The CARE Bill: Regulating minimum education and credentialing standards for allied health professionals involved in radiology pr
Cath Lab Digest talks with:
Todd Chitwood, BS, RCIS, FSICP, President Elect of the SICP (Society of Invasive Cardiovascular Professionals) and Co-founder, Oregon Chapter of the SICP
Cindy Daniels, MS, RT(R), President, American Society of Radiologic Technologists
Jeff Davis, RRT, RCIS, FSICP, Society of Invasive Cardiovascular Professionals (SICP) representative to the JRC-CVT (Joint Review Committee on Education for Cardiovascular Technology)
Patti English, RT(R)(CV), MS, RCIS, JRC-CVT (Joint Review Committee on Education for Cardiovascular Technology) representative to the Alliance for Quality Medical Imaging and Radiation Therapy
Ginny Haselhuhn, BS, RT(R)(ARRT), Assistant Executive Director, American Registry of Radiologic Technologists (ARRT)
Christine Lung, CAE, American Society of Radiologic Technologists (ASRT), Director of Government Relations
Chris M. Nelson, RN, RCIS, FSICP, Treasurer, Cardiovascular Credentialing International (CCI); Past President, Society of Invasive Cardiovascular Professionals (SICP)
Why is the CARE Act necessary and important for allied health professionals and patients?
Jeff Davis (JRC-CVT): First, it is our belief that the CARE Bill will improve patient care. Secondarily, in our corner of the cath lab world, it will provide recognition of the credentials deemed appropriate for work in radiation and medical imaging, and this includes the Registered Cardiovascular Invasive Specialist (RCIS) credential.
Chris Nelson (CCI): We have to focus on the intent of the CARE Bill, which directs the Secretary for the Department of Health and Human Services, in consultation with recognized experts in medical imaging to establish standards to ensure the safety and accuracy of medical imaging studies, as well as putting into place standards that pertain to the people performing medical imaging and radiation therapy. That, I believe, is what brought the Alliance together. Everyone (on the Alliance) believes the intent of the bill is commendable. It’s all about providing safe care, accreditation of allied health schools and credentialing.
Cindy Daniels (ASRT): Speaking as someone living in a non-licensure state (one of the very few that remain in the United States), it is imperative for the CARE bill to be adopted. Currently, in Missouri, anyone can perform ionizing as well as non-ionizing procedures without appropriate education/training. For general diagnostics, nuclear medicine, and radiation therapy, you are not required in Missouri to have any type of credential to operate the machinery related any of those procedures. Unfortunately, there is the misperception by patients that the person performing the procedure, giving radiation doses for cancer treatment, is an educated, trained professional. This is not necessarily true in non-licensure, non-credentialing states. The quality of patient care may be compromised. It is not an issue in the hospitals where credentialed medical imaging and radiation therapy professionals are employed. However, there is a concern in the rural communities relating to misdiagnosis or even images that are sub-optimal. There have been instances when the radiologist or physician cannot even use the image to make a diagnosis.
Christine Lung (ASRT): At present, nine states do not license radiography. I believe there are 26 states that currently license nuclear medicine, and 30 states that license radiation therapy. One aspect of the CARE bill that often gets overlooked, except maybe by Congress, is the cost savings that can be attributed to reduction in repeat rates and the number of procedures which can be completed successfully. Each time an image has to be repeated, or if a procedure has to be discontinued and then rescheduled, there is a cost that gets added onto the health care ticket. We estimate that the CARE bill, in its reduction of repeat and diagnostic imaging rates, can save the federal government up to 92 million dollars just in Medicare costs alone.
Ginny Haselhuhn (ARRT): To state ARRT’s reasons for supporting the CARE Bill would be reiterating what has already been said. Some states don’t have any medical imaging regulations; the CARE bill would require their development and a higher standard of patient care. It is ARRT’s mission to promote high standards of patient care by recognizing qualified individuals in medical imaging, interventional procedures and radiation therapy.
Is there any data on the extent of excessive radiation during medical procedures in the U.S.?
Christine Lung (ASRT): When we first started working on the CARE bill in 1998, the FDA had just put out information on fluoroscopy burns suffered by patients going through cardiac catheterization and cardiovascular procedures. The report describes the types and the numbers of radiation burns through fluoroscopy procedures. That information is still resident on the FDA’s website, but there have not been any subsequent studies since those initial numbers were posted. I believe it was the FDA themselves who did that initial study (http://www.fda.gov/cdrh/radinj.html).
Chris Nelson (CCI): Here is a quotation from the amendment to the Public Health Service Act of 2005:
7 of out every 10 Americans undergo a medical imaging exam or radiation therapy...
The administration of medical imaging exams and radiation therapy treatments and the effect on individuals of such procedures have substantial, direct effect upon public health. It is in the interest of public health and safety to minimize unnecessary or inappropriate exposure to radiation due to the performance of medical imaging and radiation therapy procedures by personnel lacking appropriate education and credentials. It is in the interest of public health and safety to have a continuing supply of adequately educated persons and appropriate accreditation and certification programs administered by state governments … Persons who perform or plan medical imaging or radiation therapy, including those employed at federal facilities, or reimbursed by federal health programs should be required to demonstrate competence by reason of education, training and experience.
(Note: The most comprehensive information on the CARE/RadCARE bills can be found in the Government Relations section at www.asrt.org. The quote above is from ASRT’s CARE bill materials.)
I remember one sentinel event in the publication of a particular article in a variety of journals. Cath Lab Digest also reprinted this article. It showed a picture of a patient’s back with a burn. If memory serves me correctly, it was a patient that had a 12-hour EP procedure. While the intent may have been of value, there was definitely some overkill, the results of which certainly got people’s attention. I vividly remember that this article was one of the calls to action for the field during that time.
Is it correct to say that the primary importance of the CARE bill for those working in the cardiac cath lab is in the bill’s acknowledgement of the RCIS credential?
Chris Nelson (CCI): That is the approach we are taking and why we got involved in the Alliance. Some of the benefits just discussed by Christine are not typically things seen in the cardiovascular world. In the cath lab, it’s the physician who is actually administering and managing fluoroscopy, and we rarely bring patients back for repeat exams.
Cost reduction is a salty topic at the moment. Congress stands to gain 2.8 billion in savings over five years from the imaging provision of the Deficit Reduction Act (DRA) of 2005. Reports on over-utilization of imaging services makes imaging vulnerable.
In the overall scheme of the Deficit Reduction Act, that’s small potatoes and an easy target, but for all of us in medical imaging, the cuts that have been proposed are dramatic.
Todd Chitwood (SICP): I would not say that the primary importance is the acknowledgment of the RCIS - however, it is very important that this group of professionals, who have demonstrated that they meet an educational standard through testing and credentialing, are included. After all, the RCIS has a solid education in radiation safety and principles surrounding the use of fluoroscopy in the invasive cardiovascular area. This education and training should not be dismissed; rather it should be properly exploited.
What was the role of the ASRT and then the Alliance in putting together the bill?
Christine Lung (ASRT): ASRT actually started working on this initiative back in the late 1960s. As an organization, ASRT recognized that technologists, back when they were still called x-ray technicians, needed some sort of standardized educational background as well as certification to show that they had the competency to successfully perform medical imaging procedures. This movement that started back in the 1960s came to partial fruition in 1981, when the Consumer-Patient Health and Safety Radiation Act was passed by Congress. The 1981 Act set education and credentialing standards for radiographers, radiation therapists, nuclear medicine technologists, and dental radiographers. However, the standards that were set were only a federal guideline. There was no enforcement and nothing in the legislation requiring states to adopt those standards, or even for the federal government to hold its own programs to those standards.
Fast-forward to 1998, when there were some states who had adopted part of those standards, or a variation of those recommended federal standards. Yet there was still no consistency throughout the country, and still no uniformity in what had been adopted by the participating states. As a result, the ASRT House of Delegates charged the organization with developing a legislative approach to strengthen the provisions in the act and also make it enforceable, meaning we were to come up with some way of holding the federal government responsible for enforcing the standards within their own programs, and hopefully the states as well. The first version of the CARE bill was introduced in the 106th Congress, back in late 2000. This bill dealt with education and credentialing standards but would have relied on the states to take the federal standard and write it into some sort of licensure that would apply in all state jurisdictions. It was during this period that the Alliance also started as well. ASRT at first took the approach that this legislation would affect mostly radiologic technologists; however, as we started investigating further, we realized that medical imaging had really stopped being the domain of traditional radiology. Medical imaging was being used in cath labs, it was being used more in physicians’ offices and different specialties had developed to incorporate that usage in other practice settings. So ASRT started working with cardiovascular technologists, with medical physicists, etc., all groups that eventually joined the Alliance. We were able to take a small, narrowly-focused piece of legislation and turn it into something to benefit everyone involved in the performance of medical imaging.
How many organizations are involved with the Alliance?
Christine Lung (ASRT): There are 20 organizations that currently belong to the Alliance, ranging from medical assistants doing limited-scope radiography to medical physicists who assess equipment, radiology administrators, radiology oncology administrators, sonographers, and virtually every profession involved in the technical performance of medical imaging and radiation therapy. There is a list of Alliance member organizations on ASRT’s website.
Todd Chitwood (SICP): I am probably the one with the least amount of experience as regards working with the Alliance, but I did just attend the August Alliance meeting in San Francisco and learned a great deal. Much of the groundwork for the CARE bill had been laid prior to my coming on the scene (representing the SICP), and I was impressed with how far we had come. Christine mentioned how the Alliance broadened what was once a very narrowly focused bill to include other modalities using medical imaging. Although radiologic technology programs and cardiovascular programs are very different, we do share this great common ground. Prior to coming to the CARE Act, I had worked with the state of Oregon on a plan to develop a state standard, and we were unsuccessful. I am very hopeful that at the federal level, this bill will give a push to the state of Oregon to put some minimum standards in place. I’ve been very impressed with how the CARE bill has come together and how all Alliance members have grown to support each other.
Jeff Davis (JRC-CVT): The CARE bill will establish minimum educational standards and endorse the ones we currently have in place. It will put some teeth into ensuring radiation and radiation safety are incorporated into the curriculum of accredited programs. Fortunately, these programs do already comply and teach these topics. As we move to determine who is eligible for registry exams from a JRC-CVT standpoint, the graduates of accredited invasive CVT programs will be eligible to sit for the RCIS exam. The bill speaks to the educational requirements for that eligibility.
The JRC-CVT looks to the SICP as a professional society, to help guide the curricula of invasive CVT programs, and the SICP has published educational curricula which incorporates radiation and radiation safety. We work together to enhance the curricula in place, but the bill will have the effect of further recognizing it, which is important to us. You can call a plumber to come to your home and you have some assurance that individual has a license and has had training to work in plumbing, yet in many places in the country, you don’t always have that assurance in the cath lab, and I think patients don’t always recognize that. It underscores the importance of this bill.
Patti English (JRC-CVT): I’ve been a representative to the Alliance from JRC-CVT for five years. During the Alliance meetings, the various groups have been able to look at each other’s rules and regulations. We are able to comment and we can also get good feedback. It has been very helpful.
Ginny Haselhuhn (ARRT): The ARRT offers examinations for state licensing use in areas that we don’t certify, such as examinations for the limited x-ray machine operator and the bone densitometry equipment operator. When the Alliance started, there were no education or examination guidelines for these programs. In working with the ASRT and the Alliance, we’ve discussed the radiation safety issues and developed some criteria for medical assistants and people that don’t go through an educational program where radiation safety is a priority. We have been able to establish some minimum requirements for their education and the understanding of the factors of radiation safety.
Chris Nelson (CCI): My history is a little unique. I actually got involved with the Alliance when I was the president of the SICP in 1998, after the federal minimum standards campaign was published. Frankly, my involvement was a reaction to what was perceived as territorial marking by the radiology groups. During that year, we had a meeting where we invited everybody to Denver to talk; we invited the ASRT and then all of the cardiovascular groups. We wanted to understand what was going on and why, and the result of that meeting was my joining the Alliance. After my term as president of the SICP concluded, I was asked to join the board of trustees of CCI and was asked to continue to serve as CCI’s representative to the Alliance.
I have to echo what a number of people have said - that this bill is the result of a journey. There are a number of definite concerns that have been out there in the past, relating to who does what and when in the cath lab, but the bottom line is that the focus of the bill, and certainly the focus of the people who have been serving on the Alliance, is patient care. I think that it’s important to identify that this is another volunteer group of people who are passionate about their work and their professions who have come together to draft standards to ensure that we are delivering safe patient care and that medical imaging technologists meet minimum educational requirements and are credentialed. CCI’s involvement is in support of the SICP as the credentialing group of the profession. Therefore, CCI acknowledges the SICP’s desire to advance the standards, and we believe currently, that our examination process and credential speaks to the standards that should be required for those that are working in those fields, specifically, invasive cardiovascular specialists, non-invasive cardiovascular specialists (echo sonographers) and peripheral vascular specialists.
What about bringing the bill to Congress? Any concerns that the bill may be amended or altered in a way with which the Alliance disagrees?
Christine Lung (ASRT): Any time you are in the legislative process, your initiative or bill is always amendable until Congress passes it and the president signs it. It’s pretty much anyone’s game. However, one of the reasons our bill has been relatively protected and has not had any unfriendly or opposing amendments attached to it is the fact that just about every group that would want to bring an amendment to this bill is a member of the Alliance. We’ve all come together. We’ve been able to resolve any issues or any discussion that would really affect the bill at a level where it did not have a lot of impact on the bill’s forward progress. We’ve been able to reach consensus on what we want the bill to include and how we would want the bill to move forward. We have no known national organizational opposition to the legislation. Every organization that would really be impacted by it has already had the opportunity to comment and have their comments heard throughout the process. We feel that’s one of the reasons we’ve been relatively successful in moving the legislation forward. The Alliance has been one of the factors that has not only supported the success of the bill but has shown Congress the need for the legislation.
Who should be worried if this bill passes?
Cindy Daniels (ASRT): Congressmen and Senators have had concerns regarding how this bill will impact the rural areas. Amendments made to the RAD Care bill address the concerns from the rural areas.
Christine Lung (ASRT): Also, in the rural areas you’re going to see more limited x-ray machine operators. People such as nurses, who don’t have a traditional education in imaging. We made provisions for the people working in rural settings within the bill and within the standards that will eventually be promulgated by Health and Human Services after the bill is enacted. Our job is not necessarily to take anyone out of the healthcare environment, but just to make sure that people who are using radiation or performing medical imaging in the healthcare environment have requisite educational content that supports their use of imaging modalities.
Chris Nelson (CCI): I think who should worry will really depend on the ruling of the Secretary of Health & Human Services. If, by chance, the Secretary identifies a specific discipline or disciplines to work in medical imaging, those disciplines left out would have cause to worry. The Bill contains language speaking to how much time states, and therefore individuals, would have to comply with the standards. What I would send is a very strong message to those who qualify to sit for their credentialing exams but have chosen not to that time is running out. We want medical imaging technologists to be appropriately credentialed.
Christine Lung (ASRT): That’s always been our proposition, that education and credentialing really are necessary to put a highly competent healthcare practitioner out into the medical imaging and radiation therapy field. As far as groups that could be concerned or worried about this, I think it is also important to note that the CARE bill is not a new initiative. We have been working for eight years just on the CARE initiative alone, not to mention the previous 20 years before that on minimum standards for technologists. If a group has not commented or has seen an excuse to bring their concerns forward in the last eight years (and we have been very open in the process that we have engaged in) in lobbying and moving this legislation, it is indicative that the concerns just aren’t there. The ultimate goal, which is quality patient care, is non-arguable. No one is going to stand up and say, No, we want to continue to provide poor patient care.
Cath Lab Digest has had readers express some concern about whether the ASRT will continue to act in good faith as this bill is enacted, regarding support for the role of the cardiovascular technologist.
Cindy Daniels (ASRT): The ASRT is very supportive of all the imaging modalities within the radiologic alliance. I do not see this as an issue.
Christine Lung (ASRT): ASRT is not a radiology-centric organization. We recognize that radiologic technologists, cardiovascular technologists, sonographers, etc., all work inside and outside of the traditional radiology setting. This includes our membership as well. We have members of ASRT who work outside of radiology departments and hold professional credentials from many different certification organizations. We also have cardiovascular technologist members who hold the RCIS credential. As a professional association, our job is not just to serve our members but the public and the medical imaging and radiation therapy professions and ultimately, the patient.
Todd Chitwood (SICP): I applaud the group’s collaboration, and as far as groups that might be affected, sometimes our fears are much worse than reality. Look at the demographics of radiology technologists, for example. These statistics are a few years old, but there is about a 15% vacancy rate. I heard at one point about two years ago that by 2010, we will need about 75,000 more RTs. If you look at the number of programs, I think the ARRT programs are shrinking, as are CVT programs. The labor market is not putting people into our specialty. I believe RT demand is expected to grow at one of the fastest rates, ranked at number eight by the Bureau of Labor Statistics for Health Care Professions. Cardiovascular technologists were number 14. We have more demand for labor than what is available. I can cite a program right here in the state of Oregon that’s trying to put together a much-needed invasive cardiovascular program and an open heart surgery program, and cannot hire staff. There are none available.
The collaboration in support and recognition of the RCIS credential gives us much more flexibility. I don’t think anybody that wants a job is going to be forced out of a job. If anything, it’s going to bring us much more together, and it will be less ambiguous as to what you are allowed to do with your credential. Hopefully, we will all be allowed to do what we do in the cath lab anyway: scrub, monitor, record and circulate. Certainly the SICP’s perspective, and my own personal philosophy, is that the cath lab is fortunate in that we bring to the table a diversity of skills and backgrounds. We have nurses, we have radiology techs and we have cardiovascular techs. In our particular facility we feel, and the SICP promotes, that we can help each other. Where one individual may have weaknesses in certain areas, we have others that can compensate. If everybody had the same minimum standards, then those weaknesses will be mitigated or even eliminated. We can stand confident that we are delivering great quality care.
Chris Nelson (CCI): Just to echo Todd, the SICP, from day one, has always proclaimed the value of a multi-disciplinary team in cardiovascular technology. We have and continue to recognize and support the variety of disciplines that make up the cath lab team. We firmly believe credentialing of cath lab staff should be the minimum standard for all labs. It’s important to note that the CARE bill has been a coming together of the disciplines, a respect for what’s been needed, and we have always, always, from day one, supported this approach. I think the SICP sometimes has to remind our membership of that fact that it’s always been that way. One other thing that always gets me is that our roots are in radiology. All of the forefathers for cardiovascular technology were pioneers you might go so far as to say OJT as interventional cardiac and vascular technology emerged as a specialty. Every one of them helped to develop the standards we have today for physician credentialing. These standards have been adopted by healthcare systems all over the world. We’re doing the same thing at the technologist level.
How will the CARE bill impact the curriculum of the allied health schools?
Jeff Davis (JRC-CVT): It is going to be very positive. Fortunately, the important elements are already covered in the JRC-CVT-accredited programs. We do cover extensive amounts in the domain of radiology and radiation safety. The bill will increase the number of programs though, because you can no longer be an OJT without any formal health care education, walk in the cath lab and get trained right off the street. That population will need to go to school. If they really want to work in the cath lab, they will go to an accredited invasive cardiovascular program where the curricula does incorporate what needs to be incorporated for the best patient care. The bill will increase the number of students in existing programs, and it’s going to increase the number of programs. It will help with the job shortage that Todd mentioned. We already are establishing mentorship programs where existing accredited CVT schools will partner with programs that are trying to get started up. These programs can be shepherded along as they develop. Interestingly, with the JRC-CVT-accredited invasive schools, their curriculum is not driven by JRC-CVT, but by SICP. The professional society writes the curricula and the JRC-CVT incorporates it into the standards for accreditation. The beauty of this setup is that you have the people in the field, who are on the front lines and really know what needs to be incorporated into the curricula actually writing it, and then the JRC-CVT enforces that in its programs.
SICP is in the process of updating the existing curricula, and individuals involved with that project include registered cardiovascular invasive specialists and registered radiologic technologists. We also have nurses that are involved with aspects of the curricula that are important from a nursing perspective. It does underscore the interdisciplinary nature even at the school and the curricula level. This bill will have a very positive impact in that it will recognize the credentials in our corner of the world for invasive CVT schools and cath labs the RCIS credential. It will increase the number of programs, the number of students and raise the bar overall, ultimately the bottom line for everybody, including patient care. We’re very positive about it.
Todd Chitwood (SICP): I would add to that that we have been pleased to be very successful in developing relationships with program directors of radiologic technology programs, who are very respected individuals in their profession. We asked them to be a part of helping us in our development of curriculum, to make sure that what we are teaching is going to fuel this need for high-quality radiation practices in imaging.
Ginny Haselhuhn (ARRT): The curricula for the radiologic technology schools in radiography and radiation therapy are developed by the ASRT, similar to the relationship of the SICP and JRC-CVT. I don’t think that the CARE bill is going to impact the curricula for these programs, because the model regulations referenced curricula that are already in existence. There won’t be any real impact on the curriculum or the certification examinations. Schools in some allied health areas, such as the medical assistants, may need to incorporate more radiation safety, radiation exposure principles and radiographic procedures coursework into their curricula.
Patti English (JRC-CVT): The one thing I see as an educator in the radiologic sciences is that the bill will shed more light on the importance of this type of education. I see it as a very positive thing that we are requiring individuals to have the proper education and the proper training. It will all lead to quality patient care.
Christine Lung (ASRT): Speaking for ASRT, I cannot stress enough the importance of the collaborative relationship that has come out of the Alliance. It’s not only been one of the primary reasons we’ve had such success with the CARE bill, but has trickled over into other programs undertaken by the ASRT. It has helped to drive our agenda for the last 8-9 years and allowed us to think outside of our traditional thought pathways. The ASRT has been able to take a position that ultimately will not just benefit radiology patients, but every patient in the healthcare system.
Todd Chitwood (SICP): Christine, on September 20th, the Senate committee recommended the CARE bill for a full vote. Has anything happened since then?
Christine Lung (ASRT): As you know, Congress is currently in recess. They’ll stay in recess until November 14th, when they are scheduled to come back into Washington for a lame duck session. We’re hoping that the Senate bill, the RAD CARE bill, will be picked up during the lame duck session and probably moved through to the Senate floor as part of a larger healthcare omnibus bill. Over in the House of Representatives, our plan is to have the Senate bill rolled into a larger Medicare package that the House of Representatives is working on, and then passed by the House. If this plan, as we delicately laid it out, comes to fruition, we avoid having to go to a conference situation, since the House and Senate will have passed identical versions of the bill. Then we will be done, for at least the legislative portion. Mind you, we’re working in a very tight timeframe. Chances are that when Congress comes back in on November 14th, that they will be in for that week and perhaps one or two days before Thanksgiving. Depending on how much business they’ve been able to accomplish in November, they may come back for a week or two at the beginning of December, but that’s still a very dim possibility. We’re working with about 10 more legislative days this year, but we do have a plan, we’ve been working with staff while Congress is in recess, and then I think we have a very good opportunity this year to get the bill passed.
Todd Chitwood (SICP): What about the RCIS working in the state of Idaho, for example, who reads this article and hears that the CARE bill passes? What is the next action they should take, if any?
Christine Lung (ASRT): If the Senate bill passes, and is also adopted by the House and passes the House of Representatives, there will be about a four-year implementation phase before any technologist will have to evidence needing the education and credentialing requirements that will be promulgated by the Secretary of Health and Human Services. When that time passes, these standards will be promulgated. After the four-year implementation phase, basically anyone who is performing medical imaging, radiation therapy, cath lab procedures, etc., who does not meet either the education and credentialing standards for technologists put out by the Department of Health & Human Services, or who is licensed by a state where the state’s licensure standards do not meet the federal standards, the procedures that person performs and/or assists with, will not be reimbursable under Medicare or any program under HHS. It will have a financial impact on the employers of these personnel.
Jeff Davis (JRC-CVT): Any sense on how the president feels about the bill? And what’s the likelihood that the Secretary of Health & Human Services (HHS) would change the bill’s standards?
Christine Lung (ASRT): Once legislation is passed, before the Secretary can promulgate the standards, they have to go through what’s called the Administrative Procedures Act. This is the federal law that requires an agency to accept public comment on any proposed regulation. Since the Alliance has been so diligent in coming up with what we feel the regulations should contain, all Alliance members have reached consensus on the standards and will ask the Secretary to adopt the standards as submitted. I feel very confident that the secretary will adopt what the Alliance has put forth.
We have not heard any pushback from the administration. I think from the president’s point of view, the administration is looking right now for any kind of initiative that’s going to save money. They know that the Medicare system is in the future going to be taxed by people entering the system and the cost of medical imaging that seems to be increasing in proportion to that. I think anything that we put before the administration that shows that we can save money while increasing the quality of care will have their support.
As everyone has noted, this has been a wonderful group exercise on how organizations can come together and advocate for patients. The CARE bill is a shining example.
Email discussion participants at RKapur (at) hmpcommunications. com