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Radiology’s Role in Determining Medical Necessity

Recently, a New Jersey court handed down a decision that could potential change the role radiologists play when it comes to determining the medical necessity of a study ordered by a referring physician.

Although the current ruling only applies to New Jersey radiologists, industry experts are talking about how it could possibly affect your responsibilities, daily work flow, and liabilities.

The Case
Allstate Insurance brought suit against radiologists who conducted MRIs and X-rays on patients who had submitted personal injury claims. The company argued the providers had not completed their due diligence in checking into whether these studies were warranted, suing to recoup $200,000 of expenditures.

Company lawyers asserted the radiologists were the imaging center’s medical directors and, therefore, bore the responsibility of verifying medical necessity. The radiologists countered that the chiropractors and other referring physicians who send them patients satisfy the state’s requirement of being “verified” providers. But, the judge ultimately ruled the onus of ensuring proper clinical evidence exists to support medical necessity and appropriateness lies with the radiologist.

According to Greg Nicola, MD, treasurer of the Radiological Society of New Jersey, the organization is filing an appeal of the ruling. The American College of Radiology (ACR) also considers the case to be unique – one that will likely only bind New Jersey radiologists, said Tom Hoffman, JD, the ACR’s associate general counsel.

“The lesson remains to realize that the radiologists aren’t in the driver’s seat about medical necessity decisions because they don’t interact daily with the patient,” Hoffman said. “They’re hard pressed to have all the sufficient clinical background on a patient.”

Impact on Your Daily Work
The specter of having to double-check behind your referring physicians to ensure they’re ordering proper studies can be daunting, Nicola said. In most cases, if a provider sends a study order, accompanied by either an ICD-9 or ICD-10 code, you likely assume there’s sufficient medical evidence in each case. Adding another layer to the process could slow your work flow to a slog.

“I don’t think we could do it – there are so many studies to do in a day,” he said. “If we have to validate every prescription – either with the patient or the doctor – that would be very difficult.”

But, before you worry too much, he said, you’re likely already taking steps to validate the medical necessity of nearly every study that comes into your imaging center. By having patients fill out forms and questionnaires that ask for the reasons behind their clinical visit and request for a study, you’ll have official documentation of medical necessity. For example, any patient who comes in for an MRI of the lower back can explain their experience with possible long-term back pain.

Unfortunately, emergency departments and hospital inpatient settings don’t have the resources available to disseminate and gather these forms, and in many cases, patients aren’t able to fill them out.

But, if you do have questions, Nicola said, don’t shy away from giving the referring physician a quick phone call to verify why he or she has ordered the study. And, if you disagree, offer your expert opinion. When you can, he said, make all calls to referring providers at least a day before you’re expected to perform the study.

“Always reach out to your referring physicians in the community,” he said. “Don’t ever be intimidated to do so. It helps keep the lines of communication open.

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3-D Printed Aortic Valve Helps Treat Heart Condition

While 3-D printing has been around since the mid-1980s, there is accumulating evidence that this technology has the potential to revolutionize the understanding and management of heart conditions. A team of researchers from the Cleveland Clinic created a 3-D model of an aortic valve from a patient with a severe case of calcific aortic stenosis (AS) — narrowing of the aortic valve — to simulate the patient’s beating heart and assess the blood flow, or “hemodynamics.”

“In order to better understand the physiology of AS (which can be complex), we produced a true replicate of the valve using 3-D printing technology. Then, to assess the valve hemodynamics, we placed the 3-D-printed valve into a circuit where flow can be controlled and we can try out different flow conditions. In this research, we present a proof of concept case of severe AS where the pressure gradients, obtained by cardiac ultrasound, were successfully replicated in the circuit built around the 3-D-printed version of the stenotic valve,” said lead author Serge Harb, M.D., of Cleveland Clinic, Cleveland, Ohio.

The hemodynamic results using this 3-D-printed valve in the flow circuit simulating the pumping action of the heart, were confirmed by Doppler echocardiography, the technique used in daily practice to evaluate patients with AS. Harb said, “This technology shows a lot of promise. Not only will it help us better understand the mechanisms of the disease, but it also has the potential to provide a more personalized treatment where the particular valve of the affected patient is 3-D-printed, guiding its optimal management. This may be particularly helpful for surgical planning, or when using new catheter-based technologies for non-surgical valve replacement.”

Researchers on the study, Three Dimensional (3D) Printing and Functional Assessment of Aortic Stenosis Using a Flow Circuit: Feasibility and Reproducibility, include Harb, Ryan Klatte, Brian P. Griffin and Leonardo L. Rodriguez, from the Cleveland Clinic Foundation, Cleveland, Ohio.

Harb presented a poster based on this research during the American Society of Echocardiography (ASE) 27th Annual Scientific Sessions, June 10-14 in Seattle.

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robot surgeon

Robot surgeon performs first soft-tissue operation by itself


Its name is STAR. And on Wednesday, scientists reported that the Smart Tissue Autonomous Robot could stitch together separate pieces of the bowel in pigs, the first time a surgical robot has completed a portion of an operation in living soft tissue without human guidance.

The new paper, published in the journal Science Translational Medicine, amounts to what’s known as a proof of concept — a demonstration that the new advance appears to be possible. Outside experts described it as a key achievement in efforts to move toward autonomous robotic surgery, but noted the technology is years away from being used in operating rooms, or even in a clinical trial.

“It’s one step forward,” said Dr. Dragan Golijanin, director of the Minimally Invasive Urology Institute at the Miriam Hospital, an affiliate of Brown University, who was not involved in the research.

Surgeons use robots in operating theaters around the country, but as it stands, they guide them like a puppeteer directs a marionette, conducting every move and response.

A number of studies looking at different operations have found that these robot-assisted surgeries have failed to improve outcomes over standard surgical methods, but backers of the technology say clinicians more experienced with the devices do have better results.

The goal of robotic surgery is not to replace surgeons, supporters of the method emphasize. And the system described in the new paper would be supervised by a surgeon who could step in in the case of an emergency.

But if robots could perform a portion of operations on their own, boosters say, it could reduce complications caused by human error, speed up surgeries, open up operating room availability, and enable patients to have the best techniques available to them no matter where they live.

“Consistency in surgery is important, just like in manufacturing,” said roboticist Ken Goldberg, codirector of the Center for Automation and Learning for Medical Robotics at the University of California, Berkeley.

Soft tissue presents a particular challenge for autonomous robotic surgery. Instead of sawing through bone, for example, robots trying to suture squishy organs need to differentiate between different tissues and adjust as the tissues change shape.

“It’s hard to manipulate even rigid objects — it’s hard for a robot to clear a dinner table,” said Goldberg, who was not involved in the research published Wednesday.

To develop STAR, the researchers started with an existing robot arm fromKUKA Robotics and introduced two imaging innovations to overcome the problems imposed by operating on soft tissue. They enabled the robot to track shifting shapes in 3-D and added a function, described almost like night vision, that helped the robot tease apart which tissue to suture and which to leave alone.

The researchers have filed about half a dozen patent applications for the technology and hope to see it commercialized in the future. They said the soft-tissue surgeries that could first be done autonomously include removals of the gallbladder and appendix.

“Having a tool like this, and by making the procedures more intelligent, we can have better outcomes for patients,” said Dr. Peter Kim, a pediatric surgeon at Children’s National Health System and senior author on the paper.

With their system, the researchers from Children’s National and Johns Hopkins University programmed the robot with skills taken from top surgeons, they said. An algorithm instructed STAR where it should insert the needle during sutures, how much space should be left between each stitch, and how tight to pull the suture.

The team compared the system to existing stitching methods including robot-assisted sutures, laparoscopic sutures, and hand-sewn sutures.

In one test in four live pigs, STAR made just a few suturing mistakes in connecting pieces of bowel — a procedure called intestinal anastomoses — and it took several times as long as a human surgeon, who made zero mistakes sewing sutures by hand in the one control animal. But the researchers said that they were not trying to see how fast the robot could perform the procedure, just that it could do it.

About 60 percent of the time in the experiments, the researchers left the robot to do what it would, and they made sure STAR was placing the sutures in the correct place the rest of the time. The researchers, Kim said, were like parents watching their babies learn to walk, encouraging them to try it on their own but there to ensure the steps were being taken as they should.

Andrew Joseph can be reached at
Follow Andrew on Twitter @DrewQJoseph


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Less Radiation!


This year, General Electric introduced the world’s first High Definition 64-slice CAT scan. It’s 100 times faster than other available CAT scans. This scanner produces high quality diagnostic information out of every scan with a significantly reduced radiation dose for the patient. The result: The highest quality images and up to 60 percent less radiation of CT scan.

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  • Arteriogram of small vessels
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  • Cardiac CT coronary arteries
  • PET-CT
  • Lung nodule analysis with CAD
  • Improved 3D imaging
  • The best in high resolution of brain and spine
  • CT enterography of small bowel
  • CT IVP and KUB (kidney stones)
  • Low-dose, whole-body for tumors
  • High resolution lung

Diagnostic advantages:

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  • Non-invasive alternative to angiography
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Ultrasonido controlado a distancia revoluciona la telemedicina.

Los investigadores están estudiando si la tecnología de ultrasonido telerobótico podría utilizarse para proporcionar servicios críticos de salud para las zonas del mundo de pobres recursos con resultados comparables a los de los exámenes de ultrasonido manuales.

La nueva tecnología, llamada Imagenología de Ultrasonido TeleRobótica a Distancia (TRUDI), le permite a un operador realizar un examen de ultrasonido utilizando una conexión a Internet, desde cualquier lugar. El sistema de ultrasonido es parte de un quiosco robótico y se puede mover rápidamente para realizar un examen por el operador remoto.

El sistema de ultrasonido se basa en una plataforma de Computadora Personal (PC) y fue realizada por Sistemas Médicos de Ultrasonido Telemed (Milán, Italia). El sistema se encuentra todavía en las primeras etapas de desarrollo, pero tiene el potencial de proporcionar asistencia sanitaria esencial a las áreas de pocos recursos del mundo. La tecnología podría reducir los tiempos de espera potencialmente mortales para el diagnóstico de los pacientes con insuficiencia cardíaca, por ejemplo, que a menudo no tienen acceso a un especialista. La tecnología también podría ser utilizado en el futuro para procedimientos cardíacos avanzadas tales como reemplazos transcutáneos de válvulas. Otros usos podrían ser los exámenes por parte de un especialista en ecografía fetal en las comunidades rurales de difícil acceso, en cualquier parte del mundo, reducir la mortalidad materna mediante el acceso a la atención prenatal en los países en desarrollo.

Vikram Dogra, MD, director de ultrasonido y profesor de radiología e ingeniería biomédica de la Universidad de Rochester (Nueva York, EUA), dijo: “La ecografía telerobótica tiene el potencial de revolucionar la telemedicina mediante la conexión de las zonas alejadas marginadas del mundo, con una real capacidad de imagen de tiempo real para el diagnóstico de enfermedades agudas como la apendicitis aguda y el embarazo ectópico”.

Por el equipo editorial de Medimaging en español

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