Deadline 2012: MRI Accreditation
Under the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008, those sites providing the technical component of advanced imaging must have accreditation by 2012—but not all imaging centers are waiting for the deadline. A case in point is that of the Frye Care Outpatient Imaging Center, which is operated by the Frye Regional Medical Center, a 355-bed private hospital in Hickory, North Carolina. Frye Care decided to become accredited early so that it would be ahead of the curve, according to Pamela Barbour, the outpatient center’s supervisor for mammography, MRI, and ultrasound. It also wanted to meet mandates from insurance companies for accreditation and to prepare for any new quality-control initiatives that might flow from health reform, Barbour adds. The way that Frye Care accredited its newly purchased MRI unit opens a window on the accreditation process and demonstrates the role that vendors can play. For its new open MRI system (as well as its other advanced modalities), Frye Care chose ACR® accreditation. “The ACR, for us, is the gold standard of radiology,” Barbour says. It also relied for help on its MRI vendor, Hitachi Medical Systems America, Inc (Twinsburg, Ohio), which has a program in place to assist with MRI accreditation for its systems. Barbour downloaded the applications and then turned the process over to Stacy Tramel, RT(R)(MR), an MRI technologist who has been at Frye Regional Medical Center for eight years and at Frye Care since the OIC opened seven years ago, two blocks from the hospital campus. The Old Way Tramel compares the accreditation of Frye Care’s new Hitachi Oasis high-field open MRI system with an accreditation done a year or so earlier on an MRI system from another vendor that Frye Care operates. The first accreditation was difficult. She says, “It was really hard to figure out what the ACR wanted and what they didn’t want. We passed, but it was difficult to know how to position the phantom to get the slice thickness to the exact millimeter that the ACR wanted to have.” She says that the initial imaging had been completed when someone noticed that a decimal point in a calculation had been moved the wrong way. The whole process had to be started anew. “We had to write to the ACR and explain why we were exceeding the time frame. It was really stressful,” Tramel says. “We were just reading [the instructions] online. It’s a lot easier when you have someone you can talk to who can explain what the 10 pages of the ACR requirements mean.” Frye Care had considered accrediting an even older machine, the predecessor of its new Hitachi Oasis, but that machine, from another vendor, failed some tests performed by a physicist and was so low in field strength that the OIC opted to replace it. “We withdrew the accreditation application,” Tramel says. The Hitachi Oasis open MRI system was selected by Frye Care’s radiology and business administrators. Complexity Accrediting any modality is a complex undertaking, Tramel explains. In the case of Frye Care’s new Hitachi Oasis, by the time it was installed, the ACR’s accreditation format had changed: Instead of submitting a number of generalized images, the candidate for accreditation had to choose specific categories in which to seek accreditation and submit studies for each of those. One of the categories was abdominal imaging. Tramel says that advisors at Hitachi suggested that Frye Care select a female pelvic study as its abdominal submission, but Tramel and the Frye Care staff balked. “We don’t do enough of those to attempt that category,” Tramel says. “We may do one of those exams per year. You want to apply for accreditation with exams you do quite often.” Instead, Frye Care chose a different abdominal study, MR cholangiopancreatography (MRCP), an exam used to spot certain cancers, gallstones, and pancreatic and bile-duct conditions. Having selected MRCP, Tramel and her colleagues turned to Hitachi for guidance. First, Hitachi reviewed the MRI protocols at Frye Care to make sure that they met the ACR’s criteria, Tramel says. Then, Frye Care selected a patient to use in its submission, completed the scan, and sent that to Hitachi’s team electronically. “They sent it back and told us to make a couple of changes—it had a parameter (field of view) that was out of threshold for the ACR,” Tramel says, “so we got a different patient, corrected the problem, and sent that to Hitachi again. We actually submitted three studies for the abdominal category because one patient didn’t hold the breath as well as possible. We kept on with the process until we got one that was acceptable. Hitachi was really flexible with us.” Hitachi’s accreditation-support team is divided into two parts—Hitachi Field Service, which assists in ensuring that technical components meet accreditation standards, and Hitachi Applications, which consults on the actual accreditation submission. Frye Care used both elements of Hitachi support in accrediting its Oasis MRI, according to Tramel. Frye Care submitted five studies. “We did cervical, elbow, carotid, brain, and abdominal studies,” Tramel says. “We didn’t do heart studies because we don’t do cardiac work with this machine. They do all the cardiac exams at the hospital, because they stress those patients.” When the application was completed for all categories and sent to the ACR, Tramel says, “We got a pass on everything.” Tramel gives Hitachi credit, saying, “With Hitachi support, it was a lot smoother. It wasn’t a guessing game because we had someone to talk to; if we were doing another MRI, I’d want to do it that way again.” High-quality Care Both Barbour and Tramel point out that accreditation is not just about meeting requirements for Medicare or insurance carriers. Improving patient care is the ultimate aim. As part of the ongoing accreditation process, Frye Care does weekly scans of phantoms with its Oasis MRI, and once a year, Frye Care hires a physicist to check the technical parameters of the MRI system. The physicist reviews the weekly phantom studies on file. Barbour says that although it hasn’t yet happened, the ACR can ask to see the weekly phantom studies, either through electronic submission or during random visits. The idea is that accreditation is not just a one-time certification (each ACR accreditation is good for three years), but a continual process, to ensure ongoing quality control (QC) between accreditations. The ongoing process supports internal QC. Tramel says, “You can track whether something is wrong with the machine. If I see that a number is low or not where it has been, I’ll check the machine. It gives you a hint when you’re doing QC, because each week, you look at those values.” Recently, Tramel says, she was scanning the phantom for a head study when she noticed something amiss with the numbers. The reason turned out to be benign: The latch on the head coil hadn’t been properly closed. Both Barbour and Tramel say that patient care benefits from the ongoing QC. “You’re imaging on a top-quality machine, and you can prove that, because patients do want to know,” Tramel says. “They haven’t yet asked if the MRI is accredited, but it’s not going to be long before they do ask.” Barbour adds, “QC is extremely important for image quality, and before accreditation, the only time people paid attention was if you had a problem with the machine. When you do QC on a regular basis, you pick up on issues before they become a problem.” Barbour says that Frye Care is prepared for what’s coming, now that its accreditations have been completed. “It will help us to bill with insurance carriers in the future and with Medicare under any pay-for-performance plan,” she says. “It will matter, as we progress in this health-reform process, because at some point, it is going to pass.” George Wiley is a contributing writer for