Stage 2 Meaningful Use Proposal Includes Imaging

Published on the Feb. 27, 2012 DiagnosticImaging.com website

By Whitney L.J. Howell

After being left out of the first phase of the meaningful use program, medical imaging was included in the proposed Stage 2 rule CMS and the Office of the National Coordinator released last week. Industry leaders are cautiously optimistic about how the rules will affect radiology, but they caution that providers shouldn’t act yet in response to the proposal.

Set to take effect in 2014, Stage 2 is considered by healthcare leaders to be a step toward a standards-based health information exchange, and officials announced imaging will also be included in the 2014 proposed rule for electronic health record (EHR) certification requirements. Providers who meaningfully use EHRs, based on the guidelines, qualify for $44,000 in federal incentive payments.

However, there could be some wiggle room for how strictly radiologists will need to adhere to those guidelines.

“The good news is that there’s mention of potential concessions for hospital-centric eligible professionals,” said Keith Dreyer, DO, chair of the American College of Radiology (ACR) IT and Informatics Committee-Government Relations Subcommittee and radiology vice chair at Massachusetts General Hospital. “It shows that the agencies have really paid attention to the uniqueness of specialties, such as radiology, and they are understanding that some challenges will exist when we try to comply.”

For example, many hospital-based providers are not included in and have no influence over their facility’s information technology decisions. This position could render them unable to comply with some meaningful use requirements. In the Stage 2 proposed rule, CMS has granted these practitioners an exemption.

To read the remainder of the article: http://www.diagnosticimaging.com/meaningful-use/content/article/113619/2038701

More Medical Schools Offer Instruction in Complementary and Alternative Therapies

Published in the February 2012 AAMC Reporter

By Whitney L.J. Howell

At first glance, Megan Wolf believed the man in front of her had been mortally wounded. She was horrified, until he looked up and laughed.

“I gasped, but he giggled at my reaction,” said the third-year student at the University of Pittsburgh School of Medicine. “He said it didn’t hurt at all and that he never felt better than after one of those treatments.”

What Wolf, who is the chair of the American Medical Student Association’s (AMSA’s) Wellness and Student Life Committee, saw—and what the man experienced—was a high-velocity, low-amplitude spinal adjustment. In essence, the chiropractor cracked his neck.

Witnessing this episode was part of Wolf’s introduction to complementary and alternative medicine, or CAM. Also known as integrative or mind-body medicine, these therapies are becoming more common in U.S. medical education.

The push to bring CAM into medical training began in 1999 when the National Center for Complementary and Alternative Medicine (NCCAM), part of the National Institutes of Health, launched the CAM Education Project.

Initially, the center awarded 14 grants of $1 million to $1.5 million to medical schools, teaching hospitals, and AMSA for research projects, such as training pediatric residents on the benefits of CAM in treating childhood diseases or teaching students to communicate effectively about it with patients. Today, a group of more than 50 U.S. and Canadian medical schools and teaching hospitals, called the Consortium of Academic Health Centers for Integrative Medicine, includes CAM in its curricula.

Although opinions about CAM are heated, there is no question that patients use it. According to 2008 data from the Centers for Disease Control and Prevention, nearly 40 percent of adults and 12 percent of children use at least one therapy, and many are reticent when it comes to telling their doctors. The substantial size of this group makes it vital that medical students understand how nontraditional therapies or supplements interact with standard medical care, said Aviad Haramati, Ph.D., a Georgetown University School of Medicine physiologist, who pioneered CAM education at Georgetown in 2000.

“We aren’t educating CAM practitioners,” he said. “But we are giving medical students knowledge so they can talk with their patients in an open-minded way from informed positions, and educate them on the potential risks of mixing complementary techniques or herbal supplements with prescription medications.”

The growing body of evidence-based research supporting CAM in peer-reviewed journals, such as the Annual Review of Medicine and the Journal of the American Medical Association, means academic medicine cannot ignore these modalities, Haramati added.

Opposition to CAM in Curricula

But not everyone in academic medicine agrees that medical students should learn about CAM. Steven Salzberg, Ph.D., medicine and biostatistics professor at Johns Hopkins University School of Medicine, openly opposes integrating CAM into medical education curricula, asserting that alternative modalities are ineffective.

“Whatever term is used—alternative medicine or integrative medicine—this isn’t medicine. At best, these are hypotheses,” Salzberg said. “Over 20 years, NCCAM has spent more than $1 billion, and [there is] no strong evidence that these activities work.”

He also criticized the propensity in academic medicine to group meditation and yoga with acupuncture, chiropractic, and homeopathic treatments. Clear evidence exists to support the efficacy of meditation and yoga, he said, and equating them to other modalities is erroneous.

Despite his objections to including CAM in curricula, Salzberg agreed it could be useful to train physicians proactively about treatments patients might seek on their own.

Challenges to Teaching CAM

Salzberg’s objections have not slowed the integration of CAM into education, but that does not mean getting buy-in for course additions has been easy. There are three main questions about this fusion, said Victor Sierpina, M.D., a professor in the integrative medicine program at the University of Texas Medical Branch in Galveston.

“The biggest concern is people’s unfamiliarity with the evidence behind CAM,” he said. “Once they become aware of peer-reviewed research, the resistance to including these topics drops. The same is true for administrators, faculty, and students.”

Many institutional leaders want details about how faculty will teach CAM from the evidence-based perspective, he said, and they want to know how this knowledge will augment training and turn students into lifelong learners.

Even with these questions satisfied, CAM remains divisive, said Michelle Bailey, M.D., a Duke University School of Medicine pediatric integrative medicine physician. She is also the director of medical education for Duke Integrative Medicine.

“Increasing CAM in allopathic medical training can still be considered controversial,” she said. “But there are many in the consortium who are looking for best practices, as well as the best ways to translate it to medical students.”

Current Course Curricula

Many medical schools and teaching hospitals have elaborate programs featuring CAM. For example, Haramati said, Georgetown launched a five-year program in 2005 for students to earn a master’s in CAM before pursuing their medical degree. The first degree program of its kind includes, among other topics, nutrition, mind-body skills, and CAM use in oncology.

“We brought acupuncture into anatomy and neuroscience, biofeedback into physiology, and the science of stress reduction into endocrinology,” Haramati said. “We want students to experience the mind-body connection firsthand and understand more about themselves.”

At Texas, students receive an orientation to the library that includes case-based information about herbal supplements as well as other CAM strategies, Sierpina said. Second-year students discuss chiropractic and massage in musculoskeletal classes, and others participate in grand rounds about the interaction between over-the-counter supplements and anesthesia. CAM is quickly becoming a fluid part of the curriculum, he said.

“It’s mostly invisible. It’s seamless,” Sierpina said. “We use problem-based learning to train students, and we want them to evaluate all possibilities. When treating a patient, CAM might not be the solution, but we want them to consider all options.”

But medical education is cramped, and many worry adding CAM-focused courses could overwhelm students.

To overcome this barrier, many institutions follow Texas’ example, infusing CAM theories into existing classes. For example, Duke offers two-week elective courses that give second-year students a solid foundation in CAM, Bailey said.

In addition to attending lectures, students meet CAM providers, such as acupuncturists, massage therapists, or health psychologists, and shadow these providers at the Duke Integrative Medicine building.

“It’s important for students to learn the credible information around integrative medicine so they can point patients to reliable sources,” Bailey said. “If, as patient advocates, we are to first do no harm, then we must be armed with information to educate patients and keep them safe.”

Duke students also learn about CAM during their required fourth-year capstone course. As part of this class, the school holds a four-hour integrative medicine health fair bringing in nearly 40 CAM providers from the community. Students visit booths, asking questions and gathering information. A lecture series several days before the fair also presents basic CAM details.

Student Reaction

Medical students know patients benefit when their providers understand CAM, but students also see value for it in their own lives, said AMSA’s Wolf.

“AMSA participants focus on their wellness,” she said. “Our members look at natural things like yoga to handle the stress and pressures of medicine. These things help us take better care of ourselves so we can be better physicians.”

David Darrow, a fourth-year Texas student, agreed that studying CAM gives him empathy for how patients choose to approach their health.

“It’s ironic. As medical students, we approach our education as scientists who make decisions on evidence and fact,” he said. “But learning about CAM has really led me back to the humanistic part of medicine.”

To read the article at its original location: https://www.aamc.org/newsroom/reporter/feb2012/273812/therapies.html

Dense Breast Tissue Legislation Presents Challenges for Practitioners

Published on the Feb. 20, 2012, DiagnosticImaging.com website

By Whitney L.J. Howell

It’s been two years since Connecticut enacted a law requiring providers to tell patients in writing if they have dense breast tissue. Research shows that breast cancer detection is up in the state, but industry leaders and practitioners say complying with the law is often complicated.

The move to include specific breast density information in a letter about mammography results was borne out of one Connecticut patient’s diagnosis with late-stage breast cancer. Doctors missed the malignancy because she had dense breast tissue. Her experience eventually led the state to pass a law, mandating providers inform patients of their breast tissue status. These letters have led to supplemental ultrasound screenings.

Other states are following suit. On Jan. 1, Texas enacted its version of dense breast legislation, known as Henda’s Law, and the American College of Radiology (ACR) anticipates 13 other states will introduce dense breast bills this year. Legislation has also been introduced at the federal level, but it hasn’t yet gained traction. And the potential lack of national continuity could be problematic.

“If a mandate to give patients breast density information happens state-by-state, it will be piecemeal. A national effort would, hopefully, put people all on the same page,” said Barbara Monsees, MD, chair of the ACR’s Breast Imaging Commission. “Differing laws proposed by different states could result in providers having an inconsistent understanding of what they are required to do.”

While the ACR supports patient education and notification about breast cancer risk, the organization cautions that without a standardized method for determining breast density, making categorizations is subjective. Without clear guidelines, different radiologists could rate the breast tissue differently based on the same mammogram. In addition, breast density is only one facet of breast cancer risk — others, such as family history or genetic disposition, play larger roles.

To read the remainder of the story: http://www.diagnosticimaging.com/womens-imaging/content/article/113619/2034076

Fictional Characters Bring Life to the Classroom

Published in the Winter 2012 Duke University School of Nursing Alumni Magazine

By Whitney L.J. Howell

Meet Golda and Antonio. She’s a grandmother, rearing her grandson while trying to manage myriad chronic conditions. He’s a Mexican immigrant who’s juggling the tensions of a high-stress job and a young family.

Nurse practitioner students at the Duke University School of Nursing (DUSON) spent the entire Summer 2011 semester closely following Golda and Antonio. They designed health plans to fit the patients’ lifestyles and worried about how any medical changes would affect their daily activities.

But there’s one catch—Golda and Antonio aren’t real. In fact, they’re figments of imagination of DUSON assistant professors Penny Cooper, MSN’02, C’08, RN, FNP-BC, CCRN, and Michael Scott’s, DNP, FNP-BC. They exist only on paper, and students know them simply by class-provided clinical notes. However, that was enough to launch students into intricate, and often heated, discussions about the best way to meet Golda and Antonio’s health needs.

The format for Managing Common Acute and Chronic Health Problems II, said Scott, who co-taught the class with Cooper, was a significant divergence from lecture-based courses formats. It’s a challenge for faculty to step out from behind the podium, he said, but the result is students who are prepared to be independent, proactive nurses.

“This course is a paradigm shift,” he said. “We’ve tried to demonstrate that there are ways to draw students into a discussion. We want students to see and experience for themselves the interplay between context and clinical decision making.”

By training students to look beyond rote learning and synthesize that knowledge with individual circumstances, Cooper and Scott are meeting a charge published in the Institute of Medicine’s October 2010 report The Future of Nursing: Leading Change, advancing health. The report stressed that nurses are ready to augment their roles as primary care providers who can reduce or eliminate gaps in care.

What Happens In Class
The course goal wasn’t to memorize and spout a certain number of facts about medications or conditions, Scott said. Instead, he and Cooper wanted to train students to be life-long learners —knowledgeable, well-trained healthcare providers who know where to turn for information. They wanted to produce nurses who could think beyond textbook knowledge to craft care plans to accommodate a patient’s daily routine and limitations, such as dependency on public transportation.

According to Cooper, the primary care-focused curriculum spanned roughly 20 years of each patients’ life. Students received clinical notes before each weekly class, detailing each patient’s vital statistics, laboratory test results, or life changes. Each week focused on a different content area, such as cardiology or neurology. Armed with this data, they came to class and discussed how best to address clinical, billing, and coding concerns.

The class relied on student-led conversation, Cooper said. She and Scott served as content experts who would only occasionally posit questions if the discussion began to lag. Unlike their other classes, students didn’t take tests to gauge how well they retained information. Instead, Cooper and Scott presented case studies unrelated to Golda and Antonio to evaluate how well students digested and applied their procedural knowledge. Cooper said they also required students to offer opinions during class discussions as well as reflect in writing upon certain cases. Adjusting to this format, though, was difficult.

“There was some initial resistance and discomfort with the class structure. It can be uncomfortable to change the ‘test,’” she said. “Having them do active reflection was a way to ensure that they thought about the different approaches and opinions brought forth.”

Effective and Memorable
For Mary Johnson, MSN’12, FNP, a discussion-format class was a novelty, but it was one that greatly enhanced her learning.

“This was much more effective than listening to a lecture where a professor spits out facts and you regurgitate them,” she said. “The class was like real life. We learned that we won’t always be able to do what we’d like to do medically for our patients—they will have extenuating circumstances, and we’ll have to meet them where they are.”

Talking with fellow students about specific case studies that spanned more than two decades also fit perfectly with the way Danielle DiGennaro, MSN’12, FNP, prefers to learn.

“I, personally, tend to learn best from case studies. The material clicks and sticks with me when it is related to a case,”she said. “We often had a handful of voices that were very prominent. But it was nice to hear from the class as a whole. Different colleagues brought different experiences to the class, be they RN experiences or NP clinical placements.”

The in-depth discussions about clinical conditions pushed students to think holistically about Golda and Antonio, but these small-group interactions also introduced the challenges of inter-professional communication. Some discussions, such as one about end-of-life care and Do Not Resuscitate orders, morphed into ideological fights, Johnson said, and classmates had to learn to navigate the differing, and entrenched, opinions.

Taking the Curriculum Nationwide
With such an overwhelmingly positive response to the class format, Cooper and Scott wanted to see if they could translate the
in-class experience to DUSON’s distance learning programs. The idea of fusing lively discussion with technology that connects the coasts garnered both attention and financial support.

According to Marilyn M. Lombardi, PhD, director of the new Duke Center of Nursing Collaboration, Entrepreneurship, and Technology (CONCEPT), Cooper and Scott’s desire to share the course format outside the school’s walls was a perfect fit for the first Catalyst Faculty Innovation Award. The CONCEPT Catalyst Award was created to support innovative and entrepreneurial faculty endeavors.

Lombardi stressed that entrepreneurial work doesn’t always focus on making money. In fact, many in nursing view that goal as being antithetical to the profession’s service call. She anticipates other DUSON faculty, like Cooper and Scott, will be entrepreneurial on a mainly social level—they’ll endeavor to introduce new ideas to health care delivery that will help patients.

The award gives Cooper and Scott funding to research and identify the best methods for disseminating the course curriculum to the School’s distance education students. At the time of publication, they were actively working with Duke’s videography and information technology services to bring the project to fruition. The idea is simple, but it will be a challenge to create an environment that brings students from different states and time zones together for active discussions about patient care.

“The catalyst award is the seed money that allows faculty to take risks and think beyond customary pathways for education,” Lombardi said. “What [Cooper and Scott] are using is an exciting strategy to introduce technology in support of an innovative approach to teaching and learning. This won’t be a simple matter of setting up a video conference.”

Instead, Lombardi said, the curriculum for the distance class will likely take a more multimedia, documentary approach with both visual and audio components. Using resources provided by CONCEPT, Cooper and Scott will produce 10 5-minute vignettes that cover each course module and bring Golda and Antonio to life.

Finding the right mix that reproduces the in-class experience for students will require creative collaboration with partners outside the School. The CONCEPT office exists, Lombardi said, to foster these relationships and cultivate the inventive spirit that already exists in nursing.

“We launched CONCEPT because we talk a lot about what nurses refer to as the ‘work-around culture,’” she said. “We’re faced with a care environment that isn’t set up to work optimally for patients, so nurses use the materials that they have close at hand—like cotton balls or construction paper—to create improvised alternatives to meet patients’ daily needs.”

CONCEPT gives Duke’s nursing faculty the freedom to be design thinkers, she said. Through partnerships with other schools, such as the Pratt School of Engineering or the Fuqua School of Business, faculty will have the opportunity to take their ideas further and potentially change how nurses work at the front line of care.

To read the story at it’s originial location: http://nursing.duke.edu/sites/default/files/alumni/magazine/winter_2012_issue_final.pdf

Radiology: What’s Coming in 2012

Published on the Feb. 16, 2012, DiagnosticImaging.com website

By Whitney L.J. Howell

Throughout 2011, most chatter in radiology centered around how healthcare reform would change the industry or how practitioners should manage and use newer modalities. In a look ahead at the next 12 months, many industry luminaries anticipate the same concerns will linger on the horizon even as new ones appear.

Some of the upcoming challenges touch the individual radiologist’s pocketbook; others affect practice. Regardless of the specifics, radiologists will do well to revamp how they view themselves as part of the healthcare system, said James Thrall, MD, Massachusetts General Hospital (MGH) radiologist-in-chief and former American College of Radiology president.

Financial Implications

Radiology’s biggest concern for 2012 is a holdover from last year — bundled payments and reduced reimbursement. Under the proposed accountable care model, radiology reimbursements would be wrapped up in a lump-sum amount that includes facility, physician, and technical payments.

It’s the ambiguity of these packaged payment’s impact that make them the industry’s greatest challenge this year, said, Leonard Berlin, MD, former chair of the professionalism committee with the Radiological Society of North America (RSNA).

Leonard Berlin, MD, former chair of the professionalism committee for the Radiological Society of North America

“There’s no question that there’s been a definite move to decrease reimbursement for radiology at the Centers for Medicare and Medicaid Services,” Berlin said. “All the projections for radiology reimbursement have it falling, meaning that practitioners, for 2012 and beyond, will need to find a way to maintain and manage a workload that is sometimes heavier for less money.”

The ACR is also concerned about reduced payments. Currently, the organization’s No. 1 priority is working with Congress to extend the temporary fix to Medicare’s sustainable growth rate, the formula used to control healthcare spending. The stop-gap measure, enacted in December 2011, averted a 27 percent physician payment reduction, and the ACR would like to extend the fix permanently.

“We’re also watching carefully to see if we can stop the Centers for Medicare and Medicaid Services from making any multiple procedure payment reductions,” said Cindy Moran, ACR’s government relations assistant executive director, referring to cuts in payment when two or more codes are performed to the same patient by the same physician during a single session. “But we are also assuming, with this being an election year, that we might be faced with a lame duck Congress.”

Changes could also be coming to codes that routinely appear together, said Maurine Spillman-Dennis, ACR’s senior director of health policy. CMS is analyzing whether procedure codes that are often linked 50 percent, 75 percent, and 90 percent of the time can be bundled, reducing overall reimbursement for those services.

“We are involved in an evolution toward a new payment model. The bottom line is that healthcare is turning away from the fee-for-service system and moving toward capitated services,” Spillman-Dennis said. “It will be a challenge for radiology to fight under this new care delivery model and make sure its practitioners are paid for services provided.”

To read the remainder of the article: http://www.diagnosticimaging.com/practice-management/content/article/113619/2033254

Radiologists Prep for California Dose Reporting Regulation

Published on the Feb. 6, 2012, DiagnosticImaging.com website

By Whitney L.J. Howell

Starting July 1, diagnostic radiologists in California will be required to include radiation dose levels in all CT reports. Industry response has been mainly positive, but there are still concerns about how the legislation will be enacted and the effect it will have on daily practice.

The current legislation requires radiologists to report all CT dose levels, including accidental overdoses, and mandates that medical physicists conduct an annual assessment of the dosage units in every protocol. These measures are in response to two significant overdose events at Cedar-Sinai Medical Center and Mad River Community Hospital in Aracata, Calif.

“What happened was a bad situation, so with that backdrop the response with this reporting legislation was reasonable,” said Bob Achermann, California Radiological Society (CRS) executive director. “It’s an effort to ensure radiology is doing its job correctly and that the industry is providing transparency.”

Radiology leaders anticipate the dose reporting will lead to future data mining opportunities about radiation exposure, public health effects, and long-term radiation responses.

Under the law, medical physicists have 10 days to calculate and report the dose levels to the California Department of Public Health. CRS, however, supports legislation to amend the bill’s language, making it less burdensome on radiologists. For example, Achermann said, CRS wants to limit the number of reportable procedures to the four targeted by the American College of Radiology (ACR): adult abdominal and brain, as well as pediatric abdominal and brain. The organization also wants to exclude dose reporting for any ancillary radiation experienced by organs adjacent to the target and clarify language that calls for radiologists to dictate the dose level into the patient record.

To read the remainder of the article: http://www.diagnosticimaging.com/low-dose/content/article/113619/2027591

Follow-Up: How Secure Is Cloud-based Image Sharing?

Published on the Feb. 1, 2012, DiagnosticImaging.com website

By Whitney L.J. Howell

Interest in cloud image sharing has swelled in recent months. The topic has appeared on national conference agendas, and a growing number of vendors now offer clients the ability to transfer images anywhere worldwide. But the rising popularity of sending images via the Internet doesn’t mean everyone in the radiology industry is comfortable with the idea.

In an informal, nonscientific January Diagnostic Imaging poll, 70 percent of respondents reported they are concerned about the security of cloud image sharing. According to many vendors, this type of image sharing prompts two main worries: Will images viewed through the cloud be of high enough quality to render a diagnosis, and will a cloud sharing system protect the large number of patient images effectively?

Many industry leaders and vendors said existing privacy protocols are more than enough to keep patient images safe.

But not every cloud image sharing vendor creates an entirely new privacy and safety protocol. For example, eHealth Global Technologies relies on measures that exist within health information exchanges (HIEs) to keep the images in its eHealth Connect® Diagnostic Image Exchange safe.

“Health information exchanges already have security and consent controls set up,” said Ken Rosenfeld, eHealth Global’s CEO. “Rather than asking clients to spend the time and money to put new protocols in place and reinvent security measures, we work within the framework they already have.”

To read the remainder of the article: http://www.diagnosticimaging.com/informatics-pacs/content/article/113619/2024991