January 02, 2020

My Experience as the Amis Fellow

By Kevin Wang, MD, chief radiology resident, Baylor College, Houston, TX.

For radiology trainees unfamiliar with the functions of the ACR’s Quality and Safety (Q&S) department, I would encourage those who may be interested to apply to the E. Stephen Amis, Jr., MD, Fellowship in Quality and Safety. This fellowship provides the selected applicant one of two weeks of the fellowship to visit and explore the operations of the department in Reston, Va. As a past Amis fellow, it would be an understatement for me to say that one week is anywhere near sufficient to become familiar with the workings of the department. The functions in both breadth and depth cannot be fully appreciated without an in-person visit to ACR headquarters. Nevertheless, I would like to provide but only a taste of what I learned during my visit.

The ACR via the Q&S department is an accrediting body and provides accreditation for a myriad of radiological services utilized nationally. For example, the ACR is one of the major accrediting bodies for breast imaging. Mammography facilities are required to be accredited (in addition to being certified by the FDA or the state) in order to perform mammography. In contrast, stereotactic biopsies, breast US, and MRI are voluntary accreditations — but a facility can achieve special distinction as a Breast Imaging Center of Excellence (BICOE) by achieving accreditation in all four modalities. To put things into perspective, recently, out of the over 8,500 facilities that are under accreditation for mammography, only 1,100 of those are designated BICOEs by the ACR.

Similarly, there is also a Diagnostic Imaging Center of Excellence (DICOE) distinction for facilities that go above and beyond the minimum standards of accreditation for non-breast related imaging. As part of the review process, staff from the Q&S department perform on-site surveys. The standards for recognition are very broad and rigorous (much more so than BICOE), and include assessment of quality, governance, organizational management, physical environment, equipment, radiation safety, method by which quality and performance are measured and improved, informed consent, and infection control.

Accreditation for CT, MRI, PET, and US fall under ACR’s Diagnostic Modality Accreditation Program (DMAP). The ACR is also one of the first and largest radiation oncology-accrediting bodies, currently providing accreditation to more than 3,500 facilities. Lastly, validation site surveys (VSS) are performed by surveyors contracted by the ACR, whereby unannounced site visits are performed to confirm that what facilities stated in their initial application for accreditation remains true and accurate.

In addition to accreditation, ACR Q&S staff manage the clinical data registries, of which there are many. Facilities may submit data to these registries using manual or automated methods of collection, and can compare their local data with those of regional and national benchmarks — the intent being to improve patient care and aid in quality improvement projects. For example, TRIAD software installed locally at facilities allows DICOM data to be sent automatically, whereas dictation software vendors can generate flat text files of imaging reports with built-in structured data elements intended for registries that can then be uploaded manually. Some specific clinical data registries include the CT colonography registry (CTC), national mammography database (NMD), dose index registry (DIR), lung cancer screening registry (LCSR), interventional radiology, and general radiology improvement database (GRID); altogether these can be considered under the overarching National Radiology Data Registry (NRDR®).

One of the registries I learned about, that I believe to be most important to the future of the radiology profession, is the registry that has been approved by CMS as a Qualified Clinical Data Registry (QCDR). This registry is not a separate registry per se, but rather an umbrella registry that sits on top of all the others. At this juncture, radiology trainees are probably familiar with CMS’s Merit-Based Incentive Payment System (MIPS), whereby reimbursement is tied to four performance categories (quality, improvement activities, promoting interoperability, and cost). For the quality performance category, facilities can demonstrate adherence by reporting certain MIPS measures directly to CMS or indirectly to CMS via a QCDR, such as the ACR’s. Data for two of the other performance categories — improvement activities and promoting interoperability — can also be submitted to the CMS via ACR’s QCDR. Therefore, the ACR’s QCDR provides an accessible and straightforward process for facilities to meet MIPS participation requirements that ultimately impact adjustments on reimbursement. Importantly, in addition to reporting MIPS measures, QCDRs have the privilege of helping dictate future MIPS measures. Given the vast amount of data in the NRDR, the ACR can come up with their own new QCDR measures and begin collecting data once that becomes available within the registries. Based on the collected data, these QCDR measures can then be proposed to CMS as potential future MIPS measures.

There are many other activities under the purview of the Q&S department that I have come to learn about, of which I wish I had the opportunity to elaborate further upon. In short, these include Practice Parameters and Technical Standards that serve to narrow the variability of radiologic procedures, white papers that serve as guidelines on incidental findings, PAMA Task Workgroup, Appropriate Use Criteria that serves as a guideline for appropriate imaging, ACR Select® clinical decision support (CDS) that serves as point-of-care consultation for appropriate imaging ordering, standardized reporting templates (e.g. BI-RADS®, CAD-RADS™, O-RADS™, C-RADS™), RADPEER®, and R-SCAN. Suffice it to say, it is difficult to succinctly share all the activities the department performs and it’s truly amazing this breadth of activities can be accomplished with less than 100 ACR staff members. Whether these activities may or may not currently pertain to you as a fellow trainee, you will inevitably come to appreciate the mission of the College, the basis for value-based medicine, all of the undertakings within the Q&S department — as well as its proclivity for acronyms! This fellowship was beyond any of my expectations and is perhaps one of the most edifying experiences in my radiology training. Regardless of whether your interest is in private practice or academics, I would encourage those who wish to work in a practice or academic department that continually strives for excellence and best practices, to consider applying for this fellowship!