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  • CRNP’s reading mammograms

    Posted by chirambasukwaw on October 1, 2019 at 8:25 pm

    Hi I was wondering if anyone had any experience or insight into a situation my group is currently facing.  We provide screening and diagnostic mammo in a surgery-run breast center.  The surgical CRNP’s have been ordering diagnostics based on their own reading of the screens–without consulting the radiologist (or their supervising surgeon) and before the rad writes the report.  Their reason is they don’t want to wait for the report (turnaround times, they insist on real-time reads but its very busy so some patients have to wait an hour or 2 for the report if there is a complicated diagnostic etc).
     
    We objected to this practice but they are arguing that MQSA only applies to the person who writes the report, and that ordering/interpreting diagnostic testing falls within scope of practice and CMS Evaluation and Management guidelines.   Usually they workup an obvious finding or nothing (we often end up giving both screen and diagnostic a 1 or 2, the diag gets paid anyway). They say they check the final read and call the patient back depending on what our read is.   The MQSA does not seem to explicitly forbid this as long as a rad makes the official report (of course we read independent of their assessment), however it seems to go against the intent of the MQSA to provide high quality and that making management decisions based on independent reading implies interpretation. 
     
    I’ve googled checked the BI-RADS atlas, FDA and ACR websites but haven’t found anything addressing this.  Does this seem legit to anyone?  Anybody hear of this being done elsewhere?

    chirambasukwaw replied 3 years, 3 months ago 15 Members · 44 Replies
  • 44 Replies
  • jun52.park

    Member
    October 1, 2019 at 8:39 pm

    “The surgical CRNP’s have been ordering diagnostics based on their own reading of the screens–without consulting the radiologist (or their supervising surgeon) and before the rad writes the report. ”

    What in the actual F? What is their recall rate? How many patients are being subjected to addition imaging, much of which involves extra radiation, for no reason?

    I have never heard of this and can’t believe this set up exists.

    • yao.bw39_792

      Member
      October 1, 2019 at 9:23 pm

      Can’t you just tell the techs not to do the exams until you read the screener?
      A practice where I worked 15 years ago stopped covering a site where the surgeon was doing breast US that was recommended as part of a diagnostic workup.  He had some cheap point of care US.
      At another practice the mammo techs thought they were deputized to read screeners and did spot compressions on white spots that bothered them.  One of the reasons I got pushed out of that practice was that I told them to stop. 
       

      • Unknown Member

        Deleted User
        October 1, 2019 at 10:49 pm

         
        We have one breast ultrasound tech who – if she looks at the diagnostic mammo before you get to it (e.g. you in the middle of a procedure and patients are waiting)  – will decide what area of the breast needs to be scanned, will go ahead and scan the patient, and if significant findings are seen, she’ll document them, scan the axilla, decide which lesions will need biopsy, she’ll set up the biopsy trays and get the orders and then come tell you what she saw and what she did and ask if you want something else or to proceed with biopsy.
         
        I don’t like her to do this but what can I say – 95% of the time she is right and the other 5% time no harm is done because I’m right there (in those it’s usually that she undercalls thinking I’m going to BI-RADS 3 it and but I’m recommending biopsy just to make sure it’s a fibroadenoma and she kinda rolls her eyes and thinks I’m recommending too many biopsies compared to the other radiologists). She keeps things moving along and her judgement is pretty good. No, she doesn’t know BI-RADS descriptors or high-risk lesions or how to work up a one view asymmetry (though my techs can guess when I’m going to ask for stepped obliques) and doesn’t need to know any of that stuff as a breast sonographer, but where the rubber meets the road, she is working up these patients better than some radiologists out there. She’s been doing this forever and learning from the rads and is always trying to push the boundaries. I like her pluck but if there were any chance she could start doing this work independently I’d be less amused.

        • ranweiss

          Member
          October 2, 2019 at 12:21 am

          I can feel it coming in the air tonight…..
           
          Feels a lot like the 90’s in Anesthesiology….

        • Unknown Member

          Deleted User
          October 2, 2019 at 7:22 am

          Quote from Flounce

           
          We have one breast ultrasound tech who – if she looks at the diagnostic mammo before you get to it (e.g. you in the middle of a procedure and patients are waiting)  – will decide what area of the breast needs to be scanned, will go ahead and scan the patient, and if significant findings are seen, she’ll document them, scan the axilla, decide which lesions will need biopsy, she’ll set up the biopsy trays and get the orders and then come tell you what she saw and what she did and ask if you want something else or to proceed with biopsy.

          I don’t like her to do this but what can I say – 95% of the time she is right and the other 5% time no harm is done because I’m right there (in those it’s usually that she undercalls thinking I’m going to BI-RADS 3 it and but I’m recommending biopsy just to make sure it’s a fibroadenoma and she kinda rolls her eyes and thinks I’m recommending too many biopsies compared to the other radiologists). She keeps things moving along and her judgement is pretty good. No, she doesn’t know BI-RADS descriptors or high-risk lesions or how to work up a one view asymmetry (though my techs can guess when I’m going to ask for stepped obliques) and doesn’t need to know any of that stuff as a breast sonographer, but where the rubber meets the road, she is working up these patients better than some radiologists out there. She’s been doing this forever and learning from the rads and is always trying to push the boundaries. I like her pluck but if there were any chance she could start doing this work independently I’d be less amused.

          This is a nice example of a tech pushing boundaries, but still under supervision.
          Some of the best ultrasound technologists are like this; it invests them in the process. But it still requires radiologist participation and accountability, with a clear line of ultimate authority; rolling eyes accepted.
          The situation described by the OP completely bypasses the interpreting radiologist.
           

          • khodadadi_babak89

            Member
            October 2, 2019 at 1:24 pm

            I reached out to some docs on PPP and there were a few thoughts that should be shared:

            I do feel they may be held in some way responsible by mqsa for supervising actions of the techs taking the images. 
            So these images cannot really be taken without their supervision technically. 
            There is a lead interpreting physician by acr for each site that is responsible for this oversight. 
            Mqsa May come after them as well. As we know the dr will be at blame before the nurse

             

            When I had an issue on scope of practice I contacted ACR and they were VERY helpful.

             

            • francomejiamurillo_751

              Member
              October 2, 2019 at 1:57 pm

              Deal with this earlier the better

              • Unknown Member

                Deleted User
                October 2, 2019 at 3:04 pm

                The mammoindustrial complex and the overemphasis of mammography have contributed to this bad medical practice
                The need to immediately report results of screening mammograms is absurd. Oncology and many other patients have a greater need to know imaging exam results quickly and are just as or more anxious. Waste of resources.

              • Unknown Member

                Deleted User
                October 2, 2019 at 3:08 pm

                The mammoindustrial complex and the histrionic politics of mammography have contributed to this bad medical practice
                The need to immediately report results of screening mammograms is absurd. Oncology and many other patients have a greater need to know imaging exam results quickly and are just as or more anxious. Why dont we report results immediately for all imaging patients? What makes mammo so special? Waste of resources.

                • chirambasukwaw

                  Member
                  October 2, 2019 at 4:05 pm

                  Thank you all for your input and suggestions.  While it may seem unbelievable, the situation is very real.  Another fun fact – they are looking at the mammos on the hospital EMR low resolution viewer and not the Hologic station. 
                   
                  We will be meeting with higher level hospital administration and wanted to be as prepared as possible, hence the post.  I’m cautiously optimistic they will be forced to stop but am not certain due to the political power the surgeon has with the system.  The surgeon is employed and as far as I know doesn’t personally profit from the unnecessary studies.  
                   
                  Our main fellowship trained breast imager refused to read the most recent case where this was done, another rad read it mostly to allay the patient’s fears (it was negative).  We will notify them that in the future all rads will refuse these cases.  We will also contact the FDA directly. Big thank you to those who offered assistance.
                   
                  One followup question just to be clear, am I correct to believe it would also be wrong if it was the surgeons ordering add views/mammo based on their own screening reads?  Interestingly as far as I know they have never done so, which is another reason the CRNP’s practice seems so egregious.

                  • Unknown Member

                    Deleted User
                    October 2, 2019 at 4:27 pm

                    Surgeons not MQSA, right?
                    There is one name on the report. I wouldnt loan my name and exposure to anyone.

                    • chirambasukwaw

                      Member
                      October 2, 2019 at 5:49 pm

                      Correct, only the rads and none of the surgeons meet MQSA requirements

                    • MARELE

                      Member
                      October 2, 2019 at 5:51 pm

                      Why would a patient having a screening mammogram be seeing a breast surgeon or their designated NP?

                    • Unknown Member

                      Deleted User
                      October 2, 2019 at 5:53 pm

                      The LIP takes final responsibility with MQSA. They must sign off on the audit at the time of a site visit. The call back rates in this scenario will be off the charts.

                    • Unknown Member

                      Deleted User
                      October 2, 2019 at 6:05 pm

                      Removed due to GDPR request

                    • khodadadi_babak89

                      Member
                      October 2, 2019 at 8:18 pm

                      Quote from 67ED5CC042435

                      Its not surprising NPs think they can interpret imaging at the level of a radiologist. 

                    • khodadadi_babak89

                      Member
                      October 2, 2019 at 8:20 pm

                      Quote from 67ED5CC042435

                      Its not surprising NPs think they can interpret imaging at the level of a radiologist. 

                    • khodadadi_babak89

                      Member
                      October 2, 2019 at 8:24 pm

                      Quote from 67ED5CC042435

                      Its not surprising NPs think they can interpret imaging at the level of a radiologist. 

                       
                       
                      Another day of this conference was how to read all of CT.

                    • khodadadi_babak89

                      Member
                      October 2, 2019 at 8:54 pm

                      and when that NP in the second example is saying she goes to Youtube to learn to interpret chest x-rays, this is the level of stuff she is learning….

                    • Unknown Member

                      Deleted User
                      October 2, 2019 at 6:57 pm

                      Within reason, try to accommodate tat. But MQSA is all about limiting mammographic interpretation and subsequent decision making to specifically qualified physicians, period. If they want to argue that MQSA only applies to the name on the report, they are gdamm right, and therefore they have no flipping business inserting their pitiful judgement into the interpretation process.

                      Flounces example is a whole different ball of wax. Usually love those techs, and they know their limits.

                    • khodadadi_babak89

                      Member
                      October 2, 2019 at 8:28 pm

                      Quote from uncleduke

                      Within reason, try to accommodate tat. But MQSA is all about limiting mammographic interpretation and subsequent decision making to specifically qualified physicians, period. If they want to argue that MQSA only applies to the name on the report, they are gdamm right, and therefore they have no flipping business inserting their pitiful judgement into the interpretation process.

                      Flounces example is a whole different ball of wax. Usually love those techs, and they know their limits.

                       
                      Of course TAT is not about quality. It is the only metric that administrators understand and can measure. It is antagonistic to quality. It is the idiocrats  way to judge radiologic care. (reference to Mike Judge movie “Idiocracy” Recommended.)

                    • Patrick

                      Member
                      October 2, 2019 at 8:38 pm

                      I disagree. Scenario: obvious cancer, read correctly as bi-rads 5, 1 year after imaging versus an incorrect bi-rads 1 read within 10 minutes. Which is worse?

                      Timeliness of interpretation is one dimension of quality. It is not the only dimension. It should not be ignored, and it should not be overly stressed.

                      You may suggest that a 1 yr TAT would not occur, particularly in mammo. I will tell you such things do happen.

                    • khodadadi_babak89

                      Member
                      October 2, 2019 at 8:48 pm

                      Did this really happen, or is it a thought experiment? If it really happened, unless the Radiologist just didn’t feel like reading it for a year, this is on the administration. 
                       
                      So your example may be pertinent in one case out of 10,000. 
                       
                      Timeliness is a VERY weak indicator of quality. Also,  as much to do with support people as the doc. But is nearly the only one that most administrators use. So I stand by my statement that it is basically crap.
                       

                    • Patrick

                      Member
                      October 2, 2019 at 9:00 pm

                      You are correct that the failure in this case was a systems issue. And, in screening mammo, timeliness is more convenience than anything else.

                      But… I can give you examples of acute body and neuro cases where failure to provide a timely read resulted in significant harm to patients. Again, time is not the only dimension of quality, but it can be a very important component of serving our patients appropriately.

                    • ranweiss

                      Member
                      October 2, 2019 at 10:16 pm

                      Phil I’m getting a real kick out of these NP comments lol. Keep em coming.

                    • khodadadi_babak89

                      Member
                      October 3, 2019 at 1:47 am

                      Quote from NYC

                      You are correct that the failure in this case was a systems issue. And, in screening mammo, timeliness is more convenience than anything else.

                      But… I can give you examples of acute body and neuro cases where failure to provide a timely read resulted in significant harm to patients. Again, time is not the only dimension of quality, but it can be a very important component of serving our patients appropriately.

                       
                      OK let’s end this here. I NEVER said anything resembling: TAT is never important. OF COURSE you can give such examples. Anyone can. That is stipulated.
                       
                      That is not the issue
                       
                      The issue is overusing it as often the only metric or at least the one that the admins use when they want to put you on the defensive. And we have all seen that.  and you agree

                       

                    • raddoc77

                      Member
                      October 3, 2019 at 6:37 am

                      I see another high profile whistleblower lawsuit in the making…..

                    • khodadadi_babak89

                      Member
                      March 27, 2021 at 3:11 am

                      OK – its been a year and a half
                       
                      OP _ what is happening???

                    • Melenas

                      Member
                      March 27, 2021 at 8:23 am

                      Quote from Phil Shaffer

                      OK – its been a year and a half

                      OP _ what is happening???

                      Bump. I’d like to know what happened as well. 

                    • chirambasukwaw

                      Member
                      March 31, 2021 at 10:22 am

                      The issue was settled.  I’m not allowed to talk about it (!) but the radiologists were satisfied with the outcome, so it was a win for the patients.  Thank you.

  • Unknown Member

    Deleted User
    October 2, 2019 at 1:55 am

    Crazy. So the rads are essentially there to take a cut for generating a report outside the decision stream while the actual care and management are done outside their purview.

    Guess who’s gonna look like a useless leech soon?

    • khodadadi_babak89

      Member
      October 2, 2019 at 3:49 am

      I have not seen or heard of it being done.
       
      Before I make any more comments – some questions for you
       
      The surgeon -owners are aware of this and condone it, correct?
      Do these surgeon – owners profit from the excess studies?
       
      I’ll have some more thoughts for you later. 

      • btomba_77

        Member
        October 2, 2019 at 4:24 am

        Whistleblower.  Time to hook yourself up with some sweet triple damages.
         
        —-
         
        But seriously … you should demand the practice stop.  If it doesn’t, your group should walk away.
         
        (Then blow the whistle and let the sh*t storm begin 😉 )

        • leann2001nl

          Member
          October 2, 2019 at 4:33 am

          Run don’t walk

          • khodadadi_babak89

            Member
            October 2, 2019 at 4:58 am

            1) Do the surgeon owners profit from this arrangement in the form of more studies done, more billings?

            many of the next steps depend on this. 

            2) discuss with management, although they have apparently tried this
            3) Document every case that they call back unnecessarily. EASY to do -just keep a note pad on the desk, write ’em down. EXTREMELY valuable in your discussions
            4) shut off their access to unread images. (may not be possible)
            5) call the state radiation protection board
            6) report the CRNPs to the BON. This is very clearly outside their scope of practice they could be fined or lose their license for this sort of thing. 
            7) report them to the FDA (you  have gone through the website – Too weak – gotta be more aggressive
            8) Call the insurance companies and tell them they are paying for unnecessary studies
            9) Refuse to do them.(tough at times when the patient has been frightened to death by the NP)
            10) Include this in the report “This study was done as the result of an unofficial, and erroneous reading by an unqualified person (Mary Smith CRNP). Resulting in unnecessary expense and unnecessary radiation exposure.” Let the patient see that in her report. (This of course might be a last-day sort of activity)
            11) if you leave or are forced out –  (really extreme here, maybe all the way into impractical fantasy) – Call media or (worse) Take out an ad in the local paper calling them out for unnecessary radiation exposure to their patients. (Yeah – somehow this seems like a bad idea, but nevertheless attractive)

            And, if it were me, I would do ALL of these all at once, and let them know I am doing it. Let them understand you won’t fu&k around. Unleash the furies of hell on them. They are, after all, quality of care issues, and patient safety issues.  
             
            The gods are on your side

          • carlosadube

            Member
            October 2, 2019 at 5:01 am

            Why don’t you ask the FDA?  As an earlier poster stated … there is no outcome analysis for the CRNP’s recall rate, false postives/negatives etc .. those will fall on the MQSA Rad reading the reports .. They are practicing USING YOUR MQSA!  That is unethical

            • Unknown Member

              Deleted User
              October 2, 2019 at 5:52 am

              OP. I have contacts with directors in the Breast health division of the FDA. I would be happy to run this by them if you send me the information. I will not use your name if that is what you want. PM me.

              • Unknown Member

                Deleted User
                October 2, 2019 at 5:54 am

                Again my message to aunt Minnie is to be aware that this is happening. Non-physicians are doing things that are endangering patients. This is wrong. And it is done for money and profits.

                • Unknown Member

                  Deleted User
                  October 2, 2019 at 6:44 am

                  talk to physicians for patient protection. See if they can suggest some strategies. We need to be aggressive and push back. I wish ACR came up with a task force to address this issue and train members to push back and stop these practices.

                • Unknown Member

                  Deleted User
                  October 2, 2019 at 6:44 am

                  I dont believe this

                  Something is either not accurate or just false

                  [link=https://www.acraccreditation.org/-/media/ACRAccreditation/Documents/Mammography/Forms/PersonnelRequirements.pdf?la=en]https://www.acraccreditat…Requirements.pdf?la=en[/link]

                  • Unknown Member

                    Deleted User
                    October 2, 2019 at 6:50 am

                    KPACK…this is illegal for sure. Just have to get the attention of the right people. But I think they are skirting the laws because at the end it is the radiologist who is doing the interpretation. But the radiologist didn’t order the diagnostic mammogram to begin with and so the patient is being exposed to additional testing for no reason as if breast cancer is an emergency and needs to be done ASAP. Ridiculous. 

                    • Unknown Member

                      Deleted User
                      October 2, 2019 at 7:00 am

                      Personally I would not knowingly expose myself to anything unethical or shady

                      Honestly I would just cut ties with them

                    • Unknown Member

                      Deleted User
                      October 2, 2019 at 7:08 am

                      It is pretty simple.
                      If this is done under your supervision, with your approval, it passes.
                      If this is done independent of your supervision, which is the case, then it fails.
                      Bottom line: unacceptable scenario. Would refuse to participate unless reformed.

  • Unknown Member

    Deleted User
    October 2, 2019 at 6:02 pm

    “We are impressed by the initiative shown by your CRNPs. But we are concerned for your surgery center, what happens when a patient is inconvenienced by scheduling their diagnostic breast imaging only to be told by the radiologist on site that there is no finding that needs to be worked up? We would have to explain to them why they were told to show up, i.e. that management decisions were being made by a non-physician rather than based on the official report of the radiologist. They might not be happy getting the runaround, and what if the local press were to find out – from one of these patients – that your surgery center has CRNPs interpreting screening mammograms and making decisions before the radiologist has had a chance to look at it?  This would look really bad for your surgery center…”