The Member Newsletter of the Society of Breast Imaging ���������

Presidential Message:Maintenance of Certification,Maintenance of Confidence

R. James Brenner, MD, JD

Society of Breast Imaging1891 Preston White DriveReston, VA 20191-4397

From The Editor:AIM To Improve

Mammography Performance

IHEDigital

Breast Imaging

2007CPT® Code

Update

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First ClassU.S. Postage

PAIDPermit #144Waldorf, MD

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ACRMammographyAccreditation

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government invited their participationin return for reconsidering drasticreimbursement cuts. Since the begin-ning of this Century, highlighted in anIOM (Institute of Medicine) report,the public and payers have been advo-cating a process that would improvethe quality of healthcare in a mannerthat could be objectively measured.Pointing to other industries wherecertain metrics could be used to mea-sure quality, such advocates havedeclined to accept the autonomy ofthe American physician and insistedon developing systems that at leastbegin to incentivise improvement incare. This effort in fact dates back atleast ten years; consider the HEDISstandards that were applied to pri-mary care physicians to encouragecompliance with best practice patternssuch as recommending screeningmammography. Of interest, this yearCalifornia will institute a trial program,rewarding primary care physicianswho fulfill certain medical recom-mendations.

The American Board of MedicalSpecialties (ABMS), which includesthe American Board of Radiology(ABR), has left the task of establish-ing parameters for MOC to each of

�ost of us have heard of theupcoming Maintenance ofCertification, or MOC,

program, perhaps even read about itin one of the national journals. Somemay have already participated in oneelement leading to MOC, a SAMSexam where questions are answeredfollowing a conference presentation,that can be applied toward completionof the ten year process. But I suspectthat both the rationale and even de-tails of the program are not familiar.That will change and the purpose ofthis column is to facilitate thatchange. This is an issue that affectsnot just breast imagers or even radio-logists; it affects all of medicine.

There are a number of terms thatrelate to this subject with one of themore interesting terms being “pay forperformance.” (PFP) This lighteningrod phrase is certain to capture theattention of most practitioners and itssignificance is illustrated by thechanging attitude of the AMA(American Medical Association)which initially resisted any partici-pation in a PFP initiative, until the

their respective 24 Boards. Six corecompetencies are defined by theABMS for all specialties and includemedical knowledge, patient care, in-terpersonal and communicationskills, professionalism, practice basedlearning and self-improvement, andsystem based practice. Board certi-fication reflects all of these and until2002, those who received certifica-tion were not required to demonstrateany further evidence of continuingcompetency beyond compliance withapproved programs for continuingeducation. Since 2002, ABR certifica-tion is granted for diagnostic radiologistsfor ten years, after which re-certificationis mandatory. Otherwise, evidence ofMOC is voluntary but, as will be dis-cussed below, external events maymodify this condition.

This historic assumption thatthose who are involved in approvedcontinuing education activities arehelping to insure continuing compe-tency has been challenged. The answerto this challenge is unknown. Undersuch circumstances, MOC programsmay be seen as the next step in tryingto provide the public and payers a basisfor encouraging, if not insuring that

The Member Newsletter of the Society of Breast Imaging

arla Kerlikowske’s articledescribes how the NCI’sBreast Cancer Surveillance

Consortium (BCSC) will use a 2.5 mil-lion dollar award to improve mammo-graphic interpretation. The AIM(Assessing and Improving Mammog-raphy) project will attempt to do so bya three phase effort. In phase one,researchers will determine the effectof volume of mammography examina-tions interpreted per year on radiologists’interpretive performance, independentof other variables such as patient, phy-sician, and facility factors. In phasetwo the investigators will create assess-ment tests from community practicesand determine whether cancer preva-lence or other mammographic findingsinfluence performance. Finally, theresearchers will develop in-person, inter-pretive training programs with expertbreast imagers and see if these improveperformance.

From The Editor:AIM To Improve MammographyPerformance

Murray Rebner, MD

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SBI News is published by theSociety of Breast Imaging

To submit articles for publication, pleasesend your material to the editors c/o:

SBI Headquarters1891 Preston White DriveReston, VA 20191-4397

For membership oradditional society information,

call: (703) 715-4390fax: (703) 716-4487

website: www.sbi-online.org

EDITORMurray Rebner, MD; email: sbi@acr.org

Without knowing more of thefine details I would like to offer mycomments on the program. First, I donot think any breast imager would beopposed to the AIM concept. We areall aware that mammography, albeit thegold standard for breast cancer screen-ing, is far from perfect. For phase one,determining what, if any, minimumvolumes of screening studies read peryear are associated with better per-formance is important. However, thetiming of the interpretations may alsobe important. If radiologist A reads480 cases per year and reads 40 caseseach month, and radiologist B, a backup reader in a practice, reads 480 casesover the last month of the year for twoyears to comply with FDA regulations,does radiologist A perform better thanradiologist B due to more frequent ex-posure to the modality? Also, is there adaily interpretation volume abovewhich performance declines? We areall under pressure to do more with less.Certainly, experience and ancillarysupport tools such as physician ex-tenders, checklists in lieu of dictation, etc.would factor into this determination.However, at this time I agree that a lowervolume limit is the place to begin.

The second and third compo-nents of the program, in my mind, willessentially be linked. Anytime wehear about more test taking (SAMS,recertification, etc.) the natural reactionis to say “not again!” However, as Dr.Brenner points out in his presidentialmessage, Maintenance of Certificationlikely will become linked to reimburse-ment (pay for performance). Mammo-graphy assessment tests already exist andprovide good clinical and didacticteaching for a variety of diagnosticproblems. Dr. Ed Sickles and colleaguesat the ACR have created three such selfassessment modules (InterpretiveSkills Assessment) for mammography

which are available in CD-ROM for-mat. The AIM program will start bytesting radiologists with communitypractice representative screeningcases. Over time, perhaps the pro-gram could also select diagnosticcases to further sample the breastimager’s skills. Assessment and man-agement recommendations based onthe diagnostic workup could also beevaluated. It makes no sense to this writerto identify potential areas of improve-ment to the breast imager if he/shecannot easily follow up in these ar-eas by taking more training. The ideaof providing in-person, interactivetraining with expert breast imagersis an excellent way of doing this.CME credits could be obtained in theprocess and maybe over time, a ro-tating group of expert radiologistsand technologists could travel to dif-ferent parts of the country and offerthis service. This would be a differ-ent refreshing way of meeting CMEneeds. Current topics such as CAD,breast MRI and digital mammographymight also be integrated into the in-teractive sessions.

Finally, as I said earlier, I do notthink any breast imager opposes theconcept of improving mammographicinterpretation. However, some wouldoppose participating if the processwas not made extremely “userfriendly”. I am sure that the investi-gators have realized this and donetheir best to minimize inconvenienceto the participants. Those who wishto take part hopefully will be givencredit, in the form of time, by theircolleagues. Secondary benefits fromthe program such as fewer malprac-tice suits are likely to result. If, asDr. Sickles says, the program has thepotential to substantially improvemammographic performance in clinicalsettings, why not support it? I do. ●

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Dianne Georgian-Smith, MDMassachusetts General HospitalBoston, MA

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ince June 2005 when thefirst meeting of users in digitalimaging occured. The digital

breast imaging, the IHE mammographysubcommittee has made amazingprogress working with the vendors todefine electronic and informationsystems’ standards within digitalbreast imaging.

As many of you know first hand,there are many problems currentlywithin digital breast imaging thatresulted from the fact that the FDArequired mammography vendors todevelop complete systems from acqui-sition to interpretation workstations.Consequently, manufacturers devel-oped proprietary systems that poorlyintegrated with other vendors.

A common scenario is a site withseveral manufacturers’ screen-filmmachines. Replacing these analoguemachines with each manufacturer’sdigital equivalents requires one to alsopurchase the same manufacturer’s in-terpretation workstation, albeit recentadvances in universal workstations.This latter situation is still not idealsince third party work stations may notbe able to post-process digital imagesif that post-processing is performedoutside of the acquisition station. Insummary, one may have many addi-tional workstations reflecting thenumber of mammography manufac-turers at one’s site. Additionally analternator adjacent to the interpretationworkstation is needed for comparisonfilms. Most mammography readingstations, designed for film-screen in-terpretation, are poorly designed tohandle the increased amount ofhardware needed for digital read-ing, as well as the heat output fromthe additional computers, and lightpollution from the alternators on tothe monitors.

IHE Digital Breast Imaging

Additional problems havestemmed from PACS systems nowmanaging and storing large fileswhich are approximately 30 MB perimage from an area of radiologywhere large volumes of patients passthrough daily.

Workflow issues are paramount.They can be broken down into acqui-sition, post-processing, and reportingcomponents. Problems exist in whichimages are poor quality at the acqui-sition systems making it difficult fortechnologists to screen for motion orfor radiologists to see some calcifi-cations for needle localizations. Ad-ditionally, acquisition stations do notdisplay images from other vendors.With regards to post-processing,manufacturers use proprietary algo-rithms to produce the “for presentation”images. Although a manufacturerwill be able to show a differentmanufacturer’s images, the formatwill not be in a format supportedfor interpretation. Therefore, follow-up images on patients must be per-formed on the same manufacturers’machines time after time. Otherwise,a radiologist finds himself/herselfmoving from chair to chair to compareimages, an impossible scenario. Withregards to reporting/interpretationissues, due to different number of pixelsper image per manufacturer, breastsare displayed at different sizeswhen viewed on the same monitorfrom two different manufacturers.Management of patients’ work-listsdiffers between manufacturers. Onemust also determine if the measure-ments on an acquired magnifiedimage is true size or also subject tomagnification. Manufacturers handlethis measurement step differently,and consequently this can markedly af-fect planning for needle localizations.

Hinging on workflow problemsis the issue that technologists mayhave to push images to interpretationworkstations and PACS. This prob-lem leads to human errors of forget-ting to do so particularly if sendingimages to PACS is not integrated tothe interpretation. Previous digitalimages are not always immediatelyavailable and may have to be pushedor pulled from the PACS system, butone may not know on which vendor’smachine the previous ones were im-aged if there has been cross-over.

These are some of the issues thathave made the move from analogue todigital breast imaging very difficult.

In the past year and a half, theMammography IHE subcommitteehas made significant progress toachieve integration. The purpose ofIHE is to define basic standards formanufacturers so that they can beintegrated into one seamless system.Vendors are not limited by these stan-dards and can still develop uniquefunctionality beyond the standards tocontinue to strive for market share.

Accomplished this year is theMammography Image Profile which isa supplement to the IHE Radiology Tech-nical Framework. The profile is availableon the at: http://www.ihe.net/Technical_Framework/upload/IHE_RAD-TF_Suppl_MAMMO_TI_2006-04-13.pdf).

Currently, the subcommittee isworking on the Workflow Profile(this effort being chaired by GordonSmith, neither a vendor or a radiologistbut neutral party former director ofMGH Radiology Informatics). Thesubcommittee met in July/August todefine the issues and will be meetingin November and January to hammerout line by line the Workflow Profile.

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The Member Newsletter of the Society of Breast Imaging

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�ook for pertinent changes inthe CPT® 2007 code bookthat will affect radiology prac-

tices and will require revision to computersystems and charge sheets. Significantamong the changes is the relocation ofa number of older codes to more specificsections within the CPT code book,e.g., relocation of mammography andmost guidance codes to the 77000 seriessection.

The relocation of these codes withinthe 2007 CPT codebook is part of anAMA organizational restructuring (CPT5 Data Model Project) to facilitate com-puter processing and interoperability withvarious computer systems. Codes whichwere previously listed under “Other” havebeen relocated to more descriptive sec-tions. This relocation will include a hostof codes with which many are familiarand which include: mammographycodes (76082, 76083, 76086, 76088,76090, 76091, 76092, 76093, 76094,76095, 76096); most guidance codes

(75998, 76003, 76005, 76006, 76355,76360, 76362, 76370,76393, 76394);bone studies (76020, 76040, 76061,76062, 76065, 76066, 76070, 76071,76075, 76076, 76077 76078, 76400);and vertebroplasty codes (76012,76013). Most of the codes will be re-numbered and relocated to the beginningsection of the 77000 series section of theCPT codebook prior to the radiation on-cology codes, while a few are being relo-cated to other more appropriate sections.Because of the number of radiology codesthat need to be relocated, the beginningof the 77000 series of codes was the onlychoice. Click here for a crosswalk to therevised code structure. (Link)

Among the new codes for 2007are functional MRI, nuchal translu-cency measurements, percutaneousradiofrequency ablation of pulmonarytumor(s), a unique all-inclusive codeto describe uterine fibroid emboliza-tion, placement of interstitial device(e.g., fiducial marker) in the prostate,

stereotactic body radiation therapy, ster-eotactic radiosurgery, and revision to thenuclear medicine genitourinary codesection. In addition, a number of ad-ditions and deletions will be made to theCategory III (tracking) CPT code sec-tion. See the September/October 2006ACR Radiology Coding SourceTM for anupdate on the 2007 CPT code changes.

Note: It is important that billingsystems be updated and the new 2007codes available for use when thesecodes become valid on January 1,2007. The Health Insurance Portabil-ity and Accountability Act (HIPAA)transaction and code set rules requirethe use of the medical code set thatis valid at the time the service is pro-vided. Physicians, carriers and inter-mediaries no longer provide a 90-daygrace period to implement new codesets. Reference the ACR Web site athttp://www.acr.org/s_acrdoc.asp?CID=3323 &DID=19843 for additional in-formation on this HIPAA requirement. ●

Reprinted with the permission of the American College of Radiology.

2007 CPT® Code Update Relocates Mammographyand Most Guidance Codes

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April 14-17, 2007SBI

8th Postgraduate CourseWestin DiplomatResort and Spa

Hollywood, Florida

May 8-10, 200833rd

National Conference onBreast Cancer

JW MarriottGrande Lakes Resorts

Orlando, Florida

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The Society of Breast Imaging is offering scholarships for residentsinterested in breast imaging and individuals currently in breastimaging fellowships to attend the SBI 8th Postgraduate Course,April 14 – 17, 2007 in Hollywood, Florida.

Interested individuals should submit an essay of no more than 250words along with a letter of support from a faculty member and aletter from the department chair indicating the individual will beallowed the time off to attend the conference.

The scholarship will cover travel expenses up to $2,000, within theguidelines of the Society reimbursement policy.

Submit to: sbi@acr.org

Deadline: February 1, 2007

Include: Name, address, telephone and email address

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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 fluoroscopicguidance; single level

22527 (replaces 0063T) Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopicguidance; 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 pleuraor 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 ofrepetitive body part movement and/or visual stimulation, not requiring physician or psychologistadministration

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 nuchaltranslucency measurement, transabdominal or transvaginal approach; single or first gestation

76814 Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchaltranslucency 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 OFof cerebral lesion(s) consisting of 1 session; multi-source Cobalt 60 based

77372 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment ofcerebral 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, includingimage guidance, entire course not to exceed 5 fractions

77435 (replaces 0083T) Stereotactic body radiation therapy, treatment management, per treatment course, to one or morelesions, including image guidance, entire course not to exceed 5 fractions

+0159 Computer-aided detection, including computer algorithm analysis of MRI image data for lesiondetection/characterization, pharmacokinetic analysis, with further physician review forinterpretations, 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 lesiondetection) with further physician review for interpretation and report, with or without digitization offilm 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 lesiondetection) with further physician review for interpretation and report, with or without digitization offilm radiographic images, chest radiograph(s), performed remote from primary interpretation(Effective January 1, 2007)

*Not listed in CPT code book, but effective 2007.

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2007 CPT® Code Updates

Continued on page 6

The Member Newsletter of the Society of Breast Imaging

NEW 20007 CODES CPT DESCRIPTOR

2007 Code Relocation55875 (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 vertebralaugmentation including cavity creation, per vertebral body; under fluoroscopic guidance

72292 (replaces 76013) Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentationincluding 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 orcomplete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation,any necessary contrast injections through access site or catheter with related venography radiologicsupervision nd interpretation, and radiographic documentation of final catheter position) (List separately inadditional 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 ortherapeutic 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, localizationdevice), 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, orplacement 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 forinjection) 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) withfurther physician review for interpretation, with or without digitization of film radiographic images; diagnosticmammography (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) withfurther physician review for interpretation, with or without digitization of film radiographic images; Screeningmammography (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

2007 CPT® Code Updates (continued)

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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, CPTAssistant, September/October 2006 ACR Radiology Coding SourceTM electronic newsletter.

2007 CPT® Code Updates (continued)

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Then it will be available for publiccomment in February-March. A cor-ollary committee that dovetails intothe Mammography Workflow effortsis the IHE Reporting Workflowcommittee. For the first time, cardio-logists and the American College ofCardiology (ACC) joined radiologistsand radiology vendors in October to de-fine the problems of report integration.

Planned for 2007 is the annualIHE connect-a-thon in which vendorswill bring their hardware/ software andshow the integration that has beendefined on the recently developed pro-files. At the SBI meeting in April 2007,vendors are planning to show this inte-gration to the public.

The process of IHE has been aninteresting and sometimes perplex-ing process for me. I gladly volun-teered and joined forces with Drs.Rita Zuley (Elizabeth Wende Clinic)and Judy Wolfman (Northwestern U.)as I had publicly declared that work-ing with digital mammography wasa “pencil in the eye”. At the tablewere 25-30 vendors. We, the radi-ologists were outnumbered 10 to 1.

At first it seemed that we were onseparate teams with different goals.“They” the vendors wanted to deter-mine what was going to happen andwhat could be done, and “we” theradio-logists, also the consumers andusers, were adamant to dictate theend points. The foreign language was“Vendor-IT-Speak”, having neverbeen given in high school. “Proce-dures” were not related to needles inbreasts but had been defined to bethe equivalent of any radiological ex-amination. “Actors” were not those“who play a doctor on TV” but re-ferred to “information systems thatproduce, manage, or act on informa-tion associated with operationalactivities in the enterprise.” It tookseveral face to face discussions forthe group to gel into one force anddevelop the mutual respect that is es-sential to become a team. “We” weremarkedly assisted by Drs. DavidChannin, MD, from Northwestern,and David Clunie, MBBS, fromRadPharm, who are each radiologistsand IT-gurus. They are capable ofgoing toe-toe with the vendors when

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D. David Dershaw, MD, former president ofthe Society of Breast Imaging and the first chair ofthe American College of Radiology Committee onStereotactic Biopsy Accreditation, urged the Foodand Drug Administration (FDA) National Mammog-raphy Quality Assurance Advisory Committee toremove the current exemption for stereotacticbreast biopsy units under Mammography QualityStandards Act (MQSA) regulations.

Dr. Dershaw testified that the ACR has beensuccessfully accrediting stereotactic breast biopsysystems since 1996. Currently, more than 450 ofthese units in the United States are accreditedthrough a voluntary ACR program which evaluates

vendors are in the mood of IT-double-speak-I-am-going-to-bam-boozle-you behaviors so that theradiologists’ interests are kept in theforemost goals. Nevertheless in spiteof everyone’s disparate backgrounds,I believe that the presence of radio-logists at these discussions has beenwelcomed.

Before closing, I would like totry to arouse interest in other radio-logists in IHE. Prior to my involve-ment, I had only heard of IHE as signsat RSNA on the poster floor level,but I had no idea what IHE did, prob-ably because breast imaging was thelast to become a digital modality.This year marks the 9th year of IHE.There are many profiles that havebeen written by countless hours ofvolunteer work. Prior to the develop-ment of the mammography subcom-mittee, the vendors wrote most ofthese profiles. Even long standingIHE members admitted that IHE waspoorly advertised amongst radio-logists. The involvement of the radio-logists in Breast Imaging marked a

personnel, equipment, and clinical performance ofthe biopsy procedure and provides the applicantwith suggestions for improvements in quality.

Dr. Dershaw, of the Memorial Sloan-KetteringCancer Center, spoke September 28-29 inRockville, Md., on behalf of the Society of BreastImaging and the ACR at the FDA’s National Mam-mography Quality Assurance Advisory Committee.

The FDA is drafting changes to MQSA regu-lations and is considering removing the currentexemption for stereotactic breast biopsy units. Dr.Dershaw stated that both the SBI and the ACRendorse the regulation of stereotactic breast biopsyunder MQSA. ●

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change in the process in which “we”were going to determine what “we”needed. I have now attended a fewmeetings with the Technical Commit-tee, the last one related to the Report-ing workflow. Dr. Channin and myselfwere the only radiologists. I wouldhave liked to have seen more radio-logists representing different types ofpractices. If you want a system thatworks efficiently for your practice, thenyou must take the time to become in-volved. Even if you cannot attend themeetings directly, you can ask to callin on conference call. The person tocontact at RSNA is Chris Carr(ccarr@rsna.org). When the profiles arecompleted they are available on theweb for public comment. These areopportunities to create what you needwhich and this will only happen ifyou become involved.

Familiarize yourself with theweb site: www.ihe.net.

Referencing the IHE standardswhen negotiating with vendors onnew equipment is intended to helpradiologists work more efficiently. ●

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Does your facility need help on applying for mammographyaccreditation? Do you have a question about the ACRMammography QC Manual? Check out the ACR’s newaccreditation web site portal at www.acr.org; click “Accreditation,”then “Mammography.” The “Program Overview” and “FrequentlyAsked Questions” were completely updated and reorganized inJuly to provide more useful information on accrediting digitalmammography equipment. In addition, most of the mammographyaccreditation application and QC forms are now available fordownloading. You can also call the Mammography AccreditationInformation Line at (800) 227-6440.

Monitors and Workstations

Q. Does my facility have to use an FDA-approved review work-station to interpret digital mammograms?

A. No. However, the FDA recommends that only monitorsspecifically cleared for full-field digital mammography(FFDM) use by FDA’s Office of Device Evaluation (ODE)be used. (See FDA’s Modifications and Additions toPolicy 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 thenew FFDM unit as part of the Mammography EquipmentEvaluation? Do we have to submit the review workstationtest results for accreditation?

A. Yes and yes.

Q. We have just added a second FFDM unit. Images from thisunit are interpreted on our current review workstation. Thisreview workstation was evaluated during the medicalphysicist’s Annual Survey of our old FFDM unit. Does ourmedical physicist have to retest that review workstation alongwith the new FFDM unit as part of the Mammography Equip-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-ously with another FFDM unit at that site during itsMammography Equipment Evaluation or Annual Survey,the medical physicist does not have to retest the work-station. However, the medical physicist should indicateon the Mammography Equipment Evaluation summaryforms sent with the accreditation application when theworkstation was tested and the results.

Priscilla F. Butler, MSSenior Director, ACR Breast Imaging Accreditation Programs

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IHE Demonstration atSBI 8th Postgraduate Course

Attendees will have theopportunity to participate in

an interactive IntegratedHealthcare Enterprise (IHE)

demonstration on digitalmammography display and

workstation functionality. Checkthe SBI website in the comingmonths for more information.

Gerald Dodd Lecture atSBI 8th Postgraduate Course

Etta D. Pisano, MD will presentthe Gerald Dodd Lecturetitled “What We Learned

from DIMST” onSunday, April 15, 2007.

The Member Newsletter of the Society of Breast Imaging

�he National Cancer Institute’s

(NCI) Breast Cancer Surveil-lance Consortium (BCSC) was

recently awarded $2.5 million fromthe Breast Cancer Stamp Fund andthe American Cancer Society to helpsupport new research on how to im-prove mammographic interpretation.The title of the project is “Assessingand Improving Mammography(AIM). The funding provided by the

American Cancer Society is pro-vided through a generous donationfrom the Longaberger® Company’sHorizon of Hope Campaign®.

This is a novel collaborationamong public and private agenciesthat builds on the BCSC’s history ofcollaborative research. The projectwas initiated by the American Can-cer Society, which has a longstandingrelationship with the Longaberger®

Company. Dr. Robert Smith from theAmerican Cancer Society (ACS) ap-proached NCI after an analysis andreport by the Institute of Medicine(IOM) identified a shortage of re-search regarding measuring and im-proving mammography interpretiveperformance skills. NCI oversees avariety of projects funded by moneycollected from the purchase of BreastCancer Stamps in US Post offices,and has worked with the BCSC toprovide funds to evaluate mammog-raphy performance and practice incommunity settings.

The BCSC was established in1994. The BCSC is well-suited tostudy mammographic interpretationbecause it collects longitudinal dataon mammography interpretive perfor-mance and includes large numbers ofwomen, mammograms, and radio-logists. Each of the mammographyregistries has created a mammographydatabase that is linked to population-

based cancer databases and/or pathol-ogy data. As of December 2005, theBCSC pooled database had over 5million radiology events for over 1.5million women covering the years1994 to 2005. The database has broadracial representation, similar to theUS population overall.

A recent IOM report, ImprovingBreast Imaging Quality Standards,provided an important catalyst for theAIM project by finding that mammo-graphy interpretation remains quitevariable despite the improvement inits technical quality since the imple-mentation of the MammographyQuality Standards Act (MQSA) of1992. “I participated in the IOMreview and was struck by the uniqueopportunity to act on the recommen-dations from this report and moveforward with a research agenda tobetter understand the measurement ofinterpretive performance, and toimprove it,” says Robert Smith,PhD, and Director of Cancer Screen-ing at the ACS.

The AIM project is designed todiscover factors and interventionsthat can reduce variability and im-prove the overall quality of mam-mography interpretation throughthree main research activities. In thefirst activity, BCSC investigatorswill determine the effects of volumeof mammography examinations in-terpreted per year on radiologists’clinical interpretive performance,controlling for patient, physician,and facility factors that are knownto influence performance measures.They will test the hypothesis thatlower annual interpretive volume isindependently associated with poorerclinical performance. Determiningwhether the volume of mammogramsinterpreted every year actually influences

clinical practice may help the Foodand Drug Administration and radi-ologists decide whether the currentrecommended minimum of 960mammography examinations inter-preted over 2 years is optimal forbreast cancer detection.

In the second component, the in-vestigators will create assessment testssets using representative screeningmammography examinations fromcommunity practice. These tests willbe used to assess radiologists’ interpre-tive skills and evaluate whether can-cer prevalence or the prevalence ofvarious types of mammographic find-ings influence performance measures.The BCSC investigators are workingwith the American College of Radiol-ogy (ACR) to digitize images and pre-pare tests using software developedwith ACR expertise. The tests alsoshould reveal whether performance onthese test sets is associated with per-formance measures in clinical practice.

In the final component, BCSCinvestigators will develop and testtwo innovative educational programsdesigned to improve radiologists’mammography interpretive skills byfocusing on the types and locationsof findings that are particularly chal-lenging for radiologists to identify.The first program is an in-person, in-teractive intervention in which expertradiologists will use selected mam-mography examples as teachingcases. The second is a DVD versionof the in-person intervention.

“This research has the potentialto substantially improve mammogra-phy performance measures in clini-cal settings,” says Ed Sickles MD,Professor of Radiology at the Uni-versity of California, San Francisco,and national expert in mammography.

Novel Collaboration Advances Research to ImproveMammography Performance

Continued on page 11

10

Karla Kerlikowske, MDProfessor of Medicine and Epidemiology and Biostatistics

���������

www.SBI-online.org

“This research also should have directbenefits for radiologists,” adds R. JamesBrenner MD, Professor of Radiologyat UCSF and President of the SBI.“In an era characterized by PQI (Per-formance Quality Improvement), itis a natural extension of our work tounderstand how well we are doing,and how we can better assess and im-prove performance. Such efforts setthe stage for maintaining high-qualitymammography in this country.”

The AIM project started in Septem-ber 2006 by mailing to communityradiologists, a survey designed todetermine the current practices in theradiology community as it pertainsto mammography. In the September2007, the BCSC investigators plan tostart assessing radiologists’ interpretiveskills with test sets created with fundsfrom this grant.

This novel project brings to-gether contributions from two fundscommitted to improving breast cancer

care, two agencies committed to re-search, experienced investigators andphysicians responsible for mammo-graphy interpretations. “The goal isto improve mammography perfor-mance and benefit the millions ofwomen screened in the United Stateseach year. This is a great example ofhow collaboration in funding andresearch creates opportunities,” statesStephen Taplin, MD who oversees theBCSC for NCI. “I look forward to theresults.” ●

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President’s MessageContinued from page 1

physicians are seeking incorporatenew information and approaches intoclinical practice. To that extent, theABR will ask diplomats to providedocumentation of MOC in four dif-ferent areas; professionalism, lifelonglearning and periodic self-assess-ment, cognitive exposure, and prac-tice performance.

As was outlined last year in aprevious article, a general test at theend of ten years will address gen-eral professional issues and con-tinuing education with evidence ofSAMS completion will be required.Also recall that one need not seekMOC in all radiology subspecialties,but rather those which are germaneto one’s practice. Thus those whorestrict their practice to only breastimaging will be encouraged to pur-sue projects related to this specificfield. Other specifics regarding theprogram are currently being devel-oped. The fundamental change inthis context—and the one whichmay invite the greatest degree ofconfusion—regards performancequality assurance. Rather thansimple education, the goal is to sat-isfy three benchmarks over tenyears, currently referred to as typeI and II, with a requirement for atleast one type II activity. Type Iactivities may be involvement with

local or institutional efforts. In-deed, some institutions already areinvolved in type I activities whichmight include periodic projects toassess accuracy of diagnosis (suchas cross monitors). The intent todevelop tools and enlist activeparticipation in conforming toevidence-based practices. Collectingsuch data, analyzing it, compar-ing it to peers, and institutingthose modifications which shouldimprove outcomes with a subsequentreassessment is a basic tenet ofMOC. Type II activities will seekexternal validation of a qualityimprovement activity. Current ex-amples include participation inthe ACR’s RADPEERtm programwhere online assessment of previouscomparison studies (e.g. CXR, mammo-graphy) are conducted to assesswhether a substantial error may havebeen made on the prior examinationand report. The ACR InterpretativeSkills Assessment CDs are anotherexample.

The ABR recognizes that thisparadigm shift from simple CME ac-tivities to a more active demonstration ofinvolvement with quality improve-ment measures will need to evolve. Asthe ABR studies and learns from differ-ent performance quality improvement(PQI) projects, it will develop templatesfor others to use with the assurancethat such activities are considered

accepatable. Thus, the only currentrequirement is participation; the typeof activity can be both creative andvariable, so long as it is approved bythe Board. Indeed, at a recent summitmeeting held by the ABR in whichsubspecialty societies were invited toattend, it was noted that the first tenyear cycle is not meant to be harsh orrestrictive. The Board hopes to es-tablish a web based account for eachparticipant where satisfaction of dif-ferent MOC criteria can be tracked,monitored, and validated; a modestadministrative fee will be sought tocover expenses to provide the system.

MOC requirements are man-dated for those certified after 2002.Although voluntary for others, theimplications of avoiding involvementwith MOC are both speculative andformidable. No current mechanismexists to insure that all examinationsare performed in an optimal manner.But payers seek reassurance that thosesubmitting requests for reimbursementare meeting society-established stan-dards for demonstrating continuingcompetence. Thus the possibility ofeconomic credentialing exists. Thishas already been applied primarily inclinical medicine. However, certainaspects currently relate to radiology.In order to be certified by the FDAto perform mammography, federalstatutory provisions require meeting

Continued on page 12

The Member Newsletter of the Society of Breast Imaging

���()����&��� �!�*)��������(continued)

Q. The physician’s review workstation is not at the same physi-cal location as the FFDM unit (it is off site). Is the medicalphysicist still required to test it during Mammography Equip-ment Evaluations and Annual Surveys of our facility’s unit?Does the facility still need to submit QC results on that work-station to the ACR during accreditation?

A. Possibly and yes. There are at least two possible sce-narios if the review workstation is not located at thefacility where the FFDM unit is located:● If the workstation was tested previously with another FFDM

unit (either at the location of the workstation or a sistersite), the medical physicist does not have to retest the work-station. However, the medical physicist should indicate onthe Mammography Equipment Evaluation summary formsthe MAP ID # of the facility where the workstation islocated, when the workstation was tested and the results.

● If the workstation is located off-site in an office with noFFDM units and was not tested previously, the medicalphysicist must include the review workstation in theFFDM unit’s Mammography Equipment Evaluation.

Q. All clinical images at our new FFDM facility will be printedand interpreted on hardcopy. There is no review workstationfor the physician. Do we need to have access to a reviewworkstation and submit the results of its Mammography Equip-ment Evaluation and QC testing for accreditation?

A. No. However, since this is an unusual situation (mostfacilities interpret from the softcopy), you must providea letter signed by your lead interpreting physician stat-ing that all interpretations will be done from hardcopy.Also, please note that any testing required by the manu-facturer for the FFDM unit’s display is still required sincethe technologist clinically uses this display when per-forming the examination.

Q. We just installed a new review workstation. (We have hadour FFDM unit for several years.) Does our medical physicisthave to conduct a Mammography Equipment Evaluation ofthis workstation? Do we have to submit the results of this testto the ACR?

A. Yes and no. It is important that your medical physicistconduct a Mammography Equipment Evaluation of yournew workstation (and document his results in a report)to ensure that it is operating properly for image interpre-tation. However, you do not need to send this to the ACRat this time. We will request the results of the entiresystem’s Annual Survey (which must include the reviewworkstation tests) during accreditation renewal. ●

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technical standards for image produc-tion and professional standards for acertain volume of interpretedmammogams and continuing educa-tion. United Healthcare, the largestprivate 3rd party payer, is investigat-ing in 15 states .the advisability ofpredicating reimbursement for ex-aminations such as CT and MRI onformal accreditation. The Federationof State Licensing Boards is consider-ing a showing of involvement with aformal MOC program as a conditionof relicensure. The current philosophyfor PQI is not punitive; it is assumed thatcollective data which might indicate de-ficiencies in one’s performance willbe enough to prompt individual or in-stitutional interventions to improveperformance. The data will be codedand protected under the current plan.Ultimately it is hoped that nationaldata bases will be established to bet-ter compare individual performancewith peer performance

There is little alternative to re-sponding to the mandates facingmedicine in the future. Both the ABRand the ABMS recognize that thisnew paradigm in the lifelong learningprocess will prompt changes in theway practice is conducted. Specialtysocieties were asked last year to beginto develop SAM tools, and last Mayleaders in our field indeed producedthe first module for a national breastimaging meeting (National Conferenceon Breast Cancer). Likewise, the SBIwill reach out to its pool of talentedbreast imaging specialists to assist theABR in developing approaches thatwill satisfy current mandates. It islikely that many of these initiativeswill be in conjunction with the ACRwhere resources will be employed toaddress the multitude of practice cir-cumstances related to breast imaging.

The writer Frank Clark onceobserved, “If you can find a path withno obstacles, it probably doesn’t leadanywhere.” The obstacles that havebeen set in our way are not so formidablethat we cannot succeed. This pathmay indeed lead to a better place. ●

Continued from page 11