Since RT Image has started their blog page, I have used it as an editorial page and a place to let you know what is happening in different aspects of both radiology and the peripherals that affect it and us. Having said that, I am opening this month's dialog to you, so if here is something you would like to discuss with myself and others, here is your chance.

Your topics and questions are welcome. If there is something I can help you with, please do not hesitate to ask. Some topics may require research, so, if I take a few days to get back to you, don't be discouraged.

It is now up to you. I would like to here from you.

Ok. Let's talk about GFR and contrast guidelines for NSF. Do you have any questions regarding this?

Next: Standardized MR Protocols: Comments?

Here is a few to dwell on.

In January of 2005 Medicare -CMS (www.cms.hhs.gov) came out with the Pay for Performance Initiative to help control the escalating costs of healthcare. With growing acceptance, the initiative covers almost every facet of healthcare; from hospitals, nursing homes, rehabilitation centers, physician groups, and insurance payors to diagnostic radiology. This is a collaborative effort with multiple organizations from JCAHO, AMA and others. Simply put, if the centers or groups meet and submit the outlined criteria for the performance guidelines, they will receive the full reimbursement for the facilities Medicare DRG payment schedule.

With this, the American College of Radiology (www.acr.org) has followed suit with their own (though based solely in the CMS initiative) P4P which will reward radiologists (long overdue) - value added compensation- for the superior services that they render. This will cover not only correct reporting, but also the limiting of radiation exposure during CT, Fluoroscopy and Nuclear Medicine. The guidelines must be met in order to receive compensation. In regards to insurance companies, some have also come on board with their own outlines with this initiative. They have stated that during a hospital stay, if the initial diagnosis is missed, the payor will not reimburse the facility and the patient will not be charged for the stay or the diagnostic testing that was done during said stay, though, if the diagnosis is made, the institution will be reimbursed. These are bold moves, but much needed ones. Healthcare spending was and is affecting the economy. Healthcare for most has become a distant memory because they are unable to afford it. It is a shame, that the mightiest country in the world cannot provide adequate healthcare for all at a reasonable cost.

With the advancement of gradient strength, pulse sequences and coils, breast imaging has made huge inroads in tumor detection and specificity. MR breast imaging is pushing itself to forefront of advanced breast cancer diagnosis and treatment planning. Abundant clinical quality analysis and clinical trails have translated into rapid changes in approach to clinical breast care with improved interpretive skills from the radiologist. The technologist is an integral part to the equation. We, as technologists, need to understand the same mechanisms for acquiring diagnostic images. Have the ability to identify a lesion, selecting appropriate pulse sequences and to notify the radiologist of a finding. Doing all of this will result in better diagnosis and together this translates in to better treatment planning and hopefully, better patient outcome.

These are some of clinical indications of MR Breast are as follows and all have reasoning behind them.

• Implant Evaluation
• Axillary carcinoma of unknown origin
• Screening women at high risk
• Breast Cancer patients
• Ipsilateral extent of disease
• Contralateral breast screening for occult disease
• Post-surgical with positive close margins

Along with this are the minimal technical requirements which are listed below.

• 1.0 Tesla or higher field strength.
• Dedicated breast coil.
• High Spatial Resolution (1mm all planes)
• High Temporal resolution(Maximum five minutes).
• Slice Thickness (no greater than3mm).
• Fat and Chemical Suppression.
• All should be done bilaterally.

SITUATIONS THAT MAY AFFECT THE SCHEDULING BREAST MRI.

• Prior Mammogram - Must have prior mammograms (US films also if applicable)
• Pre-menopause - Must schedule between days 5-14 of the cycle
• Post menopause - If on hormone replacement therapy, must discontinue for at least 30 days prior to the MRI Birth Control Meds Notify the facility at the time of scheduling
• Breast Biopsy - May proceed with MRI breast exam after biopsy
• Lumpectomy - May be imaged right after but prior to any additional therapy
• Chemotherapy - Insurance may cover MRI breast prior and only after the therapy has been completed
• Radiation Therapy Patient must wait for 6 months after the completion of Radiation treatments (XRT)

With all of the advancements in technology, MR of the breast has its drawbacks in regards to the manual intervention from the technologist and the radiologist. Workflow suffers because of the number of sequences that need to be acquired and that the final data sets are very large. The length of the exams may tend to lead to patient motion which will cause artifacts and possibly false positives. Having said this, if your center/hospital is going to venture into breast MR, you will need to come up with unique scheduling, screening, standardized protocols, radiologists that can make a difference and the ability to make the patient comfortable.

In the expanse of the medical profession lies radiology. Radiology is the biggest revenue producer in the United States medical profession. Within radiology lies a dilemma that continues to grow. That dilemma is the lack of radiologists that are now graduating. To compound that shortage, the baby boomers are reaching the age of medical necessity. As the population ages, the need for medical treatment increases.

Teleradiology was born out of hospitals needing emergency reads in the middle of the night and the radiologists needing the ability to make these reads without making a trip to the hospital to do so.

Today, Teleradiology is the fastest growing segment in radiology. With the demands for 24 hour reading services that use overseas radiologists, to a "new" group of teleradiology that is spawning daytime reading services. To take that one step further there are now "subspecialty" teleradiologists. They specialize in specific modalities; specific body parts (neuroradiologists, musculoskeletal, PET, Cardiac and so on).

With the technological advances in Telemedicine, networking, high speed image transmission and super fast computers, the rural portions in the United States now have access to world class expertise in all of these fields. The population now does not have to fear "standard" care in rural areas. Specialization is just a click away. Radiologists can consult with other radiologists across the country to get the correct diagnosis.

Coming from both hospital based and free standing imaging centers and now working in this area I have seen all sides. Some of you have not had that experience, some have. I would like to hear your input, good or bad, on this subject.

On January 1, 2007 Deficit Reduction Act went into effect, which reduced technical component payment on studies of contiguous body parts and limited technical reimbursement for high-tech imaging studies to the lesser of the HOPPS schedule (Hospital Outpatient Prospective Payment System). Will private payors react in a similar fashion? The reason for the enactment was because Medicare payments under the physician fee schedule for diagnostic imaging services grew by nearly 90% from $5.8 billion in 1999 to $13.7 billion in 2005 so growth in Medicare payments for imaging services prompted CMS and Congress to implement policy to lower payments. By doing this, technical reimbursement for high-tech studies performed at IDTFs was reduced by 30-70% depending on the study type. So how does affect the industry you ask? Here are several scenarios: • DRA and other payor policy changes are focused on limiting the growth of outpatient (primarily IDTF) imaging • Analysts predict that DRA will reduce total IDTF revenue by 10-15% • Revenue reduction will limit new entrants into the IDTF market and catalyze numerous acquisitions and consolidations • Additionally, because hospitals and IDTFs can compete on level reimbursement ground, hospitals will increasingly look to expand outpatient imaging programs. Now that hospitals and IDTF's have an even playing field, I am using an assumption to say that hospitals will look to open new or purchase existing imaging centers to compete. Imaging centers now will look how to differentiate themselves from the emerging hospital based imaging center influx. They can do that by targeted marketing to subspecialty practices, such as Orthopedists, Neurosurgeons etc. To do this they would need subspecialty radiologists to increase the quality of their reports, though the hospitals will look in the same areas to increase their referral base.

So how does this affect you, your center, and your careers? Let me know.

(BTW: Sorry for the long wait, been a busy couple of months)

Working in teleradiology allows us to see the new advances across all modalities which enables both radiologists and the technologists learn at an accelerated rate. Since we are doing reads "remotely" we have to utilize technology to do it faster and better. So as we learn of systems that can help, our quest for knowledge expands.

This is a relative new breakthrough in Computed Tomography. It allows for 3D visualization of the heart and the arteries that supply it. It started with the advent of Electron Beam CT (EBCT) in the early '90s, but since the slice thickness was relatively large, visualization of the coronary arteries was limited, though promising. Then came 4 slice with better resolution, but still inadequate by today's standards. Now with 64-slice CT and near isotropic pixels, better gating and smaller FOVs, CCTA has taken the non-invasive technique to the next level.

With the percentage of people that are having coronary angiography (it has grown to 373% or 1.4 million exams by 2003 since 1979), this "non" invasive technique will be huge in diagnosing CAD and allowing preventative medicine to finally make a stand. This modality is becoming the test of choice, not only in an outpatient setting, but also in the emergency room as the "triple" rule out exam for acute chest pain. It can diagnose PE, aortic dissection and CAD (though the field of view is extended for this to be definitive)

As a technologist, knowing the anatomy, knowing the techniques, having the ability to do image manipulation and the tools to do so is very important. Not only do you improve patient care you also enable the radiologist/cardiologist to make extremely accurate diagnosis while cutting down the "interpretation times." As you know the image files for these exams are very large to say the least. The more information (anatomy, physiology) the technologist can digest and understand the more they can be effective in the clinical setting.

I am writing this Blog submission to encourage feedback and hopefully make us all better prepared for this new technology.

The first questions I am seeking feedback on are the following: What do you see as near and distant possibilities for this procedure? Do you see this replacing the current coronary procedure performed in the catherization labs?

What are your best injection rates? What technology or software is available to make mapping vessels or do vessel probes work best. Is there an easier way to do this? I am looking forward to hearing from you.