocation 77072 (replaces 76020) Bone age studies 77073 (replaces 76040) Bone length studies(orthoroentgenogram, scanogram) 77074 (replaces 76061) Radiologic examination, osseous survey; limited (e.g. for metastases) 77075 (replaces 76062) Radiologic examination, osseous survey; complete (axial and appendicular skeleton) 77076 (replaces 76065) Radiologic examination, osseous survey, infant 77077 (replaces 76066) Joint survey, single view, 2 or more joints (specify) 77078 (replaces 76070) Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g. hips, pelvis spine) 77079 (replaces 76071) Computed tomography, bone mineral density study, 1 or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) 77080 (replaces 76075) Dual-energy X-ray absorption (DXA), bone density study, 1 or more sites; axial skeleton (e.g. hips, pelvis, spine) 77081 (replaces 76076) Dual-energy X-ray absorption (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral)(e.g. radius, wrist, heel) 77082 (replaces 76077) Dual-energy X-ray absorption (DXA), bone density study, 1 or more sites; vertebral fracture assessment 77083 (replaces 76078) Radiographic absorptiometry (e.g. photo densitometry, radiogrammetry), 1 or more sites 77084 (replaces 76400) Magnetic resonance (e.g. proton) imaging, bone marrow blood supply

Deleted Codes as of 01/01/07 55859 See 55875 76066 See 77077 76091 See 77056 76400 See 77084 75998 See 77001 76070 See 77078 76092 See 77057 76778 See 76775-76776 76003 See 77002 76071 See 77079 76093 See 77058 76986 See 76998 76005 See 77003 76075 See 77080 76094 See 77059 78704 See 78707-78709 76006 See 77071 76076 See 77081 76095 See 77031 78715 See 78701-78709 76012 See 72291 76077 See 77082 76096 See 77032 78760 See 78761 76013 See 72292 76078 See 77083 76355 See 77011 0082T See 77373 76020 See 77072 76082 See 77051 76360 See 77012 0083T See 77435 76040 See 77073 76083 See 77052 76362 See 77013 0062T See 22526 76061 See 77074 76086 See 77053 76370 See 77014 0063T See 22527 76062 See 77075 76088 See 77054 76393 See 77021 0120T See 19105 76065 See 77076 76090 See 77055 76394 See 77022 0152T See 0174T, 0175T

Descriptor Revisions as of 01/01/07 70540-70543 MRI Orbit, Face and/or Neck 76XXX Ultrasound (non-ophthamological) codes 78700-78760 Genitourinary Section — See Nuclear Medicine

For detailed information on the new CPT codes for 2007 see the CPT 2007 codebook, CPT Changes: An Insider’s View 2007, CPT Assistant, September/October 2006 ACR Radiology Coding SourceTM electronic newsletter. www.SBI-online.org 7 The Member Newsletter of the Society of Breast Imaging

Continued from page 3 Then it will be available for public At first it seemed that we were on vendors are in the mood of IT- comment in February-March. A cor- separate teams with different goals. double-speak-I-am-going-to-bam- ollary committee that dovetails into “They” the vendors wanted to deter- boozle-you behaviors so that the the Mammography Workflow efforts mine what was going to happen and radiologists’ interests are kept in the is the IHE Reporting Workflow what could be done, and “we” the foremost goals. Nevertheless in spite committee. For the first time, cardio- radio-logists, also the consumers and of everyone’s disparate backgrounds, logists and the American College of users, were adamant to dictate the I believe that the presence of radio- Cardiology (ACC) joined radiologists end points. The foreign language was logists at these discussions has been and radiology vendors in October to de- “Vendor-IT-Speak”, having never welcomed. fine the problems of report integration. been given in high school. “Proce- Before closing, I would like to Planned for 2007 is the annual dures” were not related to needles in try to arouse interest in other radio- IHE connect-a-thon in which vendors breasts but had been defined to be logists in IHE. Prior to my involve- will bring their hardware/ software and the equivalent of any radiological ex- ment, I had only heard of IHE as signs show the integration that has been amination. “Actors” were not those at RSNA on the poster floor level, defined on the recently developed pro- “who play a doctor on TV” but re- but I had no idea what IHE did, prob- files. At the SBI meeting in April 2007, ferred to “information systems that ably because breast imaging was the vendors are planning to show this inte- produce, manage, or act on informa- last to become a digital modality. gration to the public. tion associated with operational This year marks the 9th year of IHE. The process of IHE has been an activities in the enterprise.” It took There are many profiles that have interesting and sometimes perplex- several face to face discussions for been written by countless hours of ing process for me. I gladly volun- the group to gel into one force and volunteer work. Prior to the develop- teered and joined forces with Drs. develop the mutual respect that is es- ment of the mammography subcom- Rita Zuley (Elizabeth Wende Clinic) sential to become a team. “We” were mittee, the vendors wrote most of and Judy Wolfman (Northwestern U.) markedly assisted by Drs. David these profiles. Even long standing as I had publicly declared that work- Channin, MD, from Northwestern, IHE members admitted that IHE was ing with digital mammography was and David Clunie, MBBS, from poorly advertised amongst radio- a “pencil in the eye”. At the table RadPharm, who are each radiologists logists. The involvement of the radio- were 25-30 vendors. We, the radi- and IT-gurus. They are capable of logists in Breast Imaging marked a ologists were outnumbered 10 to 1. going toe-toe with the vendors when Continued on page 7

SBI and ACR Urge FDA for Mandatory Accreditation of Stereotactic Breast Biopsy

D. David Dershaw, MD, former president of personnel, equipment, and clinical performance of the Society of Breast Imaging and the first chair of the biopsy procedure and provides the applicant the American College of Radiology Committee on with suggestions for improvements in quality. Stereotactic Biopsy Accreditation, urged the Food Dr. Dershaw, of the Memorial Sloan-Kettering and Drug Administration (FDA) National Mammog- Cancer Center, spoke September 28-29 in raphy Quality Assurance Advisory Committee to Rockville, Md., on behalf of the Society of Breast remove the current exemption for stereotactic Imaging and the ACR at the FDA’s National Mam- breast biopsy units under Mammography Quality mography Quality Assurance Advisory Committee. Standards Act (MQSA) regulations. The FDA is drafting changes to MQSA regu- Dr. Dershaw testified that the ACR has been lations and is considering removing the current successfully accrediting stereotactic breast biopsy exemption for stereotactic breast biopsy units. Dr. systems since 1996. Currently, more than 450 of Dershaw stated that both the SBI and the ACR these units in the United States are accredited endorse the regulation of stereotactic breast biopsy through a voluntary ACR program which evaluates under MQSA. ●

8 FALL 2006

Continued from page 6 ACR Mammography Accreditation: change in the process in which “we” were going to determine what “we” Frequently Asked Questions needed. I have now attended a few meetings with the Technical Commit- Priscilla F. Butler, MS tee, the last one related to the Report- Senior Director, ACR Breast Imaging Accreditation Programs ing workflow. Dr. Channin and myself were the only radiologists. I would Does your facility need help on applying for mammography have liked to have seen more radio- accreditation? Do you have a question about the ACR logists representing different types of Mammography QC Manual? Check out the ACR’s new practices. If you want a system that accreditation web site portal at www.acr.org; click “Accreditation,” works efficiently for your practice, then then “Mammography.” The “Program Overview” and “Frequently you must take the time to become in- Asked Questions” were completely updated and reorganized in volved. Even if you cannot attend the July to provide more useful information on accrediting digital meetings directly, you can ask to call mammography equipment. In addition, most of the mammography in on conference call. The person to accreditation application and QC forms are now available for contact at RSNA is Chris Carr ([email protected]). When the profiles are downloading. You can also call the Mammography Accreditation completed they are available on the Information Line at (800) 227-6440. web for public comment. These are Monitors and Workstations opportunities to create what you need which and this will only happen if Q. Does my facility have to use an FDA-approved review work- you become involved. station to interpret digital mammograms? Familiarize yourself with the A. No. However, the FDA recommends that only monitors web site: www.ihe.net. specifically cleared for full-field digital mammography Referencing the IHE standards (FFDM) use by FDA’s Office of Device Evaluation (ODE) when negotiating with vendors on be used. (See FDA’s Modifications and Additions to new equipment is intended to help radiologists work more efficiently. ● Policy Guidance Help System #9.) Q. We just installed our first FFDM unit. Does our medical physi- cist also have to test the review workstation along with the new FFDM unit as part of the Mammography Equipment IHE Demonstration at Evaluation? Do we have to submit the review workstation SBI 8th Postgraduate Course test results for accreditation? Attendees will have the A. Yes and yes. opportunity to participate in an interactive Integrated Q. We have just added a second FFDM unit. Images from this Healthcare Enterprise (IHE) unit are interpreted on our current review workstation. This demonstration on digital review workstation was evaluated during the medical mammography display and physicist’s Annual Survey of our old FFDM unit. Does our workstation functionality. Check medical physicist have to retest that review workstation along the SBI website in the coming with the new FFDM unit as part of the Mammography Equip- months for more information. ment Evaluation? Do we have to submit the review work- station test results for accreditation? A. No and yes. If the review workstation was tested previ- Gerald Dodd Lecture at ously with another FFDM unit at that site during its SBI 8th Postgraduate Course Mammography Equipment Evaluation or Annual Survey, Etta D. Pisano, MD will present the medical physicist does not have to retest the work- the Gerald Dodd Lecture station. However, the medical physicist should indicate titled “What We Learned on the Mammography Equipment Evaluation summary from DIMST” on forms sent with the accreditation application when the Sunday, April 15, 2007. workstation was tested and the results. Continued on page 12 www.SBI-online.org 9 The Member Newsletter of the Society of Breast Imaging

Novel Collaboration Advances Research to Improve Mammography Performance Karla Kerlikowske, MD Professor of Medicine and Epidemiology and Biostatistics he National Cancer Institute’s based cancer databases and/or pathol- clinical practice may help the Food T(NCI) Breast Cancer Surveil- ogy data. As of December 2005, the and Drug Administration and radi- lance Consortium (BCSC) was BCSC pooled database had over 5 ologists decide whether the current recently awarded $2.5 million from million radiology events for over 1.5 recommended minimum of 960 the Breast Cancer Stamp Fund and million women covering the years mammography examinations inter- the American Cancer Society to help 1994 to 2005. The database has broad preted over 2 years is optimal for support new research on how to im- racial representation, similar to the breast cancer detection. prove mammographic interpretation. US population overall. In the second component, the in- The title of the project is “Assessing A recent IOM report, Improving vestigators will create assessment tests and Improving Mammography Breast Imaging Quality Standards, sets using representative screening (AIM). The funding provided by the provided an important catalyst for the mammography examinations from American Cancer Society is pro- AIM project by finding that mammo- community practice. These tests will vided through a generous donation graphy interpretation remains quite be used to assess radiologists’ interpre- from the Longaberger® Company’s variable despite the improvement in tive skills and evaluate whether can- Horizon of Hope Campaign®. its technical quality since the imple- cer prevalence or the prevalence of This is a novel collaboration mentation of the Mammography various types of mammographic find- among public and private agencies Quality Standards Act (MQSA) of ings influence performance measures. that builds on the BCSC’s history of 1992. “I participated in the IOM The BCSC investigators are working collaborative research. The project review and was struck by the unique with the American College of Radiol- was initiated by the American Can- opportunity to act on the recommen- ogy (ACR) to digitize images and pre- cer Society, which has a longstanding dations from this report and move pare tests using software developed relationship with the Longaberger® forward with a research agenda to with ACR expertise. The tests also Company. Dr. Robert Smith from the better understand the measurement of should reveal whether performance on American Cancer Society (ACS) ap- interpretive performance, and to these test sets is associated with per- proached NCI after an analysis and improve it,” says Robert Smith, formance measures in clinical practice. report by the Institute of Medicine PhD, and Director of Cancer Screen- In the final component, BCSC (IOM) identified a shortage of re- ing at the ACS. investigators will develop and test search regarding measuring and im- The AIM project is designed to two innovative educational programs proving mammography interpretive discover factors and interventions designed to improve radiologists’ performance skills. NCI oversees a that can reduce variability and im- mammography interpretive skills by variety of projects funded by money prove the overall quality of mam- focusing on the types and locations collected from the purchase of Breast mography interpretation through of findings that are particularly chal- Cancer Stamps in US Post offices, three main research activities. In the lenging for radiologists to identify. and has worked with the BCSC to first activity, BCSC investigators The first program is an in-person, in- provide funds to evaluate mammog- will determine the effects of volume teractive intervention in which expert raphy performance and practice in of mammography examinations in- radiologists will use selected mam- community settings. terpreted per year on radiologists’ mography examples as teaching The BCSC was established in clinical interpretive performance, cases. The second is a DVD version 1994. The BCSC is well-suited to controlling for patient, physician, of the in-person intervention. study mammographic interpretation and facility factors that are known “This research has the potential because it collects longitudinal data to influence performance measures. to substantially improve mammogra- on mammography interpretive perfor- They will test the hypothesis that phy performance measures in clini- mance and includes large numbers of lower annual interpretive volume is cal settings,” says Ed Sickles MD, women, mammograms, and radio- independently associated with poorer Professor of Radiology at the Uni- logists. Each of the mammography clinical performance. Determining versity of California, San Francisco, registries has created a mammography whether the volume of mammograms and national expert in mammography. database that is linked to population- interpreted every year actually influences Continued on page 11

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Continued from page 10 The AIM project started in Septem- care, two agencies committed to re- “This research also should have direct ber 2006 by mailing to community search, experienced investigators and benefits for radiologists,” adds R. James radiologists, a survey designed to physicians responsible for mammo- Brenner MD, Professor of Radiology determine the current practices in the graphy interpretations. “The goal is at UCSF and President of the SBI. radiology community as it pertains to improve mammography perfor- “In an era characterized by PQI (Per- to mammography. In the September mance and benefit the millions of formance Quality Improvement), it 2007, the BCSC investigators plan to women screened in the United States is a natural extension of our work to start assessing radiologists’ interpretive each year. This is a great example of understand how well we are doing, skills with test sets created with funds how collaboration in funding and and how we can better assess and im- from this grant. research creates opportunities,” states prove performance. Such efforts set This novel project brings to- Stephen Taplin, MD who oversees the the stage for maintaining high-quality gether contributions from two funds BCSC for NCI. “I look forward to the mammography in this country.” committed to improving breast cancer results.” ●

President’s Message local or institutional efforts. In- accepatable. Thus, the only current Continued from page 1 deed, some institutions already are requirement is participation; the type physicians are seeking incorporate involved in type I activities which of activity can be both creative and new information and approaches into might include periodic projects to variable, so long as it is approved by clinical practice. To that extent, the assess accuracy of diagnosis (such the Board. Indeed, at a recent summit ABR will ask diplomats to provide as cross monitors). The intent to meeting held by the ABR in which documentation of MOC in four dif- develop tools and enlist active subspecialty societies were invited to ferent areas; professionalism, lifelong participation in conforming to attend, it was noted that the first ten learning and periodic self-assess- evidence-based practices. Collecting year cycle is not meant to be harsh or ment, cognitive exposure, and prac- such data, analyzing it, compar- restrictive. The Board hopes to es- tice performance. ing it to peers, and instituting tablish a web based account for each As was outlined last year in a those modifications which should participant where satisfaction of dif- previous article, a general test at the improve outcomes with a subsequent ferent MOC criteria can be tracked, end of ten years will address gen- reassessment is a basic tenet of monitored, and validated; a modest eral professional issues and con- MOC. Type II activities will seek administrative fee will be sought to tinuing education with evidence of external validation of a quality cover expenses to provide the system. SAMS completion will be required. improvement activity. Current ex- MOC requirements are man- Also recall that one need not seek amples include participation in dated for those certified after 2002. MOC in all radiology subspecialties, the ACR’s RADPEERtm program Although voluntary for others, the but rather those which are germane where online assessment of previous implications of avoiding involvement to one’s practice. Thus those who comparison studies (e.g. CXR, mammo- with MOC are both speculative and restrict their practice to only breast graphy) are conducted to assess formidable. No current mechanism imaging will be encouraged to pur- whether a substantial error may have exists to insure that all examinations sue projects related to this specific been made on the prior examination are performed in an optimal manner. field. Other specifics regarding the and report. The ACR Interpretative But payers seek reassurance that those program are currently being devel- Skills Assessment CDs are another submitting requests for reimbursement oped. The fundamental change in example. are meeting society-established stan- this context—and the one which The ABR recognizes that this dards for demonstrating continuing may invite the greatest degree of paradigm shift from simple CME ac- competence. Thus the possibility of confusion—regards performance tivities to a more active demonstration of economic credentialing exists. This quality assurance. Rather than involvement with quality improve- has already been applied primarily in simple education, the goal is to sat- ment measures will need to evolve. As clinical medicine. However, certain isfy three benchmarks over ten the ABR studies and learns from differ- aspects currently relate to radiology. years, currently referred to as type ent performance quality improvement In order to be certified by the FDA I and II, with a requirement for at (PQI) projects, it will develop templates to perform mammography, federal least one type II activity. Type I for others to use with the assurance statutory provisions require meeting activities may be involvement with that such activities are considered Continued on page 12 www.SBI-online.org 11 The Member Newsletter of the Society of Breast Imaging

Continued from page 11 technical standards for image produc- Continued from page 9 tion and professional standards for a Frequently Asked Questions certain volume of interpreted (continued) mammogams and continuing educa- Q. The physician’s review workstation is not at the same physi- tion. United Healthcare, the largest cal location as the FFDM unit (it is off site). Is the medical private 3rd party payer, is investigat- physicist still required to test it during Mammography Equip- ing in 15 states .the advisability of predicating reimbursement for ex- ment Evaluations and Annual Surveys of our facility’s unit? aminations such as CT and MRI on Does the facility still need to submit QC results on that work- formal accreditation. The Federation station to the ACR during accreditation? of State Licensing Boards is consider- A. Possibly and yes. There are at least two possible sce- ing a showing of involvement with a narios if the review workstation is not located at the formal MOC program as a condition facility where the FFDM unit is located: of relicensure. The current philosophy ● If the workstation was tested previously with another FFDM for PQI is not punitive; it is assumed that unit (either at the location of the workstation or a sister collective data which might indicate de- site), the medical physicist does not have to retest the work- ficiencies in one’s performance will station. However, the medical physicist should indicate on be enough to prompt individual or in- the Mammography Equipment Evaluation summary forms stitutional interventions to improve the MAP ID # of the facility where the workstation is performance. The data will be coded located, when the workstation was tested and the results. and protected under the current plan. ● If the workstation is located off-site in an office with no Ultimately it is hoped that national FFDM units and was not tested previously, the medical data bases will be established to bet- physicist must include the review workstation in the ter compare individual performance FFDM unit’s Mammography Equipment Evaluation. with peer performance There is little alternative to re- Q. All clinical images at our new FFDM facility will be printed sponding to the mandates facing and interpreted on hardcopy. There is no review workstation medicine in the future. Both the ABR for the physician. Do we need to have access to a review and the ABMS recognize that this workstation and submit the results of its Mammography Equip- new paradigm in the lifelong learning ment Evaluation and QC testing for accreditation? process will prompt changes in the A. No. However, since this is an unusual situation (most way practice is conducted. Specialty facilities interpret from the softcopy), you must provide societies were asked last year to begin to develop SAM tools, and last May a letter signed by your lead interpreting physician stat- leaders in our field indeed produced ing that all interpretations will be done from hardcopy. the first module for a national breast Also, please note that any testing required by the manu- imaging meeting (National Conference facturer for the FFDM unit’s display is still required since on Breast Cancer). Likewise, the SBI the technologist clinically uses this display when per- will reach out to its pool of talented forming the examination. breast imaging specialists to assist the ABR in developing approaches that Q. We just installed a new review workstation. (We have had will satisfy current mandates. It is our FFDM unit for several years.) Does our medical physicist likely that many of these initiatives have to conduct a Mammography Equipment Evaluation of will be in conjunction with the ACR this workstation? Do we have to submit the results of this test where resources will be employed to to the ACR? address the multitude of practice cir- A. Yes and no. It is important that your medical physicist cumstances related to breast imaging. conduct a Mammography Equipment Evaluation of your The writer Frank Clark once new workstation (and document his results in a report) observed, “If you can find a path with to ensure that it is operating properly for image interpre- no obstacles, it probably doesn’t lead tation. However, you do not need to send this to the ACR anywhere.” The obstacles that have at this time. We will request the results of the entire been set in our way are not so formidable system’s Annual Survey (which must include the review that we cannot succeed. This path workstation tests) during accreditation renewal. ● may indeed lead to a better place. ●

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