advanced practice nurses reading studies at the VA?

[Warderino92]

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Saw this posted today and I was really dumbstruck, do nurses actually believe that they can read MR and CT studies or is this just a reaction to nurses seeking overall autonomy at the VA?

http://cqrcengage.com/acradiology/app/comment-on-a-regulation?0&engagementId=228693

 

[Radz123]

I've met a lot of cocky nurses, but I've NEVER met a nurse who thought they could interpret cross sectional imaging. It's one of the weakest aspects of mid level providers. They're absolutely lost when they open most CT's and don't even understand the absolute basics of MRI.

I'm not really sure about the language of interpreting CT and MRI as most physicians do not officially interpret these studies either. Cardiologists can officially interpret cardiac MRI. Honestly I'm having problems thinking of any other instance where imaging isn't eventually over read by an attending radiologist. Vascular surgery does some basic ultrasound evaluations.

 

[maxxor]

I've met a lot of cocky nurses, but I've NEVER met a nurse who thought they could interpret cross sectional imaging. It's one of the weakest aspects of mid level providers. They're absolutely lost when they open most CT's and don't even understand the absolute basics of MRI.

I'm not really sure about the language of interpreting CT and MRI as most physicians do not officially interpret these studies either. Cardiologists can officially interpret cardiac MRI. Honestly I'm having problems thinking of any other instance where imaging isn't eventually over read by an attending radiologist. Vascular surgery does some basic ultrasound evaluations.

They'll start from the bottom and lobby their way up. It's the Midlevel way.

 

[meister]

Neurologists and even some neurosurgeons read neuro CT/MR.

 

[RadsFTW123]

Neurologists and even some neurosurgeons read neuro CT/MR.

There's a key difference between "reading" the study and dictating a report, signing it, and being responsible for it. I'm not aware of neurologists and neurosurgeons doing that (and neurosurgeons are way better at imaging than neurologists). I think the VA proposal refers to the former way of "interpreting" described above, not what radiologists do. not that we should support the proposal either way...

 

[Kazaki]

From an IMG's perspective.
The US is the best when it comes to advances in medicine, UK, Canada and Australia do not even come close. But these midlevel idiots are ruining it for doctors. Soon enough, American physicians have to put a stop to this, or risk being overthrown by a bunch of nurses that know f*uck all.

 

[maxxor]

There's a key difference between "reading" the study and dictating a report, signing it, and being responsible for it. I'm not aware of neurologists and neurosurgeons doing that (and neurosurgeons are way better at imaging than neurologists). I think the VA proposal refers to the former way of "interpreting" described above, not what radiologists do. not that we should support the proposal either way...

It's a practice guideline written by people who don't understand medicine.

Radiology needs to stand with other physicians to block midlevel encroachment at places like the VA.

 

[meister]

There's a key difference between "reading" the study and dictating a report, signing it, and being responsible for it. I'm not aware of neurologists and neurosurgeons doing that (and neurosurgeons are way better at imaging than neurologists). I think the VA proposal refers to the former way of "interpreting" described above, not what radiologists do. not that we should support the proposal either way...

I'm aware there's a difference, and I'm also aware that neurologists have neuroimaging as a fellowship option available to them. And that there are neurosurgery groups that own magnets and generate imaging reports. It's not common but it does occur.

 

[jerry_jacuzzi]

You can voice your opposition by clicking on this link: http://cqrcengage.com/acradiology/app/comment-on-a-regulation?0&engagementId=228693

There's a pre-completed letter that you submit. It only takes a minute

 

[PL198]

I'm aware there's a difference, and I'm also aware that neurologists have neuroimaging as a fellowship option available to them. And that there are neurosurgery groups that own magnets and generate imaging reports. It's not common but it does occur.

any ordering provider who owns their own magnets is BS. see orthos who do that too. gigantic conflict of interest

 

[maxxor]

any ordering provider who owns their own magnets is BS. see orthos who do that too. gigantic conflict of interest

This is why you should lobby either for repeal of the stark laws or closure of the in office ancillary services loophole.

 

[shark2000]

There is not a whole lot of money left in outpatient imaging. Though it hurts radiology, but it also stops self-referral to some extent.

My group started to read cardiac Nucs a while ago. Before that, it was in the control of cardiologists who used to do a lot of them in their office. But they ended up selling their outpatient center to the hospital.

 

[PL198]

This is why you should lobby either for repeal of the stark laws or closure of the in office ancillary services loophole.

I thought stark laws work to prevent the previously mentioned scenario?

 

[maxxor]

I thought stark laws work to prevent the previously mentioned scenario?

They initially were to prevent referral, but through the IOAS, orthos and friends still have an uneven playing field, because they can self-refer to their magnet.

If Stark were removed, Radiology could create a "radiologist follow up clinic", staff it with an NP or PA, and have them coordinate and self-refer patients for all the followup exams we inevitably recommend, to remove the burden from the PCPs/referring physicians. Prime example is lung cancer screening followups.

 

[calvnandhobbs68]

They initially were to prevent referral, but through the IOAS, orthos and friends still have an uneven playing field, because they can self-refer to their magnet.

If Stark were removed, Radiology could create a "radiologist follow up clinic", staff it with an NP or PA, and have them coordinate and self-refer patients for all the followup exams we inevitably recommend, to remove the burden from the PCPs/referring physicians. Prime example is lung cancer screening followups.

How about we just close the loophole and don't allow anybody to corruptly refer unknowing patients to their own imaging sites.

 

[maxxor]

How about we just close the loophole and don't allow anybody to corruptly refer unknowing patients to their own imaging sites.

Good luck. People have been trying since Stark I in 1992, but the people making money from IOAS is too strong.

Now, large health systems are arguing that ACOs and new payment networks are illegal under Stark laws, which is leading the push to repeal them. The only people with bigger pockets than the local ortho group or endoscopy center (IOAS exception for pathology samples...) are the hospital systems and large ACOs.

 

[badasshairday]

Nurses can read radiology reports.

 

[badasshairday]

 

[tco]

Neurologists and even some neurosurgeons read neuro CT/MR.

Then why do they keep calling the reading room to get my report before discharging the patient? They can assume the risk associated with reading the study, issue their independent read in a note, and discharge the patient. Heck, they'd even get paid more for doing so.

 

[meister]

Because what you're describing is not what I'm describing.

 

[tco]

Because what you're describing is not what I'm describing.

I know exactly what you're describing.

They think they can find the pertinent finding in their specialty's particular imaging modality.

They're not wrong as long as it's something extremely common. Anything slightly rare or unusual, they have no friggin' idea.

 

[shark2000]

Every test has a pretest probability. If you order a brain MRI in a normal individual with just mild headache even without looking at the images, if you call it normal you are right 99.9 % of the time.

I don't say some clinicians are not good at interpreting imaging. I say that many times they have a lot of information that even without looking at the images they can predict what the images will look like.

Example: ED examines the patient with extreme wrist pain after trauma. Even without looking at Xrays they know it is going to be a fracture. But the history says arthritis. The radiologist may overlook a subtle fracture at the wrist not because he is incompetent. Because all of us are human beings and we make mistakes.

I can claim that I am as good as a 4th generation HIV test in detecting HIV. The prevalence of HIV in US population is about 1%. So on average, even if I call everybody negative I am correct 99% of the time. Now, I can choose 100 people with very low pretest probability for HIV. In a low risk group, I can be correct 99.5% of the time or even more. If I call 200-300 people all normal I may miss one case. So if a test wants to beat my accuracy, it should be 99.9% accurate or even more. If an HIV test has only 0.2% inaccuracy, I can claim that I am as good as it.

My point is pretest probability is the key. By having clinical history, a clinician can guess the pretest probability and then look at the images and make some assumptions which can be relatively accurate (like the HIV test example).

 

[maxxor]

I know exactly what you're describing.

They think they can find the pertinent finding in their specialty's particular imaging modality.

They're not wrong as long as it's something extremely common. Anything slightly rare or unusual, they have no friggin' idea.

No. Neurologists and neurosurgeons can own a magnet, refer to themselves from clinic using IOAS, and issue the report themselves, and Bill Medicare globally for all of the above.

This is very different from trying to usurp the read from a hospital owned magnet that has an exclusive contract with the radiology group for professional interpretation.

 

[tco]

No. Neurologists and neurosurgeons can own a magnet, refer to themselves from clinic using IOAS, and issue the report themselves, and Bill Medicare globally for all of the above.

This is very different from trying to usurp the read from a hospital owned magnet that has an exclusive contract with the radiology group for professional interpretation.

What did you think you were responding to? My post had to do with the subspecialists "reading" their own imaging.

 

[maxxor]

What did you think you were responding to? My post had to do with the subspecialists "reading" their own imaging.

Because you are misinterpreting @meister and me both. We aren't saying that they claim to "read" the studies. We are saying that they can legally refer to themselves, put in a dictation, and bill for it.

That's not "reading".

They can't do that in a hospital because the radiology group is the exclusive provider of imaging services.

 

[tco]

Because you are misinterpreting @meister and me both. We aren't saying that they claim to "read" the studies. We are saying that they can legally refer to themselves, put in a dictation, and bill for it.

That's not "reading".

They can't do that in a hospital because the radiology group is the exclusive provider of imaging services.

Self referral should be illegal under Stark. I know there's loopholes.

My point is that any physician can take the responsibility for a study. I thought that was the original discussion.

At my last hospital, Neurology would issue reads in their clinical notes of their patients head CTs and MRIs.

Cardiology would do the same with CXRs.

This leads to upcoding the note.

If they're willing to accept the risk, they can make a read. Just like you can prescribe medication for nearly any medical condition.