Chris L. Sistrom

Reporting instruction for radiology residents1

Abstract Rationale and Objectives. To determine the amount of formal instruction and evaluation about reporting given to radiology residents in the U.S.A., to document report generation methods and to quantify the performance of physician coding. Materials and Methods. E-mail requests with links to a web-based, anonymous survey were sent to program directors of all accredited radiology residencies in the USA. Demographic questions included university or private affiliation, number of residents, geographic location, and number of hospitals covered. Subject-specific items covered the amount of didactic instruction, formal evaluation of reports, and use of structured reports. A didactic activity index (DAI) was calculated as the sum of answers to domain-specific questions and tested for relation to demographic variables. We also asked about dictation methods and International Classification of Diseases (ICD) or Common Procedural Terminology (CPT) coding of examinations by radiologists. Results. Of the 191 active radiology residencies, 151 (79%) completed the survey. Responses for hours of didactic instruction in reporting given more than a 4-year residency were distributed as follows: 0–1 = 40%, 2–4 = 46%, >4 = 14%. The percentage of resident reports formally graded was distributed as follows: 0–1 = 82%, 2–4 = 8%, >4 = 10%. The extent to which faculty-designed, structured reports were used by residents was distributed as follows: none = 16%, minimal = 25%, few = 17%, some = 33%, most = 9%. The DAI was normally distributed with a mean of 14.8 and a standard deviation of 2.4. Military programs had higher DAIs than university residencies (P = .03). There was no significant relation between any other program demographic variables and the DAI (P > .05). A substantial number of programs reported that physicians performed coding for some or most studies: ICD-9 = 30%, CPT = 26%. The dominant method for report generation was human transcription in 79% followed by speech recognition at 19%. Speech recognition penetration (departments reporting use of the technology for at least some dictation) was estimated to be 38%. Conclusion. In 86% of sampled radiology residencies, trainees receive no more than one hour of didactic instruction in radiology reporting per year. An aggregate measure of didactic activity about interpretative reporting was identical across all program demographic variables except that military residencies seemed to do slightly more than those located at universities.

Managing predefined templates and macros for a departmental speech recognition system using common software

The authors have developed a networked database system to create, store, and manage predefined radiology report definitions. This was prompted by complete departmental conversion to a computer speech recognition system (SRS) for clinical reporting. The software complements and extends the capabilities of the SRS, and 2 systems are integrated by means of a simple text file format and import/export functions within each program. This report describes the functional requirements, design considerations, and implementation details of the structured report management software. The database and its interface are designed to allow all radiologists and division managers to define and update template structures relevant to their practice areas. Two key conceptual extensions supported by the template management system are the addition of a template type construct and allowing individual radiologists to dynamically share common organ system or modality-specific templates. In addition, the template manager software enables specifying predefined report structures that can be triggered at the time of dictation from printed lists of barcodes. Initial experience using the program in a regional, multisite, academic radiology practice has been positive.

Conceptual approach for the design of radiology reporting interfaces: the talking template.

Within the coming decade, traditional dictation supported by human transcription for radiology reports will be replaced by one or more computerized methods. This paper discusses the cognitive and process efficiency problems arising from currently available technology including speech recognition and menu-driven interfaces. A specific concept for interaction with the reporting interface is proposed. This is called the „talking template” and departs from other designs by providing for all interactions to be mediated through audible prompts and microphone controls. The radiologist can recapture efficiency and cognitive focus by dictating while viewing images without the „look away” problem inherent in other interfaces.

Use of Imaging in the Emergency Department: Physicians Have Limited Effect on Variation

PURPOSE To quantify interphysician variation in imaging use during emergency department (ED) visits and examine the contribution of factors to this variation at the patient, visit, and physician level. MATERIALS AND METHODS This study was HIPAA compliant and approved by the institutional review board of Partners Healthcare System (Boston, Mass), with waiver of informed consent. In this retrospective study of 88 851 consecutive ED visits during 2011 at a large urban teaching hospital, a hierarchical logistic regression model was used to identify multiple predictors for the probability that low- or high-cost imaging would be ordered during a given visit. Physician-specific random effects were estimated to articulate (by odds ratio) and quantify (by intraclass correlation coefficient [ICC]) interphysician variation. RESULTS Patient- and visit-level factors found to be statistically significant predictors of imaging use included measures of ED busyness, prior ED visit, referral source to the ED, and ED arrival mode. Physician-level factors (eg, sex, years since graduation, annual workload, and residency training) did not correlate with imaging use. The remaining amount of interphysician variation was very low (ICC, 0.97% for low-cost imaging; ICC, 1.07% for high-cost imaging). These physician-specific odds ratios of imaging estimates were moderately reliable at 0.78 (95% confidence interval [CI]: 0.77, 0.79) for low-cost imaging and 0.76 (95% CI: 0.74, 0.78) for high-cost imaging. CONCLUSION After careful and comprehensive case-mix adjustment by using hierarchical logistic regression, only about 1% of the variability in ED imaging utilization was attributable to physicians.

Provider Feedback about Imaging Appropriateness by Using Scores from Order Entry Decision Support: Raw Rates Misclassify Outliers.

PURPOSE To determine the relevant physician- and practice-related factors that jointly affect the rate of low-utility imaging examinations (score of 1-3 out of 9) ordered by means of an order entry system that provides normative appropriateness feedback. MATERIALS AND METHODS This HIPAA-compliant study was approved by the institutional review board under an expedited protocol for analyzing anonymous aggregated administrative data. This is a retrospective study of approximately 250 000 consecutive scheduled outpatient advanced imaging examinations (computed tomography, magnetic resonance imaging, nuclear medicine) ordered by 164 primary care and 379 medical specialty physicians from 2008 to 2012. A hierarchical logistic regression model was used to identify multiple predictors of the probability that an examination received a low utility score. Physician- and practice-specific random effects were estimated to articulate (odds ratio) and quantify (intraclass correlation) interphysician variation. RESULTS Fixed effects found to be statistically significant predictors of low-utility imaging included examination type, whether the examination was cancelled, status of the person entering the order, and the total number of examinations ordered by the clinician. Neither patient age nor sex had any effect, and there were no secular trends (year of study). The remaining amount of interphysician variation was moderate (intraclass correlation, 22%), whereas the variation between medical specialties and primary care practices was low (intraclass correlation, 5%). The estimated physician-specific effects had reliability of 70%, which makes them just suitable for identifying outliers. CONCLUSION The authors found that 22% of the variation in the rate of low-utility examinations is attributable to ordering providers and 5% to their specialty or clinic.

Use of Imaging Appropriateness Criteria for Decision Support During Radiology Order Entry: The MGH Experience

This chapter will focus on the institutional perspective of The Massachusetts General Hospital (MGH) in Boston during the first decade of the twenty-first century. We will describe the MGH experience with design, implementation, adoption and current use of a computerized radiology order entry system that displays explicit normative “appropriateness scores” for outpatient CT, MR, and nuclear cardiology procedures and is embedded in routine clinical workflow. The radiology order entry (ROE) and decision support (DS) system has come to be known as ROE-DS within MGH and among a broader community of US radiologists, various industry stakeholders, and policy makers working in the field. One key point that will be emphasized is that a system like ROE-DS in wide use is a necessary, though by no means sufficient, first step in executing comprehensive institutional programs of imaging utilization management, quality improvement, and radiation dose mitigation.

Images of Imaging: How to Process and Display Imaging Utilization for Large Populations

OBJECTIVE We propose a method of processing and displaying imaging utilization data for large populations. CONCLUSION The comprehensive and finely grained picture of imaging utilization yielded by our methods is a first step toward population-based imaging utilization management. We believe that our methods for the categorization and display of imaging utilization will prove to be widely useful.

Behavioral Health Factors as Predictors of Emergency Department Use in the High-Risk, High-Cost Medicare Population

OBJECTIVE This study measured the presence, extent, and type of behavioral health factors in a high-cost Medicare population and their association with the probability and intensity of emergency department (ED) use. METHODS Retrospective claims analysis and a comprehensive electronic medical record-based review were conducted for patients enrolled in a 65-month prospective care management program at an academic tertiary medical center (N=3,620). A two-part model used multivariable logistic regression to evaluate the effect of behavioral health factors on the probability of ED use, complemented by a Poisson model to measure the number of ED visits. Control variables included demographic characteristics, poststudy survival, and hierarchical condition category risk score. RESULTS After analyses controlled for comorbidities and other relevant variables, patients with two or more behavioral health diagnosis categories or two or more behavioral health medications were about twice as likely as those without such categories or medications to use the ED. Patients with a diagnosis category of psychosis, neuropsychiatric disorders, sleep disorders, or adjustment disorders were significantly more likely than those without these disorders to use the ED. Most primary ED diagnoses were not of behavioral health conditions. CONCLUSIONS Behavioral health factors had a substantial and significant effect on the likelihood and number of ED visits in a population of high-cost Medicare patients. Attention to behavioral health factors as independent predictors of ED use may be useful in influencing ED use in high-cost populations.