AAPM Newsletter November/December 2015 Vol. 40 No. 6

AMERICAN ASSOCIATION of PHYSICISTS IN MEDICINE

AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

AAPM NEWSLETTER Advancing the Science, Education and Professional Practice of Medical Physics

“The AAPM Newsletter is on a sound footing with sustained revenues and a good readership base, which should continue for years to come.”

— MAHADEVAPPA MAHESH, AAPM NEWSLETTER EDITOR

IN THIS ISSUE: ▶ Chair of the Board’s Report

▶ Research Spotlight

▶ ABR News

▶ IEC Update

▶ Ensuring the Future of Our Profession and more...

58th Annual Meeting & Exhibition Walter E. Washington Convention Center

JULY 31–AUGUST 4 | WASHINGTON, DC

AAPM 2016 DATES TO REMEMBER December 2015

2016 Annual Meeting website activated. View the site for the most up-to-date meeting and abstract submission information. www.aapm.org/meetings/2016AM/

January 20

Website activated to receive electronic abstract submissions.

March 10 at 5PM Eastern, 8PM Pacific Time

Deadline for receipt of 300 word abstracts and supporting data.

This deadline recognizes other conference schedules. There will be NO EXTENSION OF THIS DEADLINE. Authors must submit their abstracts by this time to be considered for review.

March 23

Meeting Housing and Registration available online.

By April 18

Authors notified of presentation disposition.

By May 10

Annual Meeting Program available online.

June 15

Deadline to receive Discounted Registration Fees.

ARTICLES IN THIS ISSUE 5 7 11 15 19 21 23 26 29 31 35 37 41 45 46

From the Editor’s Desk AAPM Chair of the Board’s Report Executive Director’s Column Science Council Report Education Council Report Professional Council Report Journals Business Management Committee Report Legislative & Regulatory Affairs Report Website Editor’s Report ABR News ACR Accreditation: FAQs For Medical Physicists Health Policy & Economic Issues Research Spotlight IEC Update Ensuring the Future of Our Profession

AAPM NEWSLETTER AAPM NEWSLETTER is published by the American Association of Physicists in Medicine on a bi-monthly schedule.

AAPM is located at One Physics Ellipse, College Park, MD 20740-3846

EDITORIAL BOARD Editor Mahadevappa Mahesh, MS, PhD Johns Hopkins University E-mail: mmahesh@jhmi.edu Phone: 410-955-5115 John M. Boone, PhD Robert Jeraj, PhD George C. Kagadis, PhD E. Ishmael Parsai, PhD Charles R. Wilson, PhD

EVENTS/ANNOUNCEMENTS 2 4 13 14 18 18 22 47

AAPM 2016 58th Annual Meeting & Exhibition AAPM DREAM Program AAPM Reception During RSNA 2015 RSNA 2015 AAPM Spring Clinical Meeting 2016 AAPM Summer School 2016 AAPM Summer Undergraduate Fellowship Program AAPM Career Services

SUBMISSION INFORMATION Please send submissions (with pictures when possible) to: E-mail: nvazquez@aapm.org AAPM Headquarters Attn: Nancy Vazquez One Physics Ellipse College Park, MD 20740 Phone: (301) 209-3390

NAVIGATION HELP Previous/Next Article

PUBLISHING SCHEDULE The AAPM Newsletter is produced bi-monthly.

Next issue: January/February Submission Deadline: December 12, 2015 Posted Online: Week of January 1, 2016

Tap the arrows at the bottom of the page to go to the next or previous page.

EDITOR’S NOTE I welcome all readers to send me any suggestions or comments on any of the articles or new features to make this a more effective and engaging publication and to enhance the overall readership experience. Thank you.

www.aapm.org

CONNECT WITH US!

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CONTENTS

AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

AMERICAN ASSOCIATION of PHYSICISTS IN MEDICINE

DREAM

Diversity Recruitment through Education And Mentoring

THE DREAM PROGRAM is a 10 week summer program designed to increase the number of underrepresented groups in medical physics by creating new opportunities, outreach and mentoring geared towards diversity recruitment of undergraduate students in the field of medical physics.

ELIGIBILITY •

Undergraduate Juniors and Seniors majoring in Physics, Engineering, or other science degrees

•

U.S. Citizens, Canadian Citizens, or Permanent Citizens of the U.S.

HOW TO APPLY •

Complete application

•

Official transcript

•

2 Letters of recommendation

•

Self statement

FOR MORE DETAILS, VISIT: www.aapm.org/education/GrantsFellowships.asp

PROGRAM CONTACT: Jacqueline Ogburn, jackie@aapm.org or 301-209-3394 AD: Sponsored by the AAPM Education Council through the AAPM Education and Research Fund

AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

FROM THE EDITOR’S DESK Mahadevappa Mahesh, Baltimore, MD

W

elcome to the final issue of the AAPM Newsletter for 2015. It is also my final column (54th!) as your Editor of this Newsletter.

It has been an interesting and fulfilling nine years serving as your Editor during which time the Newsletter underwent a number of transformations. I consider the Newsletter to be the most effective platform to disseminate information about the organization’s activities, highlights, status and so forth. Hence, I always call for members to read/ peruse the Newsletter so as to keep abreast of our organization and its varied activities.

During the nine years, in addition to publishing regular columns, I have tried to introduce many new features, including “Persons in News,” “Literature Spotlight,” “Letters to the Editor.” Thanks to Russell Ritenour and the AAPM Board of 2006, I became Editor in 2007. At that time, the AAPM Newsletter was printed on nice glossy paper and there were a limited number of pages. Over the last nine years, the Newsletter format has undergone various transformations based on the prevailing circumstances. When I started as Editor, the financial storm that grasped all of us also impacted AAPM’s budget and the Newsletter budget. In an effort to reduce Newsletter expenses, the decision was made to print on regular paper and eventually print publications were stopped and the Newsletter was published in electronic format only. Personally it was disheartening for me, as many members expressed their displeasure for having to read the Newsletter in electronic format only. In fact, I believe we lost some readership because of this change. One other concern was the possibility of loss of advertisement revenue; however, we managed to maintain the advertisement revenue by providing additional features such as linking the ads directly to respective companies’ websites. This helped us to sustain the advertisement revenues even after we moved to the electronic publication format. I also tried to publish the Newsletter on mobile platforms, such as the iPad and Android but decided to pull it back due to limited readership and publishing costs.

Throughout the nine years, I’ve had a great vantage point to observe organization activities, decisions, strategic plans, etc. and to work with various AAPM leadership, Council chairs and others while bringing all of this to the AAPM membership.

Before ending my column, I would like to thank the following individuals who were with me: For the past nine years, Nancy Vazquez has been the AAPM staff coordinator for the Newsletter. Thanks to her dedicated commitment and organized nature, my work has been effortless all these years. She was the point person for all things related to the Newsletter, which she has done admirably well. The other AAPM staff person who I’ve had the pleasure to work with for the past nine years is Farhana Khan. She has been very effective in transforming the Newsletter to the electronic format in a timely fashion and establishing the Newsletter presence on the “World Wide Web.” Thanks to Nancy and Farhana and their committed

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

Editor, cont.

dedication, I have been able to publish the Newsletter on time. I would also like to thank Angela Keyser, Michael Woodward, Abby Pardes and the other AAPM staff for all of their support and assistance. I wish all of them a smooth transition to the new AAPM Headquarters. I would also like to thank the Newsletter Editorial Board members for their advice whenever I have reached out to them. My goal has been to publish each issue on the first day or the first week of the month, and to a large extent I have been successful in doing so. In spite of our efforts, the percentage of Newsletter readership is still low (hovers around 30%) and I wish more members would access the Newsletter. I would also like to thank my wife and kids for their cooperation during my tenure as the AAPM Newsletter Editor. As this issue arrives at your desk, we are entering the holiday season and I wish you and your family Happy Holidays.

Let me end my column by citing an article that aptly captures what I personally feel regarding volunteer services that we all are involved with in various organizations.

According to Adam Grant, author of the highly popular book Give and Take, “The greatest untapped source of motivation is a sense of service to others; focusing on the contribution of our work to other people’s lives has the potential to make us more productive than thinking about helping ourselves.” (“Is Giving the Secret to Getting Ahead?” New York Times, March 27, 2013). I enjoyed my work as Editor all these years and it is with bittersweet emotions that I am ending my role as Editor; but thanks to all of you, I am taking on the responsibility as your Treasurer starting next year. You may occasionally read my columns highlighting the financial status of the Association.

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

CHAIR OF THE BOARD’S REPORT John E. Bayouth, Madison, WI

It ain’t over till the short-bearded-physicist sings…

F

irst and most importantly, I want to thank many people for having enabled me to have this experience. The first is the membership of AAPM; I thank you for electing me, providing me the opportunity to realize many of the strategic goals of AAPM, and to represent our field both nationally and internationally to many educators, clinical professionals, and scientists. It’s a tremendous honor to serve in the Presidential Chain of AAPM. I also thank my family and co-workers (both Iowa and Wisconsin) for covering the many things I was unable to address during this time. The Presidential Chain of AAPM is a substantial (nearly 3.5 year) volunteer commitment of time and effort. I have certainly developed a great appreciation for the dedication and contribution of those I’ve served with: Mike Herman, Tony Seibert, Gary Ezzell, John Hazle, John Boone, and (John) Bruce Curran. I also want to thank Beth Schueler, Matthew Podgorsak, and Todd Pawlicki for their service through EXCOM, each of whom has given countless hours of their time. Please take a moment every once in a while to thank them, as they each worked hard to do their very best while asking for nothing in return. The chairs of our four councils (Administrative, Education, Professional, and Science) also deserve recognition and gratitude, as they too oversee a large portion of the volunteer activities of the organization. Thanks to Melissa Martin, George Starkschall, Per Halvorsen, Doug Pfeiffer, Dan Low, and Jeff Siewerdsen. Lastly, I want to thank the AAPM Executive Director, Angela Keyser, and the entire AAPM Headquarters staff; they are an outstanding group of not-forprofit society professionals who dramatically enable and improve the efficiency of our activities.

As I come to the end of my service in the AAPM Presidential Chain, I have three points I would like to share with you: • The strength of AAPM is born from its breadth and depth.

• AAPM is maturing as an organization, which is critical for our survival.

• The more we attempt to accomplish and the more resources needed to succeed, the greater the need for accountability.

Strength of AAPM AAPM is a collection of educators, scientists, and medical specialists. Even within a given area of focus one finds great diversity. Simply consider the range of educational background of the individuals we are often asked to educate: graduate students, medical physics residents, medical residents in Radiology and Radiation Oncology, medical students, undergraduate students, dosimetrists, diagnostic and radiation therapy technologists. Some who work clinically spend their entire career specializing in one procedure (e.g.,

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

Chair of the Board, cont.

stereotactic radiosurgery), while many others will provide clinical support for a broad range of procedures with far less frequency. The ability to add value in a broad range of areas while being able to drill down into the minutia is one of the great strengths of Medical Physicists. The combined knowledge of basic science and our drive to fundamentally understand how systems work enables us to bring a unique perspective into medicine.

The substantial breadth and depth of our expertise can and should be nurtured; in recent years our sphere of influence has rightfully expanded into new areas including patient safety, performance quality improvement, and health economics. Why not further this trend by applying our expertise into other areas of medicine that may benefit from physics (medical oncology, digital pathology, surgery, photo optics and acoustics)? If we succeed to do so, we can have an even greater impact on medicine. Please, look for opportunities to unite the many types of experts within AAPM and strive to identify new ways you, and by extension we, can add greater value in Medicine.

Maturation of AAPM AAPM is maturing as an organization, which I believe to be critical for its survival. One clear example of this is the organization’s focus on creating and establishing financial security. Through many years of being fiscally conservative and sound we have enabled ourselves to purchase a building; in the next 20 years our loan payments will likely remain below our prior rent payments and we will be establishing equity. Beyond the life of our loan we will be even more financially secure, paving the way for the next generation, as well as creating diversification of our portfolio.

A second example is one with less broad support but equally important: a business model for sustaining the Journal of Applied Clinical Medical Physics. JACMP is widely recognized within leadership to be a great asset.

From its inception, JACMP was designed to provide an environment for dissemination of clinically relevant medical physics practice throughout the world. When JACMP was acquired by AAPM from the now defunct American College of Medical Physics (ACMP), JACMP cost $30,000 more to produce than the income earned from advertisement revenue. By virtue of growth in the number of publications produced, which increases manuscript management and typesetting fees, today’s difference has risen to $100,000 in spite of increased advertisement revenue. This is not sustainable. The current Editor of JACMP, Michael Mills, has recognized this reality and has suggested a fee for submitting an article. Although it may sound foreign to many, this is the model used by virtually all open-access journals. Without revenue from subscriptions, open-access journals have no other way to cover expenses except from advertisement fees, and our advertisers continue to select advertising in hard copy publications like Medical Physics.

A third example of our maturation is the utilization of professional staff to support the activities of the organization. Most members do not see the work being done behind the scenes, but they certainly see the outcome of that work. For example, the AAPM website contains a wealth of information, including: video presentations over the last 15 years, annual reports since 1958 and budgets since 1992, reports and minutes from most AAPM committees, all AAPM TG reports and other publications, educational resources for training (and on and on…). What was once volunteer developed and managed has become a quality resource to

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

Chair of the Board, cont.

our members through staff development and maintenance. The number of meetings held and sponsored by AAPM has increased substantially over the years, including: Spring Clinical Meeting, 2-3 specialty meetings per year (e.g., CT Dose Summit(s), SBRT/SRS, Patient Safety, etc.), and numerous face-to-face meetings of various groups. To assure productivity and cost effectiveness, each of these meetings requires coordination and planning by our staff. A final staff position I will mention is a newly created one whose responsibility is to establish partnerships with our Corporate Affiliates. Why have such a position within AAPM staff? Millions of dollars of AAPM’s income is derived from our Corporate Affiliates. AAPM is now working to secure and potentially grow the support from our vendors by assuring that they are receiving high value for their dollars.

If our Corporate Affiliates were to choose to spend those same dollars with other organizations, the impact on AAPM would be quite negative.

Accountability In the last decade the activities of AAPM have increased, providing tangible benefits to its membership, the international community of Medical Physicists, and the utilization of physics in medicine. The more we attempt to accomplish as an organization, the more resources are needed to succeed. This is a significant element to the increased budget of the organization during that time period. This also creates a greater need for communication and accountability.

The AAPM budget process is complicated and nuanced. We have a budget that when summarized, is well over 200 pages in length! It is difficult for anyone to understand all elements within the budget, and many of the activities funded have a long history. I encourage the members of AAPM, along with the next wave of leadership, to create an environment where proposed funding is critically evaluated based on the following criteria: (i) is the proposal addressing a significant/impactful need, (ii) is the proposed approach likely to succeed, (iii) if already in progress, is the activity adding significant value. In the last month the Budget Subcommittee reviewed requests for funding in 2016. I personally was thrilled to see our volunteer members have an overwhelming number of good ideas — far more than the funding we have to support all of those ideas. So how does one prioritize? How to evaluate if the new ideas are better than the current projects that appear to be institutionalized? How can AAPM be most impactful? These questions require each current activity and future proposals to be held accountable for the value they add. Members and leaders should work to create an environment that promotes this evaluation. One that identifies and enables individuals who know the strategic direction of the organization, as well as the breadth of current and proposed activities to prioritize. AAPM’s budgeting process is an optimization problem, one that we should be able to use our rich understanding in solving such problems to find the “global minima” of effective expenditures.

In closing, let me thank you all once again. Being a member of the AAPM Presidential Chain has been a wonderful experience that I appreciate more as each day passes. n

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COMP

OCPM

Quality Matters – travaillons enseMble !

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Learning Objectives in brief

beautiful Château Montebello in Quebec.

• Learn how to meaningfully involve patients in quality and safety committees

Highlights • Patient participation

• Learn strategies to improve medical data at your centre

• Proffered presentations (abstracts due 23 Nov 2015)

• Learn change management techniques to help put the strategies into practice

• Radiation therapist scholarship competition • Workshops on addressing quality and safety issues at your centre • New and returning faculty Curling, cross-country skiing and skating at one of Quebec’s most beautiful winter settings!

Curriculum • Patient involvement • Quality of medical data • The Second Victim • High-reliability organizations • Teamwork

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

EXECUTIVE DIRECTOR’S COLUMN Angela Keyser, College Park, MD

Prince Street in Progress — Your New AAPM Headquarters AAPM’s new HQ building is running a bit behind schedule, with the proposed move date in mid–late November. This is the time in any construction project where it can seem as if all the details just may never come together, but they do. As of October 18, we have carpet and paint in some areas, with furniture scheduled to arrive within the next 2 weeks. The HQ team is busy “purging” and scanning documents as part of our “move prep.” It was very exciting to have 20+ AAPM volunteers in Alexandria for meetings in mid-October that allowed them to tour the new space. I received a great deal of positive feedback about AAPM’s investment for the future. I look forward to sharing additional photos with the membership in 2016.

AAPM events during RSNA 2015

REMINDER! AAPM’s Headquarters during the RSNA meeting will be located at: The Hyatt Regency Chicago located at 151 E. Wacker Drive.

AAPM Committee meetings and annual reception will be held at the Hyatt. Make plans to join your colleagues on Tuesday, December 1 from 6:00 PM – 8:00 PM for the annual AAPM Reception. Special thanks to Dade Moeller Health Group and Landauer for their financial contributions to offset the costs for this event.

Visit AAPM at Booth 1109 in McCormick Place — South Building — Hall A to charge your mobile devices at AAPM’s booth! Pick up information on association programs, obtain the current list of AAPM publications, and receive complimentary copies of Medical Physics. In addition, be sure to check out the recent advancements in the AAPM Virtual Library.

The most up-to-date schedule for AAPM meetings during the RSNA meeting is available online. www.aapm.org | 11

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Executive Director, cont.

AAPM Medical Physics Practice Guideline On September 18th, the fifth Medical Physics Practice Guideline (MPPG) titled: AAPM Medical Physics Practice Guideline 5.a.: Commissioning and QA of Treatment Planning Dose Calculations — Megavoltage Photon and Electron Beams was published in the Journal of Applied Clinical Medical Physics (JACMP); Volume 16, Number 5 (2015).

Mark your calendar with 2016 Meeting Dates The 2016 Spring Clinical Meeting is scheduled for March 5–8 at The Grand America Hotel in Salt Lake City, Utah. Registration will open in early December.

The 2016 Summer School, Medical Physics Leadership Academy, will be held June 12-16 at the Westfields Marriott Conference Center in Chantilly, Virginia.

The 58th AAPM Annual Meeting & Exhibition will be held July 31 – August 4 in Washington, DC.

2016 Dues Renewal 2016 dues renewal notices were distributed in early October. You may pay your dues online or easily print out an invoice and mail in your payment. Twenty AAPM Chapters have elected to have HQ collect chapter dues. Make sure to check to see if your chapter is participating. If it is, we hope that you will appreciate the convenience of paying your national and chapter dues with one transaction!

Your Online Member Profile This is a reminder to keep your AAPM Membership Profile information up to date by going here and making any changes necessary. Please upload your picture if you have not already done so.

Remember to review the “Conflict of Interest” area of the Member Profile to self-report conflicts per the AAPM Conflict of Interest Policy.

The AAPM Headquarters office will be closed: Thursday, November 26 – Friday, November 27 Thursday, December 24 – Friday, December 25 and Friday, January 1 I wish you and your loved ones a happy and healthy holiday season.

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Executive Director, cont.

AAPM’s Headquarters Team I firmly believe that part of the success of AAPM HQ operations is our ability to attract and retain an excellent team of high performing association management professionals. The years of service documented below is very telling; the AAPM HQ team is very committed to serving the AAPM membership. The following AAPM team members have celebrated an AAPM anniversary in the last half of 2015. I want to publicly thank them and acknowledge their efforts.

Lisa Rose Sullivan.......22 years of service Michael Woodward....19 years of service Farhana Khan..............17 years of service Yan-Hong Xing...........9 years of service Tammy Conquest........8 years of service

Corbi Foster............... 8 years of service Jackie Ogburn............ 8 years of service Janet Harris................ 3 years of service Abby Pardes............... 2 years of service

THE AMERICAN ASSOCIATION OF PHYSICISTS IN MEDICINE

cordially invites you to attend the

AAPM Tuesday Evening Reception at RSNA during the 2015 AAPM / RSNA Meeting Tuesday, December 1, 2015 • 6:00 pm – 8:00 pm Crystal Ballroom BC, Hyatt Regency Chicago • Chicago, Illinois

light hors d’oeuvres AAPM gratefully acknowledges the following sponsors for their contribution to this reception:

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PLANNING TO ATTEND

RSNA 2015?

Be Sure to Book Your Room at the AAPM Headquarters Hotel:

The Hyatt Regency Chicago 151 E. Wacker Drive AAPM Meetings and Annual Reception will be held at the Hyatt Regency Chicago RSNA 101st Scientific Assembly and Annual Meeting November 29 – December 4, 2015 Chicago, IL

AMERICAN ASSOCIATION OF PHYSICISTS IN MEDICINE | WWW.AAPM.ORG

AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

SCIENCE COUNCIL REPORT Jeffrey H. Siewerdsen, Baltimore, MD

“October is the fallen leaf, but it is also a wider horizon more clearly seen.” —Hal Borland, American author, 1900 – 1978

A

t the President’s Symposium in Anaheim, Dr. John Boone presented his vision to reinvigorate scientific excellence in the medical physics enterprise. He reminded us not only of the things that drew us to physics in the first place – a driving curiosity to understand physical principles and apply our knowledge to the betterment of mankind – but also of how scientific excellence should manifest in every aspect of our work. “We are all scientists,” he said, and our role as scientists in medicine is not limited to research; it should be evident in every aspect of our daily work – in our capacity for critical analysis to identify problems, in the rigorous methodology by which we identify solutions, in our technical ability to create, measure, and innovate, and in our restlessness to bring positive change.

Among the panel of invited speakers were Rod Pettigrew (Director of the NIBIB), Ed Jackson (Professor Medical Physics at the University of Wisconsin), and Cedric Yu (Professor of Radiation Oncology at the University of Maryland). Each echoed the importance of scientific excellence in medical physics research and clinical practice. No one in the audience could deny the sheer wonder of seeing a small packet of optical photons reflecting from the surface of mirror — an example of work by Dr. Liang Gao (University of Illinois at Urbana-Champaign) shown by Dr. Pettigrew. The same principles enabling the ~billions of frames per second temporal resolution required to image a packet of photons in flight is, in fact, being applied in medical physics – e.g., in compressive sensing techniques at the heart of 3D image reconstruction techniques under development by Dr. Guang-Hong Chen and colleagues at the University of Wisconsin.

Ed Jackson showed how medical physicists can and should play a vital role in quantitative imaging methods that will be integral to major challenges in big data and personalized medicine. Ideally positioned with respect to the imaging technologies and patient data, he showed how medical physicists will be essential to the standardization of image acquisition methods that are so important in quantitative imaging, to the curation of large image datasets, and to data-intensive analysis of large image datasets, where our expertise in math, computing, and image science make us well suited to innovation and discovery.

Finally, Cedric Yu recounted the development of the GammaPod system for stereotactic breast radiotherapy, leveraging a keen recognition of clinical challenges in SBRT and drawing inspiration from established technologies such as the Gamma Knife. His presentation demonstrated how medical physicists are ideally positioned to recognize shortfalls in the state of the art, devise innovative solutions, and translate their ideas from concept to first clinical studies.

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Science Council, cont.

These are but the latest examples of medical physicists demonstrating their enormous potential for innovation and scientific excellence, and our field grew to a position of critical importance in healthcare on the merits of such work over the last 50 years. The examples are numerous: tomotherapy, 3D treatment planning, conebeam CT, digital subtraction angiography, deformable image registration, flat-panel detectors, MR-guided radiotherapy, and so on. It is that track record of scientific excellence in medical physics that has helped to shape modern medicine and the role of physicists therein, tracing (in the modern era, at least) to roots that include medical physicists working on things like the Coolidge tube and Cobalt machine.

Photo used with permission of AAPM. Convention Photo by Joe Orlando, Inc.

The AAPM 2015 President’s Symposium in Anaheim CA. (Left) Dr. Boone (President, AAPM) described his vision for reinvigorating scientific excellence in the medical physics enterprise – including scientific research and the application of our scientific training in the daily practice of medical physics. (Right) Invited speakers (left to right) Ed Jackson (Professor, University of Wisconsin), Roderic Pettigrew (Director, NIBIB), Bruce Minsky (President, ASTRO), and Cedric Yu (Professor, University of Maryland) expounded on that vision on topics ranging from molecular imaging to novel strategies for treatment of breast cancer.

Recalling the examples presented in Dr. Boone’s symposium, and never knowing from where the next innovation will come, I will take this opportunity to provide an update on an exciting new program – the AAPM Expanding Horizons Travel Grant. This grant program is intended to stimulate new expertise, excite early-career medical physicists for innovation and cutting-edge research, and bridge our discipline with fields outside the conventional sphere of medical physics. The program is designed to provide early-career medical physicists with “…an opportunity to broaden the scope of scientific meetings attended in order to

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

Science Council, cont.

introduce students and trainees to new topics which may be of relevance to medical physics research and which may subsequently be incorporated into future research in order to progress the field in new directions.”

The travel grants were announced this year, and we received nearly 40 applications which were reviewed by a panel formed under the AAPM Research Committee and the Working Group on Student and Trainee Research. I am happy to report that the program yielded 20 awards for students to attend approximately 15 conferences outside the usual sphere of medical physics. Examples include conferences such as: The Society for Neuroscience, the American Control Conference, the Radiomics Meeting, the Data Mining conference, the World Molecular Imaging Society, the 3D Printing Conference, the GPU Technology Conference, and more. Each awardee is expected to present his / her experience at the 2016 Annual Meeting of the AAPM in Washington DC, where the Scientific Program Subcommittee is arranging a format providing an open exchange to share feedback, bring home the knowledge gained from these exciting topics on the horizon of our discipline, and discuss how these methods could be incorporated in the science and daily practice of medical physics.

How will the knowledge gained from such experiences affect our field? No one knows – just as no one knew how advances in photocopiers could bring x-ray imaging into the digital age. It does not require much extrapolation, however, to imagine how such experiences will help advance the vision of reinvigorating scientific excellence in our field. For example, topics covered in these conferences could directly shape medical physics research in areas such as: daily treatment planning, where control theory could be applied to optimize strategies for adaptive radiotherapy; the use of molecular imaging in understanding the complexities of radiotherapy treatment response; the development and broader dissemination of methods for highspeed parallel computing in tools for image registration or 3D image reconstruction; and the application of “big data” principles to assist in the diagnosis and treatment of patients in the emerging area of precision medicine. The possibilities are endless, and they suggest bright horizons in many directions.

Imagine also the accumulated knowledge for early-career medical physicists gained by this program, where in the 5 years ahead, AAPM will have helped to inculcate ~100 medical physicists with an awareness of problems, methods, and potentially disruptive technologies beyond the conventional sphere of medical physics. This program is one answer to Dr. Boone’s challenge and will help to promote a generation of physicists ready to tackle major challenges in 21st century medicine, incorporate multi-disciplinary and interdisciplinary knowledge, elevate the recognition and expertise of physicists among our peers, and reinvigorate science not only in the medical physics research enterprise but also in our approach to daily practice. n

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ONLINE ABSTRACT SUBMISSION OPEN NOW THROUGH NOVEMBER 23, 2015 www.aapm.org/meetings/2016SCM/

2016

Medical Physics Leadership Academy June 12 –16, 2016 | Chantilly, VA www.aapm.org/meetings/2016SS/

MEDICAL PHYSICS is at a crossroad. With the new objectives of value-based operation, personalized care, and evidence-based medicine, medical physicists need to re(vision) their contribution to quality healthcare. In any progression of this nature, it is crucial to understand the goals and set a standard that can define the trajectory and motivate the advancement. The Medical Physics Leadership Academy is an effort to offer an inspirational educational opportunity towards this objective. The goal is to define leadership models and motivate excellence in the medical physics discipline and practice in five areas of

Medical Physics advancement: clinical, scientific, educational, administrative, and professional. The goal of this summer school is to provide a focused, immersive environment to initiate the leadership institute. The cohesive opportunity is specifically designed with the needs and challenges of medical physicists in mind and encompasses both the therapy and imaging components of the discipline. This summer school further attempts to bring to the membership a “mini” version of a Master’s of Business Administration program interwoven into the framework of medical physics.

AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

EDUCATION COUNCIL REPORT George Starkschall, Houston, TX

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ecently I attended a meeting in which I was asked to provide a brief presentation on the major achievements of AAPM in education in 2015. Having done the work in preparing for my presentation, I thought I would share with you my observations. My presentation was based on the idea of enumerating educational needs in the medical physics community, then identifying the ways in which AAPM has tried to meet these needs. I was limited to a single PowerPoint slide and a five-minute presentation, so my list was not complete, but limited to the major achievements.

The first of these needs was to ensure equitable placement of graduates of medical physics programs into clinical residency positions. As you well are aware, we have had a large number of applicants (almost 300) competing for just over 100 residency positions, with many programs offering only one position a year. This competition in the past led to many problems, especially with residency programs that interviewed residency candidates early and made offers, often requiring a response before a candidate had had an opportunity to visit other residency programs. This was certainly unfair to the residency candidate, and very likely, not the optimal choice of candidate for the residency program. Our solution to this problem was to establish a residency match program similar to the match program that physicians have used for many years to place residents into residency programs. To encourage programs and candidates to participate in the Medical Physics Match Program, AAPM, with the support of SDAMPP, ensured funding to fully subsidize the match program for its initial two years, and partially subsidize the program for an additional two years.

Along with the requirement that medical physicists who take the ABR Certification Examination must have completed a clinical residency program is the need to provide an adequate number of clinical residency positions to meet the needs of the job market. Almost 10 years ago, representatives from AAPM along with several other organizations met several times in Chicago to develop strategies for meeting the need for residency programs. Our estimates for the number of required residency positions have been based on our perception of the job market, but we recognize that large error bars surround our estimated numbers. Given those estimates, we are very close to meeting our needs for radiation oncology physics residency positions and almost reaching our goal for imaging physics residency positions. In order to get us over the top, we have undertaken two initiatives: We are partnering with other societies, in particular, RSNA and SNMMI, to provide seed funding for new clinical residency programs. The seed funding covers half the cost of support for a resident (salary plus fringe benefits), with the host institution paying the other half. The host institution must also commit to full funding of the residency program after the seed funding expires as well as to apply for CAMPEP accreditation. Eight institutions have received awards to initiate imaging physics residency program; this year is the first year that our partnership with SNMMI will partially fund nuclear medicine physics residency programs.

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Education Council, cont.

We also recognized that much of the clinical work in medical physics is done by private practice consultants, especially in imaging physics. Whereas these consultants have the expertise, the breadth of experiences, and the desire to provide mentorship to medical physics residents, they often find the administrative overhead, which includes developing a Self-Study for CAMPEP accreditation, as well as keeping detailed records of residents, presents a serious barrier to initiating and maintaining a successful residency program. Because it is easier for an existing residency program, which has already developed the support infrastructure, to add a clinical site in a hub-and-spoke arrangement, we have developed a webinar to assist potential program directors from small practices with the application process for CAMPEP accreditation through the hub-andspoke mechanism.

Next, we found that many more students were graduating from accredited graduate programs than there were residency positions open for them to obtain their clinical education. This meant that a significant number of individuals would be completing medical physics graduate programs without the ability to move into clinical employment. Because medical physics students are the cohort that is most directly affected by this mismatch, we tasked the Students and Trainees Subcommittee with compiling and disseminating information regarding non-clinical careers in medical physics. As you may have read in the previous issue of the AAPM Newsletter, they have made much progress in this regard. I am also pleased to report that one company is developing an industrial internship for students to spend some time in industry. This internship is a beneficial opportunity both for students, who have the opportunity to learn about what goes on in industry, as well as for the host company, which obtains the opportunity to identify talented students early on. We are hoping the idea of an industrial internship will be adopted by many companies.

A final educational need for the medical physics community is the need to provide adequate continuing education opportunities for practitioners. For ABR Maintenance of Certification, for renewal of state medical physics licenses, and for good medical physics practice, continuing education is essential, and busy medical physicists cannot always come to our annual meetings. In the past few years, we have made many strides to capture and post on the AAPM website continuing education sessions at our meetings, including the Annual Meeting, the Spring Clinical Meeting, and our specialty meetings. Access to the AAPM Virtual Library is provided to AAPM members at no charge as a privilege of membership; access to Virtual Library examinations, from which one can obtain documented credit for participation in online continuing education activities, is provided at a nominal cost.

What do we do for an encore? After six years as Chair of Education Council, my term is ending at the end of the calendar year 2015, but Education Council will be in good hands with Jim Dobbins, who is taking over Education Council in January. I still have one more opportunity to make my voice known through the Newsletter article, and that will be in the next Newsletter, in which I will try to identify some of the issues that I believe Education Council will need to address in the coming years. n

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

PROFESSIONAL COUNCIL REPORT James Goodwin, Burlington, VT

Professional Council Changes

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nfortunately, this month’s Professional Council article is bittersweet to write. Doug Pfeiffer who has served as Council Chair since January 2015 is stepping down as PC Chair for personal reasons. While I understand Doug’s reasons I am saddened for both the Council and the Association as a whole that we will lose his advice and counsel.

His leadership and dedication to Professional Council and AAPM has been exemplary and I welcome his return to active Professional Council activities in the future. I look forward to serving as Professional Council Chair for the next months while AAPM leadership decides on a long term replacement for this critical position of the organization. Please don’t hesitate to contact Lynne Fairobent, AAPM Staff Liaison or myself regarding professional issues. n

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AMERICAN ASSOCIATION of PHYSICISTS IN MEDICINE Interested in applying your physics or engineering knowledge in medicine?

Want to make a clinical impact this summer?

Then the SUMMER UNDERGRADUATE FELLOWSHIP PROGRAM is for you!

We provide opportunities for excellent undergraduates to gain experience in medical physics at leading clinical and research institutions. A large menu of mentordefined projects is available and Fellows select their mentor according to their mutual interests.

Fellowships are offered for 10 weeks during the summer (May through September) and available to students not in their final year.

For more details, visit: www.aapm.org/education/GrantsFellowships.asp

Sponsored by the AAPM Educational Council through the AAPM Education and Research Fund

AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

JOURNALS BUSINESS MANAGEMENT COMMITTEE REPORT Samuel Armato, III, Chicago, IL

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cientific publishing is a major endeavor of AAPM. Although publishing requires substantial resources, it has the potential to generate both reputation and revenue to further the missions of our society. AAPM owns and publishes two journals: Medical Physics and the Journal of Applied Clinical Medical Physics (JACMP), which synergistically span the breadth of our membership’s professional endeavors. Medical Physics publishes research concerned with the application of physics and mathematics to the solution of problems in medicine and human biology, with an emphasis on theoretical and experimental approaches. JACMP is an applied journal that publishes papers designed to help clinical medical physicists and other health professionals perform their responsibilities more effectively and efficiently for the increased benefit of the patient. The two journals reflect two different missions, engage two different publication approaches, and operate under two different financial models. Nevertheless, the two journals, each with its own identity, are complementary in their mission and scope; in effect, the “new science” of today fostered by Medical Physics becomes the “practical clinical science” of tomorrow disseminated by JACMP. The purpose of this article is to explain the complex interplay of economic factors that impact financial decisions governing the journals and the returns they bring to AAPM. 1. Who has financial responsibility for AAPM’s two journals, Medical Physics and JACMP?

The unified Journals Business Management Committee (JBMC) was created this year as a merger between two previous committees that were responsible for each journal separately. The JBMC is tasked with overseeing the financial aspects of AAPM’s two journals to strategically evolve their financial stability while ensuring the highest level of quality for both journals. The voting members of the JBMC include the Chair, the AAPM Treasurer, three at-large members, the Editor-in-Chief of Medical Physics, and the Editor-in-Chief of JACMP. The Chair of the JBMC is an ex officio member of the editorial boards of both journals. The JBMC reports to the Administrative Council.

2. How much does it cost to publish the journals?

The scientific literature represents a compact between the scientific community and society. Articles that become part of “the literature” are held in high regard by the public, with imposed expectations of a robust scientific peer review process; a product that is consistent in format, well organized, free from errors, and visually appealing; accessibility through known and accepted portals (electronic or otherwise) with standard indices that allow for efficient retrieval of specified content; and long-term persistence through reliable archival approaches. This complex set of requirements has associated costs that are significant.

The 2016 budget for Medical Physics reflects expenses that total $1.6 million. These expenses include diverse items such as printing and paper, shipping, commissions on advertising sales, copyediting and production, compliance with the open-access policies of the NIH and other funding sources, editor and editorial office expenses, and AAPM staff support charges. It is important to note that a substantial fraction of these expenses are incurred for the express purpose of generating revenue. The revenue side of the 2016 Medical Physics budget is estimated to be $2.5 million. Sources of revenue include advertising (e.g., printed ads, online banner ads, PDF cover pages), non-member subscriptions (e.g., libraries, consortia), excess page charges, printed color figure fees, reprint fees, and author-select open access article processing charges. Note that an allocation from member dues is not considered a source of

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Journals Business Management Committee, cont.

revenue in the Medical Physics budget. The net revenue from Medical Physics in 2016 is projected at $884,000, all of which remains with AAPM to fund its broad range of activities that benefit members and the field of medical physics.

JACMP is an online-only, gold open-access, bi-monthly journal that follows a very different publication model.

The 2016 budget for JACMP reflects expenses that total $199,000. These expenses include article layout and proofreading, copyediting, metadata markup, the manuscript platform, article hosting, and editor and editorial office expenses. The revenue side of the 2016 JACMP budget is estimated to be $133,000, with two sources of revenue: online banner ads ($25,000) and the newly instituted $500-per-article processing charge ($108,000). The net deficit for JACMP in 2016 (with the article processing charge in place) is projected at just over $66,000.

3. How much of my membership dues pays for Medical Physics?

In a word, none; although a more detailed explanation is warranted. The financial viability of AAPM is sustained by three main funding sources: member dues, Medical Physics, and the Annual Meeting; revenue derived from these three main sources is used to fund all the activities that AAPM undertakes in fulfilling its mission to advance our field.

AAPM members receive Medical Physics as a benefit of membership. To the extent that a member would be in a position to legally claim an income tax deduction for their AAPM dues, the IRS requires an accounting of the value of any tangible item (e.g., a journal subscription) received as a result of the dues payment. To satisfy this requirement, the monetary value of a member’s subscription to Medical Physics was set at $65, a figure that appears on your dues receipt and in other AAPM documentation. For the sake of consistency, the Medical Physics budget has included a revenue line item of $65 per member (for appropriate membership categories) for many years. This accounting practice, which added $504,000 derived from member dues to the revenue side of the 2015 Medical Physics budget, has ceased beginning with the 2016 budget. All net revenue from Medical Physics belongs to AAPM, so the impact on AAPM and its members is exactly the same whether this $504,000 is used to further increase the net revenue of Medical Physics for 2015 or remains accounted for as revenue from 2015 dues. Medical Physics is budgeted to net $884,000 in 2016 without member dues considerations, so dues clearly are not needed to subsidize Medical Physics.

In fact, Medical Physics has returned net revenue to AAPM, without dues considerations, every year since 1997.

4. Who pays to publish JACMP?

JACMP has made important contributions toward advancement of the gold open-access publishing paradigm.

Consistent with the gold open-access movement, JACMP is freely available to all readers. An open-access journal, however, is not inherently less expensive to publish than a subscription-based journal; under the usual openaccess paradigm, publication costs are shifted from the readers/subscribers to the authors, who benefit from more widespread access to their work. Most (if not all) reputable open-access journals require authors to pay an article processing charge, which typically runs between $1,500-$3,000. While the JACMP has allowed authors to publish without fees since its inception 16 years ago, JACMP publication costs have been funded solely by AAPM since it acquired the journal in 2012. Recent growth of the JACMP has increased the financial burden of publication.

Advertising revenue currently covers a relatively small fraction of JACMP publication costs. The JBMC is exploring a variety of strategies to expand advertising opportunities in JACMP. Consistent with the open-access paradigm, authors are now assessed an article processing charge of $500 for an article published in JACMP; a waiver policy for authors from developing countries is being developed. Advertising and article processing charges are expected to offset roughly two-thirds of JACMP publication costs, with the AAPM funding the remainder. The goal under which the JBMC currently operates is to put JACMP on a trajectory of financial self-sufficiency, to ensure the long-term sustainability of this resource to the community.

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Journals Business Management Committee, cont.

5. JACMP is published online only, which avoids all the costs associated with printing; when will Medical Physics follow this cost-saving model?

Medical Physics was first published on paper long before online publishing was viable, and it is currently published in both paper and online formats. It is reasonable to question the rationale behind continued production of paper copies given the significant additional expense of paper, printing, and delivery. The paper version of Medical Physics actually continues to attract enough revenue from subscriptions and advertising to significantly exceed those additional print-related expenses, so the print version has remained independently profitable. For the past two years, however, the print version of Medical Physics has experienced a slight decline in revenue. The JBMC constantly monitors the profitability of print and seeks to understand any possible negative economic impact of a transition to an online-only publication; the JBMC is prepared to make such a transition when (and if) a transition would be of net economic benefit to AAPM. It should be noted that five categories of Medical Physics content are already published only online (e.g., review articles and task group reports).

6. How might the journals operate in a process environment that is cost effective, mutually supportive, and synergistic?

AAPM recently has devoted substantial effort toward defining, integrating, and reaffirming its interests in scientific publishing. AAPM President John Hazle created the Ad Hoc Committee on Journal Publications, which deliberated between 2013 and 2014. The charge of this committee was to address the scope of the journals; to review business management approaches to maintain quality of content, to maintain a healthy financial position, and to ensure availability to medical physicists throughout the world; and to maintain a process of editorial review that balances speed of publication and quality of review. The final report contains valuable recommendations that are still being evaluated for practical implementation, but two key foundation-laying initiatives already have been enacted. The first initiative was the creation of a single Journals Business Management Committee in January 2015 so that both journals, despite having different financial models, could benefit from a common group of individuals setting policy and providing economic oversight. The second initiative was the recent release of a request for proposals (RFP) to seek a common platform of publishing and manuscript review services for both journals. A common platform will provide a uniform experience for authors and readers of both journals, facilitate efficient exchange of manuscripts between the journals when appropriate, strengthen the AAPM branding of the two journals, and yield an economic benefit to the AAPM. This RFP is under active solicitation.

7. What does the future hold for AAPM’s journals?

Publishing will continue to play an important role in the AAPM mission to advance the science, education, and professional practice of medical physics. AAPM, therefore, is committed to ensuring that its two scientific journals thrive and flourish. The JBMC is the steward of the journals’ collective financial welfare, while the editors along with the editorial boards cultivate the scientific quality and integrity of their respective journals. Together, these efforts have nurtured two highly respected journals that make important complementary contributions to our field.

The scientific publishing enterprise, however, is undergoing significant transformation, presenting challenges that the JBMC monitors constantly; AAPM publishing strategies must anticipate, assess, and respond in a manner that balances sometimes-competing interests. Examples of such strategies include the designation of more Medical Physics content as open access (including the hybrid gold open-access option that allows authors, for a fee, to select open-access status for their article), the integration of a single JBMC for the two journals, seeking to implement a common publication platform, and enhanced online features for both journals. The ultimate goal has always been the advancement of the journals’ status in the literature combined with fulfillment of AAPM’s mission. n

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

LEGISLATIVE & REGULATORY AFFAIRS REPORT Lynne Fairobent, College Park, MD

ACMUI Meets: Commission Recognizes Chairman Bruce Thomadsen’s Years of Service The Nuclear Regulatory Commission’s (NRC) Advisory Committee on the Medical Uses of Isotopes (ACMUI) met October 8-9. This meeting marked Bruce Thomadsen’s last face-to-face meeting as chair of the ACMUI. Commission Chairman Burns presented Dr. Thomadsen with several mementos and expressed the Commission’s gratitude for his years of service to the ACMUI.

T&E Requirements for Alpha and Beta Emitters A number of subcommittees presented their reports and recommendations to the Committee. The ACMUI considered training and experience (T&E) requirements for authorized users (AUs) of alpha and beta emitters, recommending that the Subcommittee explore the feasibility of reducing the current requirement of 700 hours.

The ACMUI discussed the marked decrease in Zevalin use, concluding that the infrequent and steadily decreasing use of radiopharmaceuticals for the treatment of lymphoma is complex and the consequence of many factors. The Subcommittee’s report stated it could not determine whether the declining use of these radiopharmaceuticals could be attributed to a shortage of AUs caused by the current T&E requirements.

Radioactive Seed Localization In addition, the ACMUI addressed a number of issues relating to radioactive seed localization (RSL) procedures. RSL for non-palpable breast tumors began in the early 2000s, and use has increased. In RSL procedures, which typically employ I-125 low activity sources, the dose to surrounding tissue is very low if the seeds are removed in a timely manner, but can be significant if the seeds are permanently left in place.

The ACMUI considered the AU requirement for source placement of the radioactive seeds, recommending that source placement be allowed under the “supervision of an AU.” This recommendation would remove the requirement that the physician placing the source must be an AU. The ACMUI recommended that the Written Directive requirement be maintained, but did not address issues that may arise if the physician placing the source is not an AU. The ACMUI also recommended that a licensee report any event resulting in unintended permanent functional damage to an organ or a physiological system. The indications for a “Medical Event” with the low activity sources remains based upon therapy requirements, assuming a lost or non-retrieved source will become “therapy activity” delivered over time.

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Legislative & Regulatory Affairs, cont.

Moreover, the ACMUI addressed a number of related patient-safety issues. The Committee’s recommendations include requiring that the activity of sealed sources be determined prior to each RSL procedure either through direct measurement or based on manufacturer’s indicated activity, and requiring that that seed removal be verified by a radiation survey.

Germanium/Gallium-68 Medical Use Generators At the Spring ACMUI meeting, the Committee expressed concerns that under current regulations, the facilities using germanium/gallium-68 generators are required to provide a decommissioning plan, which creates a barrier for patient access to this isotope. The NRC staff provided an update on their efforts to address the decommissioning funding issues related to these medical use generators. The NRC staff announced that the agency will implement a case-by-case exemption for the generator decommissioning plan requirement. They will require that the facility show it can handle the generators safely and that the manufacturer will take back the generator when depleted.

The NRC recognized that rulemaking would be the best long-term solution, but stated that the exemption would facilitate patient access to this isotope in the near term.

Please contact Richard Martin or Lynne Fairobent, if you have any questions regarding the ACMUI meeting.

OIG Audit of Medical Uses Summary In an audit of NRC’s oversight of medical uses of radioisotopes released October 8, 2015 (OIG-16-A-02), the Office of the Inspector General (OIG) found NRC provides adequate oversight of the medical uses of radioactive isotopes to protect public health and safety. The OIG, however, was critical of NRC’s medical event policy and its relationship with ACMUI. The OIG concluded that medical event reporting requirements are inconsistently understood by licensees and NRC staff, and NRC provides insufficient medical event data to medical licensees. Moreover, the OIG stated that NRC is not effectively achieving all the possible benefits of medical event reporting. According to the OIG, licensees either underreported or reported, and later retracted, medical events. The OIG specifically cites confusion surrounding the medical event interim enforcement policy for permanent implant brachytherapy as well as the proposed revisions to Part 35.

The OIG noted that the purpose of reporting medical events is not listed anywhere in NRC regulations or licensee guidance. The OIG concludes that if the purpose of medical event reporting is to collect data to prevent future events, the information collected could be used in a more effective way that enhances its benefit as a learning tool. It recommends that NRC clearly define the purpose of reporting, clarify reporting requirements, and provide all medical licensees with medical event tracking/trending information.

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Legislative & Regulatory Affairs, cont.

The OIG is highly critical of NRC’s failure to conduct periodic self-assessment of its medical events reporting requirements.

The OIG believes self-assessments should identify weaknesses and show whether reporting practices are consistent among licensees. Acknowledging that some stakeholders perceive NRC’s current approach as punitive and a deterrent to self-reporting, the OIG urges NRC to solidify its position-articulated in internal documents- that medical event reporting is about public safety and not about punishing licensees for their mistakes.

Accordingly, the OIG recommends that NRC establish a periodic self-assessment program, including evaluation of whether the intended purpose is being met and whether the thresholds of the reporting requirements are appropriate.

Want to improve patient safety with less time spent on QA?

NRC does not routinely provide sufficiently detailed feedback to ACMUI. Efficiency Without Compromise – A New Day The OIG recommends that the NRC For Patient Safety develop policies and procedures that It is now possible to reduce your QA workload while improving patient safety. PerFRACTION 3D is articulate the expectations for providing automated radiation measurement QA for both pretreatment verification and per-fraction in-vivo monitoring. Delivery results are automatically captured, analyzed, and saved for you. QA failures, feedback to ACMUI. Currently, the including patient setup and anatomy errors, are automatically emailed to you. PerFRACTION identifies the likely source of error automatically and quantifies the impact to clinical goals.

OIG states, NRC provides ACMUI PerFRACTION - Visit sunnuclear.com/PerFRACTION to learn more. with only marginal feedback on its proposed recommendations by means of a spreadsheet designed primarily as a tracking tool that is provided to each © 2015 Sun Nuclear Corporation. All rights reserved. member during the semi-annual meetings.

The OIG explains that ACMUI members, who are not experts in regulatory matters, are at a disadvantage when trying to understand the NRC’s regulatory approach to reviewing recommendations and the subsequent decision making process. n

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

WEBSITE EDITOR’S REPORT George C. Kagadis, Rion, Greece

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he majority of us are getting prepared for the 101st RSNA Annual Meeting which is going to take place in Chicago, Illinois (November 29 – December 4).

I would like to bring to your attention that we now have a Social Media Policy for AAPM Groups that was approved August 7, 2015.

Furthermore, with regard to the appropriateness of the content you wish to post in any of our web presences, we have concluded to the following guidelines: a. You are personally responsible for whatever you post online.

If you use your capacity as an AAPM member of any type (i.e.

Full Member, Student Member, Fellow Member, etc.), ensure that what you say about yourself looks professional. b. Do not post advertisements, promotions, or solicitations for products and/or services without written permission from the AAPM Website Editor. c. Only post accurate and reputable information. If you are in doubt about the reliability of the information’s source, consider not using it and/or ask for advice from the AAPM Website Editor. d. AAPM followers of our social media presence expect the most up-to-date and reliable information. Please post information with “as of” date only in your area of expertise and please review the already available posts to avoid redundancy and/or errors. e. Always avoid posting provocative statements and/or giving irritable, angry responses to posted material.

Please point out any observed errors, but never disparage the person. f.

Do not release members-only content (journal articles, videos, member newsletters, etc.) to a wider audience.

g. Be respectful of the privacy of others. Avoid publishing or citing personal details and photographs of individuals without their permission. h. Comments are a foundational aspect of conversations in social media. Don’t delete comments just because you disagree with the commenter’s opinion. Please, monitor your social media account/subaccount and delete only comments that are obviously spam, abusive, obscene or contain links to irrelevant or inappropriate blogs or websites.

Please, do not hesitate to contact us should you need any further clarification about the policy and guidelines for posting any material on the various AAPM social media sites.

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Website Editor, cont.

The AAPM Virtual Library now has 1,527 videos available (as of October 10, 2015) to the membership (Figures 1 and 2).

Figure 1: Vimeo Total Loads and Total Plays Statistics October 10, 2014 – October 10, 2015.

(Total Loads: 295,876 with a peak in July 2015 of 15,856. Total Plays: 64,397 with a peak in November 2014 of 1,979.)

Figure 2: Vimeo Geographic Statistics.

I am pleased to report that as of October 10, 2015 we have 39,707 images posted to AAPM’s Flickr, 3,622 likes on Facebook, 8,502 members on LinkedIn, and 4,311 followers on Twitter.

The Website Editorial Board will meet during RSNA 2015 on Monday, November 30 from 12–2 pm in the Picasso Room (Bronze Level / West) of the Headquarters Hotel (Hyatt Regency Chicago). There is always space for members interested in knowing what we do firsthand as well as those who possibly want to join.

Please stop by!

I am looking forward to seeing as many of you as possible next month in Chicago! I hope you find the AAPM website useful, visit it often and send your feedback to me at george@aapm.org. n

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

ABR NEWS Jerry D. Allison, Geoffrey S. Ibbott and J. Anthony Seibert ABR Medical Physics Trustees

Improvements to the ABR Medical Physics MOC Program

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he ABR has required Maintenance of Certification (MOC) for sustaining diplomate status since 2002. MOC is part of a major shift in emphasis, in which quality and safety are recognized as key components in the practice of medical physics, not only by the profession but also by the public, legislators, and regulators. The MOC program encourages development of six competencies in medical physics: • Medical knowledge • Patient care and procedural skills • Interpersonal and communication skills • Professionalism • Practice-based learning and improvement • Systems-based practice Maintenance of these competencies is measured by the ABR MOC program, which has four key elements: • Part 1: Professional Standing • Part 2: Lifelong Learning and Self-Assessment • Part 3: Cognitive Expertise • Part 4: Practice Quality Improvement (PQI)

Since the original development of the MOC program for medical physicists in 2007, the ABR has strived to make improvements in the process. Recently, an additional group of improvements was announced.

2015 MOC Improvements Part 4: Practice Quality Improvement (PQI) The biggest change regards the recognition of the many ways in which diplomates participate in quality and safety activities. These “Participatory Quality Improvement Activities” provide a new avenue for physicists to meet their Part 4 PQI requirement. A table of participatory quality improvement activities and acceptable documentation (in case of an audit) is below. Please note that some activities may not apply to all disciplines.

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ABR News, cont.

Participatory Quality Improvement Activities

Acceptable Documentation of Active Individual Participation (retain for use if audited)

One of the following bulleted options: Participation as a member of an institutional/ • Institution/department documentation of attendance departmental clinical quality and/or safety review at committee meetings (such as minutes, if committee available),OR Examples include meaningful participation as a member responsible for creating, reviewing, and/or implementing • Submission of completed and signed MOC Part clinical quality improvement safety activities; service as 4 Participatory Quality Improvement Activity: radiation safety officer (RSO).

Participation Confirmation Form One of the following bulleted options:

Active participation in a departmental or institutional peer-review process, including participation in data entry/evaluation and peer-review meeting process or Ongoing Professional Practice Evaluation (OPPE)

• Minutes, with peer-protected information redacted, showing attendance at peer-review meetings, or other forms of participant feedback, OR • Logs showing active participation in submitting and reviewing cases as well as having your own individual work reviewed in the course of daily workflow, OR • Submission of completed and signed MOC Part 4 Participatory Quality Improvement Activity:

Participation Confirmation Form One of the following bulleted options: • Minutes or other institutional/ departmental documentation showing attendance at RCA Participation as a member of a root cause analysis team meetings, OR evaluating a sentinel or other quality- or safety-related event • Submission of completed and signed MOC Part 4 Participatory Quality Improvement Activity:

Participation Confirmation Form One of the following bulleted options: Participation in at least 25 prospective chart rounds every year (peer review of the radiation delivery plans for new cases — radiation oncology and medical physics only)

• Conference attendance sheets, OR • CME credit logs (if appropriate), OR • Submission of completed and signed MOC Part 4 Participatory Quality Improvement Activity:

Participation Confirmation Form One of the following bulleted options: Active participation in submitting data to a national registry Publication of a peer-reviewed journal article related to quality improvement or improved safety of the diplomate’s practice content area

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• Log of cases/data submitted to organization, OR • Letter from registry stating participation (including dates of participation) • Copy of journal article

AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

ABR News, cont.

Participatory Quality Improvement Activities

Acceptable Documentation of Active Individual Participation (retain for use if audited)

Invited presentation or exhibition of a peer-reviewed poster at a national meeting related to quality improvement or improved safety of the diplomate’s practice content area

• Copy of the meeting program showing that the poster was presented/exhibited and listing the diplomate as an author One of the following bulleted options:

Regular participation (at least 10/year) in departmental or group conferences focused on patient safety

• Conference attendance sheets, OR

Examples include regular attendance at tumor boards, M&M conferences, interprofessional conferences, surgical/pathology correlation conferences, etc.

• Submission of completed and signed MOC Part 4 Participatory Quality Improvement Activity:

Creation or active management of, or participation in, one of the elements of a quality or safety program Examples include a department dashboard or scorecard, a daily management system to ensure quality and safety, or a daily readiness assessment using a huddle system.

Local or national leadership role in a national/ international quality improvement program, such as Image Gently, Image Wisely, Choosing Wisely, or other similar campaign Local participation roles include implementation and/or maintenance of, or adherence to, program goals and/ or requirements.

• CME credit logs (if appropriate), OR

Participation Confirmation Form One of the following bulleted options: • Other documents describing and documenting work (i.e., copies of scorecards created, minutes from daily readiness huddles, etc.), OR • Submission of completed and signed MOC Part 4 Participatory Quality Improvement Activity:

Participation Confirmation Form • Submission of completed and signed MOC Part 4 Participatory Quality Improvement Activity:

Participation Confirmation Form

Completion of a Peer Survey (quality or patient safetyfocused) and resulting action plan. Survey should contain at least five quality or patient safety-related questions and have a minimum of five survey responses.

• Summary of process, including a copy of the survey administered, results, and action plans taken

Completion of a Patient Experience-of-Care (PEC) survey with individual patient feedback. Survey should contain at least five quality/patient safety-related questions and have a minimum of 30 survey responses.

• Summary of process, including a copy of the survey administered, results, and action plans taken

Active participation in applying for or maintaining accreditation by specialty accreditation programs such as those offered by ACR, ACRO, or ASTRO

• Submission of completed and signed MOC Part 4 Participatory Quality Improvement Activity:

Annual participation in the required Mammography Quality Standards Act (MQSA) medical audit or ACR Mammography Accreditation Program (MAP)

• Submission of completed and signed MOC Part 4 Participatory Quality Improvement Activity:

Participation Confirmation Form

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

ABR News, cont.

Participatory Quality Improvement Activities

Acceptable Documentation of Active Individual Participation (retain for use if audited)

Completion of a Self-directed Educational Project (SDEP) • Summary of process, including results and action plans on a quality or patient safety-related topic (medical taken physics only) One of the following bulleted options: Active participation in an NCI cooperative group clinical • Log of cases submitted, OR trial (for diagnostic radiologists, radiation oncologists, and interventional radiologists, entry of five or more • Letter from registry stating participation (including patients in a year. For medical physicists, active dates of participation), OR participation in the credentialing activities) • Other documents showing individual participation

Traditional Practice Quality Improvement Projects, including those using the Plan-Do-Study-Act (PDSA) model, are still acceptable and encouraged. We feel that physicists have many strengths in the areas of practice quality improvement that can benefit their practices. Thus, physicists may meet their Part 4 requirement either with one of the new Participatory Quality Improvement Activities or with the more traditional Practice Quality Improvement Project.

In March 2016, the first full MOC lookback will take place, requiring completion of a PQI Activity or Project in 2012, 2013, 2014, or 2015. As part of the improvements to the MOC program, a new system of attestation will be in place beginning January 4, 2016, requiring the diplomate simply to attest to having completed a Part 4: PQI Activity or Project. Documentation will be required only if audited.

MOC Parts 1, 2 and 3 Attestation is also acceptable for other key elements in the MOC process. For Part 1, diplomates who practice in one of the four licensure states (Florida, Hawaii, New York, or Texas) must have a valid medical physics license in one of those states. A current, valid license from one of those four states will also meet the Part 1 requirement for medical physicists practicing in other states. For all other situations, diplomates must verify that they have two available attesters, one a medical physicist diplomate and the other a physician diplomate of the ABR. Written attestations will be required only in the case of an audit.

For Part 2, 75 hours of CE must be completed between 2012 and 2015, with 25 of these hours being Self-Assessment CE (SA-CE). For this part, the physicist may use CMEgateway.org or the ASTRO Gateway and simply attest to completion of the requirements but retain documentation in their own files. All documentation is subject to audit. Finally, for Part 3 an exam must have been passed within the past 10 years.

Maintenance of Certification (MOC) is an integral part of the quality movement in healthcare. Patients, your medical physics and physician peers, and your colleagues all value MOC because it demonstrates your support for continuous quality improvement, professional development, and quality patient care. We hope that these changes will make the MOC process more robust and useful. n 34 | www.aapm.org

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

ACR ACCREDITATION: FAQS FOR MEDICAL PHYSICISTS Priscilla F. Butler, MS, Senior Director and Medical Physicist ACR Quality and Safety

D

oes your facility need help on applying for accreditation? In each issue of this newsletter, I’ll present frequently asked questions (FAQs) of particular importance for medical physicists. You may also check out the ACR’s accreditation website portal (click “Accreditation”) for more FAQs, accreditation applications, and QC forms.

The following questions are for the ACR Stereotactic Breast Biopsy Accreditation Program. Please feel free to contact us if you have questions about stereotactic breast biopsy accreditation.

Q. In order to obtain continuing education credit for stereotactic breast biopsy, must the coursework be specifically designed for stereotactic breast biopsy?

A. No. Many general or breast continuing education activities include topics relevant to stereotactic breast biopsy. The following are just a few examples: • Breast imaging conferences that include discussion of stereotactic breast biopsy cases • Breast tumor board meetings that include cases undergoing stereotactic breast biopsy • Quality control seminars that include topics on film printer or processor quality control or mammography phantom image evaluation.

• Quality control seminars that include discussions on repeat analyses.

• Physics courses that cover generators or digital detectors.

• Courses on radiation dose that include discussions of dose from stereotactic breast biopsy.

You are responsible for documenting your own continuing education in stereotactic breast biopsy. This can be done by documenting how much time was spent on the stereotactic breast biopsy related subject and attaching a note to the syllabus or CME certificate.

Q. I have a Hologic Multicare Platinum stereotactic breast biopsy unit. The manufacturer specifies a maximum compression force of only 12-15 lbs under power drive. Is this acceptable for the Compression test in the Radiologic Technologist’s section of the ACR 1999 Stereotactic Breast Biopsy Quality Control Manual?

A. Yes. The 1999 ACR Stereotactic Breast Biopsy Manual recommends a maximum compression force of at least 25 lbs (and between 25 to 40 lbs under power drive). Although the Hologic MultiCare Platinum’s automatic compression only reaches a maximum of 15 lbs, manual compression can provide nearly 30 lbs of compression force. Your facility should watch to see that these numbers do not change significantly over time (both during compression and over the years), and that the compression meets the manufacture’s specifications.

Q. The Stereotactic Breast Biopsy Quality Control Manual’s Automatic Exposure Control (AEC) test calls for performance testing at phantom thicknesses of 2, 4, 6 and 8 cm. The performance criteria for digital systems specifies that “the signal value should remain within ±20% of the signal obtained for the 4 cm phantom…if it does not meet this criterion, the medical physicist should develop a technique chart which meets this criterion.” I have units which do not provide enough signal to pass this test for an 8 cm phantom. Manual techniques that meet this criteria result in excessively long www.aapm.org | 35

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ACR Accreditation FAQs, cont.

exposure times. However, our radiologists have been using manual modes with lower signals on very thick breasts, and don’t find the lower signal a problem. How can these units become compliant with ACR’s requirements?

A. Although the 1999 manual recognizes that it may be difficult to maintain signal at 8 cm under AEC (and thus allows for a manual technique at 8 cm), more recent experience has shown that these techniques can be quite long, and in some cases, not permissible on the equipment. In addition, medical physicists are finding that radiologists are used to “reading through” noisier images of very thick breasts. Consequently, in order to pass this test, only 2, 4 and 6 cm must meet the ±20% criteria. However, if the 8 cm test does not meet the criterion, the medical physicist should develop a technique chart for 2, 4, 6 and 8 cm showing 2-6 cm within range and 8 cm being as close as possible using a manual technique (and clinically acceptable).

Q. Our unit has an add-on stereotactic breast biopsy device that is used with an upright digital mammography unit. The ACR 1999 Stereotactic Breast Biopsy Quality Control Manual requires that the medical physicist performs a test for Automatic Exposure Control (AEC) or Manual Exposure Performance Assessment. This is difficult to accomplish with the add-on device since the needle apparatus remains in the way. May the equivalent test that is annually performed for the digital mammography unit be used to satisfy this stereotactic breast biopsy requirement?

A. Yes, the test that is used to evaluate performance of automatic exposure control for the digital mammography unit may be used to satisfy the requirements for the stereotactic breast biopsy unit. It should be representative of stereotactic breast biopsy performance.

Q. The performance criteria of the Average Glandular Dose test in the Medical Physicist’s section of the ACR 1999 Stereotactic Breast Biopsy Quality Control Manual specifies that the “average glandular dose to an average (4.2 cm compressed) breast should not exceed 3 mGy (0.3 rads) per view for screen-film or digital image receptors.” For digital, does this only apply to a 512 matrix? Is a higher dose acceptable if a 1024 matrix is used?

A. For ACR accreditation, the intent is that the dose be assessed at the mode used clinically. The manual directs the medical physicist to use the technique that is clinically used to assess dose: • Page 78 – “Measure the typical entrance exposure for standardized breast thickness and composition (approximately 4.2 cm compressed breast thickness – 50%adipose, 50% glandular composition), calculate the associated average glandular dose, and assess short-term exposure reproducibility.”

• Page 78 – “4. Select the exposure technique normally used for stereotactic localizations.”

If the facility typically uses the 1024 matrix for stereotactic breast biopsies, the dose requirement applies to that mode; if the facility typically uses the 512 matrix for stereotactic breast biopsies, the dose requirement applies to 512.

Q. Is the stereotactic breast biopsy facility required to provide a gelatin phantom on site for the physicist to use in performing the Localization Accuracy test that is outlined in the Medical Physicist’s section of the ACR 1999 Stereotactic Breast Biopsy Quality Control Manual?

A. No. Although most medical physicists provide their own test tools, it is also acceptable for the medical physicist to use test tools provided by the facility. As long as the medical physicist has access to a gelatin phantom to perform this test, it is a decision between the medical physicist and the facility who provides the phantom. n 36 | www.aapm.org

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

HEALTH POLICY & ECONOMIC ISSUES Wendy Smith Fuss, MPH, AAPM Health Policy Consultant

AAPM Submits Comments on 2016 Medicare Proposed Rules

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APM recently submitted comments to the Centers for Medicare and Medicaid Services (CMS) regarding the 2016 Medicare proposed rules for payments to hospital outpatient departments, freestanding cancer centers, and physicians.

CMS will address public comments in the 2016 final rules, which will be published on the first of November. AAPM’s full comments to CMS can be found here.

Medicare Physician Fee Schedule In 2015 CMS put in place a revised set of codes for treatment delivery and image guidance. These codes were implemented in 2015 in the hospital outpatient setting and will be effective on January 1, 2016 in the physician office and freestanding radiation therapy center settings.

• 77402 Radiation treatment delivery, >1 MeV; simple • 77407 Radiation treatment delivery, >1 MeV; intermediate • 77412 Radiation treatment delivery, >1 MeV; complex • 77385 IMRT, includes guidance and tracking, when performed; simple • 77386 IMRT, includes guidance and tracking, when performed; intermediate • 77387 Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed In describing the work and materials that constitute these services, AAPM recommended that CMS add two (2) minutes to specific equipment inputs and include an intercom as a direct practice expense included in radiation treatment delivery codes 77402, 77407, 77412, 77385 and 77386.

All of the new treatment delivery codes proposed for 2016 include an IMRT linear accelerator as previous generations of “low energy” linear accelerators are no longer commercially available. CMS did not include onboard imaging as a separate item in the direct practice expense inputs for these codes. AAPM recommended that CMS include the cost of onboard imaging associated with CPT codes 77385, 77386 and 77387 as imaging equipment is now a significant capital equipment cost associated with radiation treatment delivery.

Currently, CMS assumes that all radiation oncology equipment is utilized 50 percent of the time, which is defined as 50 hours per week. CMS proposes to adjust the equipment utilization rate assumption for the IMRT linear accelerator reflecting a significant increase in use. Instead of applying the default 50 percent assumption, CMS is proposing to use 70 percent based on their recognition that the accelerator is now www.aapm.org | 37

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

Health Policy, cont.

being typically used to provide more intensive treatments, which would increase its overall usage. AAPM recommended that CMS delay the 70% equipment utilization rate specific to IMRT linear accelerators until January 1, 2017. If implementation is not delayed, AAPM requested that the equipment utilization rate be phased-in over a four-year period (i.e., 2016-2019). Because AAPM believes that this proposal will significantly harm rural and medically underserved freestanding radiation therapy centers, which typically treat a smaller number of patients, it was suggested that these providers be permanently exempted from the increased 70% equipment utilization rate.

Lastly, AAPM advised CMS of significant concerns regarding the overall proposed reductions to radiation oncology (-3.0%) and freestanding radiation therapy centers (-9.0%) in the 2016 Medicare Physician Fee Schedule. AAPM wrote that, “Cuts of this magnitude could harm cancer care, especially in rural areas, and will negatively impact Medicare beneficiary access to life-saving treatments. For many facilities, fixed budgets for physical plant and capital equipment have been made based on long-term pro forma revenue projections that CMS proposes to substantially change in the short-term. It is almost certain that a cut of this scope and depth in projected operational revenue will immediately and directly result in reductions of expenditures for non-physician clinical labor, which includes the Medical Physicist. AAPM is deeply concerned that the loss of substantial necessary Medical Physicist work under the proposal can be expected to result in a decrease in both the quality and safety of the radiation services delivered to the patients insured by CMS.” Medicare Hospital Outpatient Prospective Payment System AAPM also provided written comments to CMS regarding the 2016 Medicare Hospital Outpatient Prospective Payment System (HOPPS) proposed rule.

CMS continues its comprehensive payment policy from January 1, which applies to several radiation oncology services including intraoperative radiation therapy (77424, 77425), breast brachytherapy catheter placement (19296, 19298) and single session cranial stereotactic radiosurgery (77371, 77372) procedures assigned to C-APCs 5093 Level 3 Breast/Lymphatic Surgery and Related Procedures and 5631 Single Session Cranial Stereotactic Radiosurgery, respectively.

The comprehensive APC (C-APC) payment policy bundles or “packages” payment for supportive services which are tied to a primary service. Under this policy, CMS calculates a single payment for the entire hospital stay, defined by a single claim, regardless of the dates over which the services are provided.

AAPM generally supports the concept of comprehensive APCs. However, AAPM recommended that CMS reconsider the creation of C-APCs based on clinical coherence, similarity of resource cost, and appropriate complexity adjustments.

Last year AAPM commented that choosing a bundling benchmark such as “on the same claim” is not a good foundation for a comprehensive payment procedure set. A “per claim” approach leads to confusion and variation in the payments made to different facilities based on their claim process. It also creates incentives for claim timing, which is not in the best interest of payment reform or patient care.

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

Health Policy, cont.

AAPM thinks that C-APC 5631 Single Session Cranial Stereotactic Radiosurgery is a good example of a comprehensive APC that includes similar clinical services. However, the comprehensive payment does not reflect similar resource costs. An underlying assumption of the C-APC policy is that a hospital will report all services that are related to the primary service on a single claim. This assumption may not apply to radiation oncology services as was evidenced by the CMS stereotactic radiosurgery (SRS) claims analysis that identified differences in billing patterns between SRS procedures delivered using Cobalt-60 and those using linear accelerators. This led to one technology receiving additional payment for pre-planning and preparation services that were not typically billed on the same claim as the treatment delivery, which was the primary service.

Based on their analysis, CMS is proposing to change payment for stereotactic radiosurgery treatment under C-APC 5631 by identifying any services that are differentially billed for codes 77371 and 77372 on the same claim and on claims 1 month prior to delivery of SRS, including planning and preparation services, and removing them from the C-APC calculation for 2016 and 2017. For any codes that CMS removes from the C-APC bundle, CMS is proposing that those codes would receive separate payment even when appearing with procedure code 77371 or 77372 on the same claim for both 2016 and 2017.

AAPM believes that the recent experience with bundling related to this composite APC has been unduly complex. It has clearly has caused both confusion and miscoding subsequent to SRS procedures. AAPM recommended a careful re-evaluation of the process that led to the valuation of this APC and the codes that are to be included and the methodology for assuring accurate coding. AAPM does not support unbundling planning and preparation services associated with stereotactic radiosurgery codes 77371 and 77372 in C-APC 5631 Single Session Cranial Stereotactic Radiosurgery.

Further for data collection purposes, CMS proposes to require hospitals in 2016 to report a modifier identifying any supporting services furnished prior to an associated primary service to better estimate payments under an encounter-based comprehensive APC. AAPM supports CMS’s efforts to better capture the costs of supporting services involved in providing primary services but does not support implementation of the currently proposed modifier policy. The addition of an even more complex system of modifiers is unlikely to bring clarity or accuracy to the data collected or to the payment process and would likely result in flawed data for rate-setting. n

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

BIG DATA OFFERS A BIG ROLE FOR MEDICAL PHYSICS RESEARCH Highlights From Today’s Cutting Edge Medical Physics Research

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ehind the scenes of a smoothly functioning physician-patient relationship is a complex body of research — supported by a team of scientists, statisticians, and developers — that seeks to continually improve that relationship. Big data in medical physics is one of the main drivers of those improvements.

Research Spotlight

As the systems for data collection and analysis have grown more refined over the last few decades, the way clinicians diagnose ailments, design treatment protocols, and track success rates over time has grown more sophisticated and accurate.

“It’s become extremely expensive to conduct prospective clinical trials,” explains Jean Moran (University of Michigan). “And while prospective clinical trials are still critically important, the NIH has recognized it’s also crucial to develop ways to leverage the information that’s being found in all these different research centers at a larger scale.”

Since prospective clinical trials test hypotheses in a very specific patient population under controlled settings, it is often less clear how the results apply to the broader patient population. Andre Dekker and colleagues demonstrated in 2014 the value of a rapid learning approach in relying on routine care data1. Among groups of non-small cell lung cancer patients, the researchers made use of a decision support system to better validate which patients ought to receive individualized therapies based on predicted outcomes. As healthcare costs continue to rise, clinicians see an equal rise in the need for cost-effective approaches that avoid burdening patients unnecessarily.

“Whether it be for diagnosis or for assessing the effectiveness of treatment, big data can help us figure out at the diagnostic stage which tools and treatment regimens should be used to treat that particular patient,” Moran explains. “Then big data can be used to help us assess if those tools are effective during the course of therapy or if the clinician needs to make a change in that patient’s treatment regimen.”

Oncologically, the ways in which big data can help innovate care are vast, both in terms of directly impacting an individual patient’s care as well as supporting an ongoing refinement process by which the data improves itself. Beginning with development of a national radiation oncology registry to organize and sort specific forms of data2, to using observational research in radiation oncology that is informed by those data registries and claim-based sets3, clinicians will likely find that what emerges is something of a feedback loop to improve both diagnosis and treatment.

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

Research Spotlight, cont.

At the AAPM Annual Meeting in July 2015, Peter Gabriel argued in favor of widespread standardization in the terminologies used in clinical settings4. The power of ontologies in gathering data and guiding its use lies in a streamlining effect, Moran says. AAPM Task Group 263, led by Charles Mayo, seeks to standardize the nomenclature for radiation therapy. Similar standardization efforts have been ongoing for imaging data.

“A lot of work is being invested into how we can standardize those labels to then benefit from the data mining that can be done downstream. We want to be able to have scientific advances leveraged throughout the broader community.”

When the labels agree, no matter where the care is being given, patients and clinicians can feel confident nothing is getting lost in the shuffle. Emerging software is currently ironing out that process5. Standardization also has the added benefit of making clinical trials more efficient, as investigators will have greater insights into where knowledge gaps may still lie. In that way, they can avoid doubling back to obtain data which already exist in the system under a different label, making it inaccessible without significant manual effort.

Another significant outlet for big data is in its imaging applications, Moran says. Projects such as the NCI’s Quantitative Imaging Network and free, open-source technology, such as 3D Slicer, allow large banks of data to remain wholly accessible and versatile. David Mankoff and colleagues showed earlier this year6 that molecular imaging techniques heighten the level of sophistication over traditional methods of tissue sampling.

“The lack of a standard nomenclature for defining targets and normal tissues hinders the promise of Big Data in radiation therapy. AAPM Task Group 263 is developing a standardized nomenclature for use in radiation therapy treatment planning systems which can be applied to clinical trials and within individual departments. This work is fundamental to benefiting from big data applications in the future.”

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“Imaging methods, especially PET,” they write, “can provide a highly accurate measure of regional probe concentration to enable robust quantification of regional molecular properties from imaging data.” In this regard, the quality of the biomarker is couched directly in the quality of the data, which, reinforcing the above point, must be standardized during input.

The tools facilitating data analysis are open-source, which adds room for innovation and learning in the future, Moran says. “In addition, the availability of curated, high quality datasets such as TCIA (The Cancer Imaging Archive) for evaluating those tools is also crucial.”

AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

Research Spotlight, cont.

“The fascinating thing is that because it’s big data, the research is ongoing in so many different directions and there are so many ways in which we are learning how to improve patient care. The more we can get these diverse experts together, the more we’ll be able to leverage and advance the science in a more rapid way to benefit individual patients.”

In summer of 2015, AAPM, ASTRO, and NIH co-sponsored a workshop on big data. The participation of medical physics researchers was an important aspect of the workshop, and it will continue to be an important area of emerging science. AAPM participation in the continuing dialogue will help address major challenges and advances to be shared at next year’s meeting on Precision Medicine. n

1. Dekker A, Vinod S, Holloway L, Oberije C, George A, Goozee G, Delaney G, Lambin P, Thwaites D. Rapid learning in practice: A lung cancer survival decision support system in routine patient care data. Radiotherapy & Oncology. 2014 Oct; 113(1)47-53.

2. Palta JR, Efstathiou JA, Bekelman JE, Mutic S, Bogardus CR, McNutt TR, Gabriel PE, Lawton CA, Zietman AL, Rose CM. Developing a national radiation oncology registry: From acorns to oaks. Practical Radiation Oncology. 2012 Jan-Mar;2(1):10-7.

3. Jagsi R, Bekelman JE, Chen A, Chen RC, Hoffman K, Shih YC, Smith BD, Yu JB. Considerations for observational research using large data sets in radiation oncology. Int J Radiat Oncol Biol Phys. 2014 Sep 1;90(1):11-24.

4. http://amos3.aapm.org/abstracts/pdf/99-27275-365478-111590.pdf 5. Mayo C, Conners S, Warren C, Miller R, Court L, Popple R. Demonstration of a software design and statistical analysis methodology with application to patient outcomes data sets. Med Phys. 2013 Nov;40(11):111718.

6. Mankoff DA, Farwell MD, Clark AS, Pryma DA. How Imaging Can Impact Clinical Trial Design: Molecular Imaging as a Biomarker for Targeted Cancer Therapy. Cancer J. 2015 May-Jun;21(3):218-24.

The Research Spotlight highlights projects, people, and emerging science in medical physics. The article is arranged and edited by Dr. Taly Gilat-Schmidt on behalf of the AAPM Research Committee.

PRINCE STREET IN PROGRESS! Your New AAPM Headquarters as of December 7, 2015 Contact us at: 1631 Prince Street, Alexandria, VA 22314 Phone: 571-298-1300 • Fax: 571-298-1301 Staff contact info: www.aapm.org/org/contactinfo.asp

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

IEC UPDATE Cynthia McCollough, Rochester, MN

International Electrotechnical Commission (IEC) Maintenance Team 30 (CT) and Project Team 62985 (SSDE) Update

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EC Maintenance Teams (MT) are similar to AAPM working groups; they are comprised of subject matter experts who focus on a specific topic or concern on an ongoing basis. Unlike IEC Project Teams (PT), they do not disband when one standard is complete, as they are tasked with ongoing maintenance of all IEC standards related to their subject matter.

IEC MT 30 is tasked with maintaining the CT safety, constancy testing, acceptance testing and standards (IEC 60601-2-44, IEC 61223-2-6 and IEC 61223-3-5, respectively). They meet twice a year, with venues rotating between Europe, Asia and North America. Currently, Mike McNitt-Gray and Cynthia McCollough serve as AAPM representatives to MT30 from the CT subcommittee and Keith Strauss serves as the AAPM representative to MT30 from the pediatric imaging subcommittee. Additional AAPM members serving on MT30 are from academia, industry and the FDA. The current work of MT30 is to update the CT acceptance and constancy testing standards, which have not been updated since 2004 and 2006, respectively. As part of this effort, the two standards are being combined to ensure that the descriptions and criteria of tests are harmonized.

PT 62985 is a new PT, which was convened to develop an IEC standard for the calculation of CT size specific dose estimates (SSDE). A number of AAPM members also serve on this PT. The 2nd meeting of PT 62985 was recently held in conjunction with the fall meeting of MT30. I had the pleasure of hosting this meeting at Mayo Clinic in Rochester, MN. The combined meetings, which were very productive, lasted for 4 days.

At the end of the MT30 meeting, all homework items had been reviewed, the testing methods and criteria reviewed for the entire testing draft standard, and the few remaining open items assigned as homework. The convener of the team, John Jaeckle from GE Healthcare, will finalize the changes made during the meeting, with the goal of sending the draft to the IEC central office yet this year for circulation to member countries for comment. The final standard is expected to be complete in 12-18 months.

In addition, some members of PT 62985 were able to meet in August in Milwaukee to develop a working draft, which was further refined during the September meeting. A number of open questions remain to be resolved, and the team will continue their work via web conference.

The two teams will meet together again in March at a location to be determined in Europe.

In summary, there are two particularly active IEC teams working on standards related to CT, both with active participation from AAPM members. More news will be shared as the current standards move closer to completion. n

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

ENSURING THE FUTURE OF OUR PROFESSION John M. Boone, Bruce H. Curran, John E. Bayouth, Todd Pawlicki, Matthew B. Podgorsak

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he seismic changes in healthcare today have the potential to rattle any medical professional. This is especially true in professions like medical physics where the bulk of our important work is performed after hours and out of view of the patients, whose lives and health depend on it, and the colleagues and administrators on whom we depend for our livelihoods.

Changes in reimbursement, scope of practice for medical physicist’s assistants and how purchasing decisions are made are among the many challenges that combine to threaten not just the careers of individuals, but the very vitality of the profession as a whole.

AAPM is keenly aware of these threats and is making it a priority to address them. We believe that not to address them could have dire consequences for the medical physics profession.

We also believe this needs to be a joint effort involving all of us, not just AAPM leadership. We want our members to know what we’re doing and, more important, how you can join us in taking action to keep medical physics and qualified medical physicists indispensable in ensuring safe and efficacious diagnostics and therapies to the patients who need them.

Possibly the most important thing we can do is step out from behind the curtain and make our value known to our colleagues, supervisors, administrators and patients. Radiologists did just this, getting out of the reading rooms and engaging with their colleagues, administrators and directly with patients.

• We are creating a member support kit that will include “how-to” information and template materials you can use to help communicate the value of medical physics with your peers and hospital leadership.

• AAPM is looking at the future of the profession through Medical Physics 3.0, the new paradigm of clinical medical physics practice extending from traditional insular models of compliance towards team-based models of operational engagement.

• To assist you as you adapt to the changing profession and meeting the new objectives of value-based operation, personalized care and evidence-based medicine, AAPM will offer a continuous leadership program. The Medical Physics Leadership Academy will launch in June 2016 as part of the AAPM Summer School. The Leadership Academy will define leadership models and motivate excellence in the medical physics discipline and practice in five areas of medical physics advancement: clinical, scientific, educational, administrative and professional. In the near future, AAPM will also offer courses in health economics to further prepare medical physicists for the future of the profession.

• AAPM leadership is re-assessing AAPM’s governance structure to better ensure various member constituencies are represented. This will allow AAPM to consider and respond to the challenges and professional concerns you face in your day-to-day work.

Here’s what you can do: • Participate in the International Day of Medical Physics on November 7. Watch for more information this coming week about how you can participate to increase awareness of the value of medical physicists.

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AAPM Newsletter • Volume 40 No. 6 NOVEMBER | DECEMBER 2015

Ensuring the Future of Our Profession, cont.

• If appropriate to your position and work, look for ways to become more directly involved in patient care, partnering with radiologists, oncologists and other physicians who rely on your expertise.

• Look for ways at your institution to be seen and heard. Make a presentation, write an article for your hospital newsletter or offer a colleague training to meet CME requirements.

The more people know about the skills and expertise of medical physicists, the easier it will be to address the other challenges to the profession. It will be easier to make the point that medical physicists assistants, while important team members to us, do not have the training, experience and expertise to replace us. We will also be better equipped to advocate for appropriate reimbursement.

Although there is broad diversity within our membership, our profession and our institutional roles and responsibilities, the one thing we all have in common is the opportunity to convey the value medical physicists bring to our hospitals and the larger healthcare community. We hope we can count on all of you. n

AMERICAN ASSOCIATION of PHYSICISTS IN MEDICINE

Visit the AAPM Career Services’ webinars page to REGISTER NOW for

“TRANSITIONING YOUR CAREER BEYOND ACADEMIA” being held NOVEMBER 5, and to view a recording of September’s “Identifying and Seizing Value from Conference Participation” event.

Go to: www.aapm.org/careers/jobseekers/ resources/webinars/ for links to both as well as a catalog of previously recorded careers-related webinars.

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UPCOMING AAPM MEETINGS: March 5–8, 2016 AAPM Spring Clinical Meeting Salt Lake City, UT June 12–16, 2016 AAPM Summer School Medical Physics Leadership Academy Chantilly, VA July 31–August 4, 2016 AAPM 58th Annual Meeting & Exhibition Washington, DC

AAPM | One Physics Ellipse | College Park, MD 20740 | 301-209-3350 | www.aapm.org