MAHADEVAPPA MAHESH, MS, PhD
THE MEDICAL PHYSICS CONSULT
Practical Considerations for ACR MRI Accreditation Yunhong Shu, PhD, Krzysztof R. Gorny, PhD, Joel P. Felmlee, PhD, Robert A. Pooley, PhD, Heidi A. Edmonson, PhD INTRODUCTION
Since 2008, nonhospital providers of advanced imaging techniques have been required to obtain and maintain accreditation from eligible accreditation bodies to receive federal reimbursements [1]. Several private insurance payers are also adopting these accreditation requirements. MRI practice at our institution has been accredited by the ACR since 2001. On the basis of our experience, we present steps and practical considerations for the efficient and timely ACR MRI accreditation. TIMELINE OF ACR MR ACCREDITATION
For newly installed MR scanners, a period of 120 days is given to finalize accreditation from the date of first clinical use [2]. Immediately after acceptance testing and applications training, the ACR should be notified of the new installation. Once the supervising radiologist is satisfied with scan protocols and the performance of the new scanner, the site may begin collecting clinical examinations for submission with the ACR application. For previously accredited scanners, ACR accreditation renewal occurs every 3 years. The ACR notifies a site to start the renewal process 8 months before the expiration date [3]. Specific time frames are given to the facility for submitting the application and testing materials. Clinical and phantom examinations may predate the application by as much as 6 months. For proactive sites immediately submitting their renewal applications upon ACR notification, clinical examinations from 94
14 months ahead of the accreditation expiration might be used for submission (with application 8 months before expiration plus examinations predating application by 6 months). The ACR review timeline is designed to allow time for the image reviewing and, if necessary, for resubmission to address any deficiencies. Submitting materials earlier can protect the site from loss of revenue. Our institution usually strives to begin the process several months before the deadline. Between renewal cycles, other events that require accreditation activity include replacing a unit or adding a new unit to the facility. Note that a new system installed near the end of a 3-year cycle may trigger early renewal of all the scanners at that site. PERSONNEL INVOLVED
The ACR accreditation process is a team effort. All personnel involved in accreditation must meet qualifications specified by the ACR [3]. The responsibilities of the supervising physician include developing policies and procedures, communicating with the ACR, and ensuring qualifications compliance of all the interpreting physicians. The medical physicist is charged with performing quality control (QC) surveys of the MRI scanners and providing signed annual physics reports. The MR technologists collect appropriate patient examinations and communicate with the radiologists and physicists to understand the specific imaging requirements. At our institution, two MR technologists are designated to coordinate the clinical examination collection. Their involvement is
certainly crucial to our success with ACR accreditation. APPLICATION SUBMISSION
For module selection, after carefully evaluating the patient volumes and examination types on specific scanners, the site administrator and supervising physician should identify the most frequently used clinical modules and corresponding examinations required for ACR accreditation. Our institution is equipped with 24 clinical MR scanners, and each scanner is designated with a specific clinical focus. It is crucial to ensure that patient volume supports the choice of modules. Imprudent selection of the module may later create difficulty in collecting the required clinical examinations for submission. The ACR allows only 10 examinations per month or 50 examinations per year for unaccredited module scanning, so module selection should also consider backup use of the scanner when other scanners are temporarily out of service. Each clinical module contains at least one required specialty examination. Note that the MR angiography module requires a specialty examination of either a renal or an aortic arch and carotid MR angiography. Our institution rarely performs renal MR angiography because of concerns about nephrogenic systemic fibrosis. Thus, the aortic arch and carotid examination is the only choice, even for scanners that do not routinely perform neurologic examinations. Similarly, scanners that routinely do knee examinations may rarely perform
ª 2014 American College of Radiology 1546-1440/13/$36.00 http://dx.doi.org/10.1016/j.jacr.2013.09.024
The Medical Physics Consult 95
the required wrist, forefoot, or elbow examinations required for the musculoskeletal module. Under this circumstance, it is crucial to plan ahead and allow time to collect the examinations as appropriate patients present for care. After the selection of modules and examinations, the application can be submitted with the unit information and payments. TESTING MATERIALS
After the ACR has received the application, online testing forms for the sites become available on the ACR’s website. The next step is for the site to prepare the testing materials. Phantom Testing
ACR phantom scanning protocols and analysis instructions are available online at the ACR’s accreditation website [4,5]. Note that phantom images from the site protocols will be evaluated in case the ACR examination fails. Always ensure that the site phantom scanning protocols meet the ACR resolution requirement. In our experience, the main reason for phantom measurements to fail has been phantom misalignment. Commercially available phantom holders that fit inside the head coil prevent the misalignment, decrease the failure rate, and improve the efficiency of daily and weekly QC scanning. Image uniformity may also fail the ACR criteria when using a multichannel phased-array coil, especially at 3.0 T. In this case, it is important to use a coil intensity correction algorithm on the phantom images if the correction is also used for clinical care. Annual MRI System Performance Evaluation
It is the medical physicist’s responsibility to perform the annual MRI system performance evaluation and provide a full data report. Test procedures, data analysis, and sample data forms are described in the ACR’s MRI QC manual [6].
The report should also contain a summary based on the physicist’s review of the daily and weekly QC records, service log, and MR safety program. It should be indicated if the system is still within normal operating specification, and any specific details about the scanner should be included. If any system failure is detected, the physicist should make recommendations for corrective action. Documented procedures addressing the deficit should also be provided. Clinical Examinations
The supervising physician plays a very important role in reviewing and approving the quality of the examinations representing the best work of the site. The MR technologist or medical physicist can help check the imaging parameters, anatomic coverage, and artifacts to ensure that the examinations satisfy the ACR clinical image quality guide [7]. Incorrect imaging parameters could cause deficiency but can be easily avoided by careful review. If CD-ROM submission is used, clinical images can be burned in DICOM format on CD-ROMs with an embedded viewer. Our institution has historically used eFilm Lite (Merge eFilm, Chicago, Illinois), which has all the functionalities required by the ACR. Note that reformatted images from 3-D acquisitions are acceptable provided the reformats still meet the spatial resolution requirements. However, only one reformat is allowed per 3-D acquisition. TESTING PACKAGE SUBMISSION
A time period of 45 days is given for returning the testing package. If more time is needed, the facility should contact the ACR to seek an extension. Once all the materials are ready, the last step is to assemble the testing package. Our institution has been using hard-copy and CDROM submission. The testing
package should contain all the phantom and clinical examination CD-ROMs, the completed image data forms from the ACR online system, and the annual physics report. All the CD-ROMs and documents must be correctly labeled with the ACR-provided barcodes. It is important to always double-check whether all images are included on the CD-ROMs. We have routinely enclosed a cover letter from the supervising physician listing the package contents and technical notations. The ACR passes the cover letter to the reviewers for reference. The ACR has recently implemented an electronic submission method. If chosen, all the testing materials, including documents and images, will be uploaded. Images can be uploaded from either electronic file folders or the PACS directly. DEFICIENCY
In case of deficiency, the supervising physician and physicist should evaluate the situation and promptly develop plans for repeating the examination or appealing the decision. Additional time may be needed if the appeal is denied and the site still needs to repeat the examination. If the site failed because of incorrect image submission, the judge of the appeal will still base the determination on the originally submitted images. FINAL REPORTS
Once the site passes accreditation, the supervising physician receives notification from the ACR. The accreditation certificates will be sent, and any submission materials will be returned. A report with comments from the expert reviewers is also returned to the site for each MRI scanner. These comments provide an excellent opportunity to find areas for improvement. On the basis of the reviews from our institution’s
96 The Medical Physics Consult
most recent renewal, effort is being made to further reduce flow artifacts for cervical spine examinations. Meanwhile, it is also important for sites to gather information and prepare documents for unannounced site surveys from the ACR. SUMMARY
The ACR accreditation program is an educational program that strives to ensure that clinical MR sites are providing high quality and safety, serving the best interests of patients. Dedicated personnel are needed to bring attention to each detail and fulfill all the requirements in every step of submission.
REFERENCES 1. Centers for Medicare and Medicaid Services. Advanced diagnostic imaging accreditation. Available at: http://www.cms. gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/ AdvancedDiagnosticImagingAccreditation. html. Accessed September 3, 2013. 2. Centers for Medicare and Medicaid Services. Advanced diagnostic imaging accreditation. Provisional accreditation status. Available at: http://www.acr.org/ w/media/ACR/Documents/Accreditation/ CMSProvisionalAccreditationStatusPolicy. pdf. Accessed September 3, 2013. 3. American College of Radiology. MRI accreditation program requirements. Available at: http://www.acr.org/w/media/ ACR/Documents/Accreditation/MRI/ Requirements.pdf. Accessed September 3, 2013.
4. American College of Radiology. Site scanning instructions for use of the MR phantom for the ACR MRI accreditation program. Available at: http://www.acr.org/ w/media/ACR/Documents/Accreditation/ MRI/LargePhantomInstructions.pdf. Accessed September 3, 2013. 5. American College of Radiology. Phantom test guidance for the ACR MRI accreditation program. Available at: http://www.acr.org/ w/media/ACR/Documents/Accreditation/ MRI/LargePhantomGuidance.pdf. Accessed September 3, 2013. 6. American College of Radiology. Magnetic resonance imaging quality control manual. Reston, Virginia: American College of Radiology; 2006. 7. American College of Radiology. MRI accreditation program: clinical image quality guide. Available at: http://www.acr.org/ w/media/ACR/Documents/Accreditation/MRI/ ClinicalGuide.pdf. AccessedSeptember3,2013.
Yunhong Shu, PhD, Krzysztof R. Gorny, PhD, Joel P. Felmlee, PhD, and Heidi A Edmonson, PhD, are from the Department of Radiology, Mayo Clinic, Rochester, Minnesota. Robert A. Pooley, PhD, is from the Department of Radiology, Mayo Clinic, Jacksonville, Florida. Yunhong Shu, PhD, Mayo Clinic, Department of Radiology, 200 First Street SW, Rochester, MN 55902; e-mail: shu.yunhong@ mayo.edu.
THE MEDICAL PHYSICS CONSULT
Practical Considerations for ACR MRI Accreditation Yunhong Shu, PhD, Krzysztof R. Gorny, PhD, Joel P. Felmlee, PhD, Robert A. Pooley, PhD, Heidi A. Edmonson, PhD INTRODUCTION
Since 2008, nonhospital providers of advanced imaging techniques have been required to obtain and maintain accreditation from eligible accreditation bodies to receive federal reimbursements [1]. Several private insurance payers are also adopting these accreditation requirements. MRI practice at our institution has been accredited by the ACR since 2001. On the basis of our experience, we present steps and practical considerations for the efficient and timely ACR MRI accreditation. TIMELINE OF ACR MR ACCREDITATION
For newly installed MR scanners, a period of 120 days is given to finalize accreditation from the date of first clinical use [2]. Immediately after acceptance testing and applications training, the ACR should be notified of the new installation. Once the supervising radiologist is satisfied with scan protocols and the performance of the new scanner, the site may begin collecting clinical examinations for submission with the ACR application. For previously accredited scanners, ACR accreditation renewal occurs every 3 years. The ACR notifies a site to start the renewal process 8 months before the expiration date [3]. Specific time frames are given to the facility for submitting the application and testing materials. Clinical and phantom examinations may predate the application by as much as 6 months. For proactive sites immediately submitting their renewal applications upon ACR notification, clinical examinations from 94
14 months ahead of the accreditation expiration might be used for submission (with application 8 months before expiration plus examinations predating application by 6 months). The ACR review timeline is designed to allow time for the image reviewing and, if necessary, for resubmission to address any deficiencies. Submitting materials earlier can protect the site from loss of revenue. Our institution usually strives to begin the process several months before the deadline. Between renewal cycles, other events that require accreditation activity include replacing a unit or adding a new unit to the facility. Note that a new system installed near the end of a 3-year cycle may trigger early renewal of all the scanners at that site. PERSONNEL INVOLVED
The ACR accreditation process is a team effort. All personnel involved in accreditation must meet qualifications specified by the ACR [3]. The responsibilities of the supervising physician include developing policies and procedures, communicating with the ACR, and ensuring qualifications compliance of all the interpreting physicians. The medical physicist is charged with performing quality control (QC) surveys of the MRI scanners and providing signed annual physics reports. The MR technologists collect appropriate patient examinations and communicate with the radiologists and physicists to understand the specific imaging requirements. At our institution, two MR technologists are designated to coordinate the clinical examination collection. Their involvement is
certainly crucial to our success with ACR accreditation. APPLICATION SUBMISSION
For module selection, after carefully evaluating the patient volumes and examination types on specific scanners, the site administrator and supervising physician should identify the most frequently used clinical modules and corresponding examinations required for ACR accreditation. Our institution is equipped with 24 clinical MR scanners, and each scanner is designated with a specific clinical focus. It is crucial to ensure that patient volume supports the choice of modules. Imprudent selection of the module may later create difficulty in collecting the required clinical examinations for submission. The ACR allows only 10 examinations per month or 50 examinations per year for unaccredited module scanning, so module selection should also consider backup use of the scanner when other scanners are temporarily out of service. Each clinical module contains at least one required specialty examination. Note that the MR angiography module requires a specialty examination of either a renal or an aortic arch and carotid MR angiography. Our institution rarely performs renal MR angiography because of concerns about nephrogenic systemic fibrosis. Thus, the aortic arch and carotid examination is the only choice, even for scanners that do not routinely perform neurologic examinations. Similarly, scanners that routinely do knee examinations may rarely perform
ª 2014 American College of Radiology 1546-1440/13/$36.00 http://dx.doi.org/10.1016/j.jacr.2013.09.024
The Medical Physics Consult 95
the required wrist, forefoot, or elbow examinations required for the musculoskeletal module. Under this circumstance, it is crucial to plan ahead and allow time to collect the examinations as appropriate patients present for care. After the selection of modules and examinations, the application can be submitted with the unit information and payments. TESTING MATERIALS
After the ACR has received the application, online testing forms for the sites become available on the ACR’s website. The next step is for the site to prepare the testing materials. Phantom Testing
ACR phantom scanning protocols and analysis instructions are available online at the ACR’s accreditation website [4,5]. Note that phantom images from the site protocols will be evaluated in case the ACR examination fails. Always ensure that the site phantom scanning protocols meet the ACR resolution requirement. In our experience, the main reason for phantom measurements to fail has been phantom misalignment. Commercially available phantom holders that fit inside the head coil prevent the misalignment, decrease the failure rate, and improve the efficiency of daily and weekly QC scanning. Image uniformity may also fail the ACR criteria when using a multichannel phased-array coil, especially at 3.0 T. In this case, it is important to use a coil intensity correction algorithm on the phantom images if the correction is also used for clinical care. Annual MRI System Performance Evaluation
It is the medical physicist’s responsibility to perform the annual MRI system performance evaluation and provide a full data report. Test procedures, data analysis, and sample data forms are described in the ACR’s MRI QC manual [6].
The report should also contain a summary based on the physicist’s review of the daily and weekly QC records, service log, and MR safety program. It should be indicated if the system is still within normal operating specification, and any specific details about the scanner should be included. If any system failure is detected, the physicist should make recommendations for corrective action. Documented procedures addressing the deficit should also be provided. Clinical Examinations
The supervising physician plays a very important role in reviewing and approving the quality of the examinations representing the best work of the site. The MR technologist or medical physicist can help check the imaging parameters, anatomic coverage, and artifacts to ensure that the examinations satisfy the ACR clinical image quality guide [7]. Incorrect imaging parameters could cause deficiency but can be easily avoided by careful review. If CD-ROM submission is used, clinical images can be burned in DICOM format on CD-ROMs with an embedded viewer. Our institution has historically used eFilm Lite (Merge eFilm, Chicago, Illinois), which has all the functionalities required by the ACR. Note that reformatted images from 3-D acquisitions are acceptable provided the reformats still meet the spatial resolution requirements. However, only one reformat is allowed per 3-D acquisition. TESTING PACKAGE SUBMISSION
A time period of 45 days is given for returning the testing package. If more time is needed, the facility should contact the ACR to seek an extension. Once all the materials are ready, the last step is to assemble the testing package. Our institution has been using hard-copy and CDROM submission. The testing
package should contain all the phantom and clinical examination CD-ROMs, the completed image data forms from the ACR online system, and the annual physics report. All the CD-ROMs and documents must be correctly labeled with the ACR-provided barcodes. It is important to always double-check whether all images are included on the CD-ROMs. We have routinely enclosed a cover letter from the supervising physician listing the package contents and technical notations. The ACR passes the cover letter to the reviewers for reference. The ACR has recently implemented an electronic submission method. If chosen, all the testing materials, including documents and images, will be uploaded. Images can be uploaded from either electronic file folders or the PACS directly. DEFICIENCY
In case of deficiency, the supervising physician and physicist should evaluate the situation and promptly develop plans for repeating the examination or appealing the decision. Additional time may be needed if the appeal is denied and the site still needs to repeat the examination. If the site failed because of incorrect image submission, the judge of the appeal will still base the determination on the originally submitted images. FINAL REPORTS
Once the site passes accreditation, the supervising physician receives notification from the ACR. The accreditation certificates will be sent, and any submission materials will be returned. A report with comments from the expert reviewers is also returned to the site for each MRI scanner. These comments provide an excellent opportunity to find areas for improvement. On the basis of the reviews from our institution’s
96 The Medical Physics Consult
most recent renewal, effort is being made to further reduce flow artifacts for cervical spine examinations. Meanwhile, it is also important for sites to gather information and prepare documents for unannounced site surveys from the ACR. SUMMARY
The ACR accreditation program is an educational program that strives to ensure that clinical MR sites are providing high quality and safety, serving the best interests of patients. Dedicated personnel are needed to bring attention to each detail and fulfill all the requirements in every step of submission.
REFERENCES 1. Centers for Medicare and Medicaid Services. Advanced diagnostic imaging accreditation. Available at: http://www.cms. gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/ AdvancedDiagnosticImagingAccreditation. html. Accessed September 3, 2013. 2. Centers for Medicare and Medicaid Services. Advanced diagnostic imaging accreditation. Provisional accreditation status. Available at: http://www.acr.org/ w/media/ACR/Documents/Accreditation/ CMSProvisionalAccreditationStatusPolicy. pdf. Accessed September 3, 2013. 3. American College of Radiology. MRI accreditation program requirements. Available at: http://www.acr.org/w/media/ ACR/Documents/Accreditation/MRI/ Requirements.pdf. Accessed September 3, 2013.
4. American College of Radiology. Site scanning instructions for use of the MR phantom for the ACR MRI accreditation program. Available at: http://www.acr.org/ w/media/ACR/Documents/Accreditation/ MRI/LargePhantomInstructions.pdf. Accessed September 3, 2013. 5. American College of Radiology. Phantom test guidance for the ACR MRI accreditation program. Available at: http://www.acr.org/ w/media/ACR/Documents/Accreditation/ MRI/LargePhantomGuidance.pdf. Accessed September 3, 2013. 6. American College of Radiology. Magnetic resonance imaging quality control manual. Reston, Virginia: American College of Radiology; 2006. 7. American College of Radiology. MRI accreditation program: clinical image quality guide. Available at: http://www.acr.org/ w/media/ACR/Documents/Accreditation/MRI/ ClinicalGuide.pdf. AccessedSeptember3,2013.
Yunhong Shu, PhD, Krzysztof R. Gorny, PhD, Joel P. Felmlee, PhD, and Heidi A Edmonson, PhD, are from the Department of Radiology, Mayo Clinic, Rochester, Minnesota. Robert A. Pooley, PhD, is from the Department of Radiology, Mayo Clinic, Jacksonville, Florida. Yunhong Shu, PhD, Mayo Clinic, Department of Radiology, 200 First Street SW, Rochester, MN 55902; e-mail: shu.yunhong@ mayo.edu.
