Radiologists at Growing Risk for Carpal Tunnel Syndrome

Although carpal tunnel syndrome has long been a curse of cubicle-dwelling office workers, a new study verifies that the repetitive-motion disorder is affecting radiologists who read in filmless environments.

The study, published in the July edition of the American Journal of Roentgenology, looked at work-related upper extremity musculoskeletal disorders in four radiologists. The conclusion: the increasing dependance on computers in radiology, such as with PACS, is putting staff radiologists at risk for carpal tunnel syndrome and cubital tunnel syndrome.

Carpal tunnel and cubital tunnel syndromes are two of the most common compressive neuropathies of the upper extremities and represent common causes of referral for electrodiagnostic studies. Both have been linked to computer use, with carpal tunnel being the result of median nerve compression from inflammation and thickening of the flexor tendons, and cubital tunnel syndrome resulting from ulnar nerve compression between the medial epicondyle, olecranon, and overlying cubital tunnel retinaculum.

Researchers from the US Army and US Department of Defense studied four radiologists who had complained of upper extremity pain, numbness, and weakness. In addition, the work activities and duties of 12 staff radiologists in the filmless department were studied, with the number of years working on staff, hours, and academic activities recorded. Nonoccupational activities were also recorded, and an industrial hygienist evaluated the department work areas and staff offices.

Nuclear medicine technologists in protective gear were stationed at key posts.

Of the four radiologists studied, one had bilateral carpal tunnel syndrome, and all four had cubital tunnel syndrome. All four spent 3.4 years as staff radiologists in the filmless department, performing computer keyboard and mouse or trackball image manipulation and work list navigation, typing preliminary reports and telephone notifications, and editing electronically and approving dictated final reports. Three of the four performed sonography routinely, and the industrial hygienist identified hazardous working conditions related to ergonomics in the reviewing areas and staff offices.

The researchers concluded that the current technology puts radiologists at risk for  upper extremity musculoskeletal disorders including carpal tunnel and cubital tunnel syndromes. They recommended that proper equipment, ergonomics, and professional consultation be used in all radiology departments.

Dirty Bomb Tests Seattle Hospital

At 12:45 pm on May 12, a Code Delta 60 was called at Seattle's Harborview Medical Center (HMC). The alert signaled an external disaster in the city, and the staff was told to expect 60 incoming patients. Among those who would be meeting the incoming wounded was HMC's radiology department.

The disaster, a simulated radiation dispersal device (RDD) detonated by the fictional GLODO terrorist group, was part of the nationwide TOPOFF 2 exercise designed to test the ability of local, state, and federal agencies to respond to a terrorist attack. This was the first large-scale terrorist drill since the September 11, 2001, attacks.

As soon as the Code Delta 60 was called, HMC's radiology department activated its departmental disaster plan. At the time of the simulated attack, the plan did not include a section on RDDs, but revisions are being made, according to Cindy L. V. Hokanson, imaging technologist supervisor, radiology, at HMC.

Implementation of the disaster plan included sending staff on duty to the emergency department (ED) and calling in additional personnel. "For this particular drill, nuclear medicine technologists under the direction of the radiation safety officers with Geiger counters and radioactive contamination forms were positioned at key postsat barricades on the street outside of the emergency department for walk-in patients, at the decontamination tent, on the ED ramp, and in the dirty' ED trauma room," says Joseph Marotta, administrative director of radiology at HMC. This staff was dressed in full radioactive protective gear including coveralls, boot covers, gloves, and masks. All communication was done via radio.

The role of the radiology department was not modality specific. According to Marotta, modality choices were based on the nature of the injury. Several of HMC's trauma imaging roomsa portable x-ray, a trauma x-ray room, and the trauma CTwere designated as "dirty," ie, designated for the imaging of victims of the radioactive blast. There were also designated "dirty" technologists, outfitted like those in the emergency department, who could perform the imaging studies on contaminated patients. In addition to the designated trauma rooms, patients could also be sent directly to the operating room.

As a result of its participation in TOPOFF 2, the radiology department is investigating several practical questions surrounding an RDD attack, including how to decontaminate equipment after it has been exposed to radiation, what type of protective equipment staff needs to wear, how to minimize contamination to examination rooms, and where emergency supplies such as protective gear and plastic sheeting are to be located.

In addition, says Marotta, there are other issues that have direct implications for patient care during a large-scale radioactive disaster. One such issue would be the question of whether to continue to clear a contaminated trauma patient's abdomen noninvasively with a portable ultrasound unit and risk contamination, or do only deep peritoneal lavage.

C. Wolski NCQDIS to Proceed with Cost Study

Board members of the National Coalition for Quality in Diagnostic Imaging Services (NCQDIS) unanimously endorsed a motion to proceed with an imaging procedure cost survey focusing on practice expenses involved in the provision of diagnostic imaging services and hopes to collaborate with the American College of Radiology, which is also interested in conducting such a study.

The vote came during the organization's board meeting in the Washington, DC law offices of association counsel Diane Millman, JD, Powers, Pyle, Sutter & Verville. Both the ACR and NCQDIS announced plans to conduct a survey of practice expenses after the Centers for Medicare & Medicaid Services (CMS) indicated last June that it intends to modify the methodology used to determine allowances for technical (TC) services by subtracting the allowances for professional component services from global allowances. (Technical and professional fees are currently combined to arrive at the global allowance.) CMS strongly urged the specialty to gather data to determine the costs per hour of providing global services. While the nature of the collaboration between the ACR and NCQDIS is not well defined at this point, the vote was taken after representatives from both organizations expressed interest in using a common survey tool.

The issue has gained greater urgency because Congress is believed currently to be considering the modification of Medicare payment methodology for reimbursing medical oncologists for cancer drugs and chemotherapy administration services. Medicare payment for practice expenses involved in the provision of medical oncologyas well as diagnostic imaging and other capital-intensive services reimbursed under the Physician Fee Scheduleis subject to a special payment methodology called the Non-Physician Work Pool (NPWP) methodology. Because all services are grouped together, a modification in the payment methodology for medical oncology could have an unintended effect on diagnostic imaging. NCQDIS and a number of other organizations have lobbied successfully for the inclusion of a provision in the House and Senate versions of the prescription drug legislation that would ensure that services in the NPWP would not be inadvertently affected by modifications of the payment methodology for chemotherapy administration.

In a June 3 letter addressed to all relevant House and Senate committees, Cherrill Farnsworth, NCQDIS executive director, wrote: "The NPWP methodology was put in place because CMS does not have any reliable cost information regarding diagnostic imaging and other highly capital-intensive services. We understand CMS's concerns about the current methodology, and we are conducting a survey to collect the data needed to substitute a more accurate methodology&.For these reasons, we request that Congress enact legislation that precludes CMS from modifying the current allowances for NPWP services pending the collection of reliable cost information for these services."

The board also voted to support the extension of the Stark Rule to include nuclear medicine, proposed by CMS. The rule would amend the definition of radiology and radiation therapy in the Stark regulations to make nuclear medicine services and supplies subject to the Stark Law prohibition on physician ownership, a move that would impact a significant number of physician-owned PET centers.

C. Proval

SNM 2003 Image of the Year

Johannes Czernin, MD, associate professor of molecular and medical pharmacology, and University of California Los Angeles director of Nuclear Medicine, and Benjamin Halpern, MD, visiting scholar, received the Society of Nuclear Medicine's 2003 Image of the Year award. The scan, obtained in seven minutes with 3D-LSO PET/CT technology, clearly shows cancer in a 60-year-old patient. Whole body scans typically take more than an hour. Magnus Dahlbom, MD, associate professor of molecular and medical pharmacology, and Osman Ratib, MD, PhD, professor and vice chair, information systems, UCLA Department of Radiology, also contributed to the study.

SCAR

The 20th symposium of the Society for Computer Applications in Radiology

Key Image Notes: Problems and Solutions

Radiology departments that provide enterprise-wide access to all images for referring clinicians can greatly improve the utility of the system for both clinicians and radiologists by implementing the Integrating the Healthcare Enterprise (IHE) Key Image Notes (KIN) integration profile. "One of the key things the clinician wants is quick access to images that are relevant," said Gary Wendt, MD, PhD, assistant professor of radiology, and vice chair for informatics in the radiology department at the University of Wisconsin-Madison Medical School, where clinicians have access to all images. "Essentially, key image notes is an electronic grease pencil."

Incentives for implementing KIN include time savings and improved service for referrers, as well as easing follow-up of abnormalities. Improvements to radiologist productivity can also be obtained when comparing to prior images and in protocoling future examinations. KIN can also help reduce the number of images assigned to teaching files. "The problem is that residents don't learn image management tools and this is going to be key to what radiologists do in the future," noted Wendt.

The downside is that the entry of KIN requires radiologist intervention. In training physicians to use the system, it is important to stress the benefits: reduced phone calls and easier follow-up. While the University of Wisconsin does not require its radiologists to use KIN, mandating compliance is an option, Wendt noted. Various prompts for the radiologist to select key images prior to completing the reading could be designed and adopted. Another problem is that the image selected as key may have a different window/level or pan/zoom than the original presentation state. While the Wisconsin system asks the radiologist if he or she wants to save the presentation state, if the answer is affirmative, the entire studynot just the designated imagesis saved in the presentation state used to view the key images. Yet another issue that should be addressed is that the system allows marking by multiple people. "You want to be sure that the oncologist who goes in and sees KIN understands that it was just a medical student who keyed it to ask questions later rather than a radiologist marking pathology, " Wendt noted. Every clinician currently sees all KIN and the department is considering limiting the enterprise visibility of all but the diagnosing radiologist's KIN.

Computed Radiography QA: Is It Necessary?

In their report on a multi-center evaluation of CR/DR productivity and workflow, Bruce I. Reiner, MD, director of research, and Frank J. Hooper, Baltimore VA Medical Center, described the total time associated with producing radiographs at four institutions with simultaneous use of computed radiography (CR) and digital radiography (DR). For the study, data collection sheets were developed after observations at each site, and observers were trained to collect time-motion data using stop watches. The total time to produce a study included: preparation time, positioning time, exposure time, and Q/A time, which encompassed image transfer and image manipulation.

The radiograph via DR was faster to obtain than with the CR technology at all four institutions, with significant variations among institutions attributed to differences in technology and workflow. At the Baltimore VA, the total time associated with a radiograph produced by CR was more than 4 minutes, compared to 2.5 minutes for DR; at The Lahey Clinic, total time associated with CR was about 5.5 minutes compared to 2 minutes with DR. However, the presenters noted that between 60% and 100% of the time difference between CR and DR could be attributed to the time it took to complete the Q/A activities, leading the presenters to ask: Is technologist QA necessary for computed radiography? Reiner cited a study by the BVA that showed retakes dropping from 5% to 1% when the switch was made from film to computed radiography. "One proposal I would make is to transition from QA as a front-end requirement of the technologist to a back-end responsibility of a Q/A specialist as a batch mode," Reiner suggested.

ROE: Online, All the Time

The problems with a paper-based radiology order system are legion: a sizable percentage of requests are illegible, ambiguous, lost, delayed, or never sent, according to Daniel I. Rosenthal, MD, who presented a report on the online order system in place at Massachusetts General Hospital, where he is professor and associate radiologist-in-chief. Additionally, there is the frequent lack of ICD-9 coding. In undertaking the transformation of the paper system into an electronic radiology order entry (ROE) system, the department identified the following criteria: the system had to capture all required information; pass the middleman and go direct to the radiologist; and, by minimizing key strokes, not exceed the time required to use a paper system.

The solution required the electronic capture of all information, structured data input, and a history for each examination ordered. The architects of the system obtained lists of indications from three sources: 1) review of 1 year of billing data to come up with indications for ICD-9 codes; 2) study of appropriateness lists produced by various agencies including the American College of Radiology; 3) consultation with radiologists in each subspecialty area. The indications lists were tested on paper for several months before computer implementation. The design of the resulting system minimizes keystrokes by offering virtually all common indications in the form of "check boxes," and screen transitions are kept to a minimum. It utilizes a 48-hour blackout period for elective examinations.

Each order page has three components: studies ordered; special considerations (optional) and signs and symptoms or known diagnosis (mandatory, as one of the two must be captured); and a calendar.  A free text field for additional information is offered, but not required. On completing the request, a calendar is displayed showing available appointments for the examination requested. Selection of a date and time creates the appointment. A page can be printed for the patient giving directions to the site and instructions for the examination. However, no "hard-copy" requisition is required.

Although no one was required to use the system, Rosenthal  reported that utilization has climbed dramatically since it was instituted in 2002. During that time, the number of rejections for bills has dropped precipitously and no problems have been reported in assigning protocols. The only difficulty cited was the complexity in scheduling multiple examinations, as each must be scheduled separately, and the occasional difficulty in finding consecutive time slots.

C. Proval

Industries News

GE Medical Systems, Waukesha, Wis, has introduced a new breast algorithm, Premium View, for the GE Senographe® 2000D full-field digital mammography system. The company also announced an agreement with CADx Systems Inc, Beavercreek, Ohio, to distribute two new CAD technologies, Second Look and Second Look AD, to help physicians identify breast cancer. Both products are designed to be compatible with the GE Senographe 2000D. In addition, GE and Deus Technologies, Rockville, Md, have announced a new digital CAD technology, RapidScreen® Digital, developed for assistance in detecting lung cancer. GE also announces that it has finalized the acquisition of Thales Ultrasound Probes SA, Paris, a supplier of custom, extended performance transducers for medical ultrasound...CPS Innovations, Knoxville, Tenn, announced that the Society of Nuclear Medicine 2003 Image of the Year was acquired on the company's 3D-LSO PET/CT machine in only 7 minutes...Health Level Seven, Ann Arbor, Mich, has announced that the American National Standards Institute (ANSI) has approved HL7 Version 2 XML Encoding Syntax as an American National Standard...Morning Star Molecular Imaging, New Orleans, will open state-of-the-art PET/CT medical imaging centers nationwide...Scimage, Los Altos, Calif, has entered into an agreement with Konica Medical Imaging, Wayne, NJ, to represent Konica's Regius and XPress CR products and DryPro Laser Imagers. The agreement authorizes Scimage to offer its customers Konica's CR equipment and dry laser printers with Scimage's PICOMEnterprise PACS product. Konica has also announced that  it was voted the leading systems provider in CR in the category of overall user satisfaction, according to the latest MD Buyline Intelligence Report. The report is a comprehensive survey that measures data from end-users nationwide...Merge eFilm, Milwaukee, has signed a definitive agreement to acquire RIS Logic® Inc, a privately held Ohio-based company that develops and supports RIS software...FujiFilm Medical Systems USA Inc, Stamford, Conn, has partnered with MedStrat, Downers Grove, Ill, to bring digital x-ray to orthopedic practices. The partnership combines MedStrat's technology with Fuji's digital x-ray SmartCR system for the acquisition of digital images...The Photonics Center at Boston University announced today that one of its graduate companies, PhotoDetection Systems Inc, a developer of positron emission tomography (PET), has received a minority investment from Analogic Corp. The investment allows Analogic to obtain an exclusive technology license to use PhotoDetection Systems' proprietary PET system, in conjunction with its own CT system. Analogic will combine the two companies' technologies to develop hybrid PET/CT systems...The American Society for Therapeutic Radiology and Oncology (ASTRO) has announced it will open a satellite office in downtown Washington, DC. The ASTRO Board of Directors approved the plans at its most recent meeting...Canon USA, Lake Success, NY, has announced that its CXDI-31 portable digital radiography system has helped to identify the mummy that some believe is Queen Nefertiti, the ancient Egyptian ruler. The Discovery Channel will broadcast a program on the search for Nefertiti's long-lost tomb on August 17 from 9-11 pm ET/PT).