James P. Borgstede

ACR Guidance Document for Safe MR Practices: 2007

E. Kanal is a consultant for, is a member of the speakers bureau of, and provides research support for Bracco Diagnostics and GE Healthcare; is a member of the speakers bureau of and provides research support for Siemens Medical Solutions; and provides research support for Berlex and Medtronic. T. Gilk is a consultant for Mednovus, Inc. J. R. Gimbel provides research support for St. Jude Medical, Medtronic, and Biotronik. J. Nyenhuis is a consultant for and provides research support to Medtronics. J. Weinreb is a consultant and member of the speakers bureau for GE Healthcare.

ACR guidance document on MR safe practices: 2013

Because there are many potential risks in the MR environment and reports of adverse incidents involving patients, equipment and personnel, the need for a guidance document on MR safe practices emerged. Initially published in 2002, the ACR MR Safe Practices Guidelines established de facto industry standards for safe and responsible practices in clinical and research MR environments. As the MR industry changes the document is reviewed, modified and updated. The most recent version will reflect these changes. J. Magn. Reson. Imaging 2013;37:501–530.

Addressing Overutilization in Medical Imaging

The growth in medical imaging over the past 2 decades has yielded unarguable benefits to patients in terms of longer lives of higher quality. This growth reflects new technologies and applications, including high-tech services such as multisection computed tomography (CT), magnetic resonance (MR) imaging, and positron emission tomography (PET). Some part of the growth, however, can be attributed to the overutilization of imaging services. This report examines the causes of the overutilization of imaging and identifies ways of addressing the causes so that overutilization can be reduced. In August 2009, the American Board of Radiology Foundation hosted a 2-day summit to discuss the causes and effects of the overutilization of imaging. More than 60 organizations were represented at the meeting, including health care accreditation and certification entities, foundations, government agencies, hospital and health systems, insurers, medical societies, health care quality consortia, and standards and regulatory agencies. Key forces influencing overutilization were identified. These include the payment mechanisms and financial incentives in the U.S. health care system; the practice behavior of referring physicians; self-referral, including referral for additional radiologic examinations; defensive medicine; missed educational opportunities when inappropriate procedures are requested; patient expectations; and duplicate imaging studies. Summit participants suggested several areas for improvement to reduce overutilization, including a national collaborative effort to develop evidence-based appropriateness criteria for imaging; greater use of practice guidelines in requesting and conducting imaging studies; decision support at point of care; education of referring physicians, patients, and the public; accreditation of imaging facilities; management of self-referral and defensive medicine; and payment reform.

RADPEER scoring white paper.

The ACRs RADPEER program began in 2002; the electronic version, e-RADPEER, was offered in 2005. To date, more than 10,000 radiologists and more than 800 groups are participating in the program. Since the inception of RADPEER, there have been continuing discussions regarding a number of issues, including the scoring system, the subspecialty-specific subcategorization of data collected for each imaging modality, and the validation of interfacility scoring consistency. This white paper reviews the task force discussions, the literature review, and the new recommended scoring process and lexicon for RADPEER.

Diagnostic radiology milestones.

Kay H. Vydareny, MD, is Associate Executive Director for Diagnostic Radiology at the American Board of Radiology; E. Stephen Amis Jr, MD, is Professor and University Chair in the Department of Radiology, Albert Einstein College of Medicine/Montefiore; Gary J. Becker, MD, is Executive Director of the American Board of Radiology; James P. Borgstede, MD, is a Vice Chairman and Professor at the University of Colorado Hospital; Dorothy I. Bulas, MD, is in the Division of Diagnostic Imaging and Radiology, Children’s National Medical Center, and Professor of Radiology and Pediatrics at the George Washington University Medical Center; Jannette Collins, MD, is Ben Felson Professor and Chair of Radiology in the Department of Radiology, University of Cincinnati Medical Center; Lawrence P. Davis, MD, is Vice Chair and Program Director in the Department of Radiology, Long Island Jewish Medical Center; Jennifer E. Gould, MD, is Program Director and Assistant Professor of Radiology at the Mallinckrodt Institute of Radiology, Washington University; Jason Itri, MD, PhD, is Assistant Professor and Director of Quality and Safety in the Department of Radiology, University of Pittsburgh; Jeanne M. LaBerge, MD, is Professor of Radiology and Director of the VIR Fellowship Program at the University of California, San Francisco, School of Medicine; Lynne Meyer, PhD, MPH, is Executive Director for the Resident Committee of Diagnostic Radiology at the Accreditation Council for Graduate Medical Education; Duane G. Mezwa, MD, is Chair of Diagnostic Radiology and Molecular Imaging at the Oakland University-William Beaumont School of Medicine; Richard L. Morin, PhD, is Brooks-Hollern Professor in the Department of Radiology at the Mayo School of Graduate Medical Education; Steven P. Nestler, PhD, is Senior Consultant in the Education Department at the Accreditation Council for Graduate Medical Education; and Robert Zimmerman, MD, is Vice Chair for Education and Professor of Radiology at Weill Cornell Medical College.

Adopting a Commercial Clinical Decision Support for Imaging Product: Our Experience

WHY COMMERCIAL DECISION SUPPORT Clinical decision support (CDS) has emerged as a tool to improve patient care across many specialties [1]. Broadly defined, CDS is a method of delivering organized clinical knowledge and recommendations to a clinician to assist in selecting the best course of action for a specific clinical scenario. With regard to imaging, the purpose of CDS is to assist a referring physician in requesting the most appropriate imaging study for a specific clinical scenario [2]. CDS for imaging has been integrated into electronic ordering systems at other institutions with success. Some institutions have reported adoption across virtually all specialties, reduction in low-yield imaging, and even elimination of the need for preauthorization by thirdparty payers when using CDS [3-6]. Therefore, one can reasonably infer that a successful CDS system for imagingcouldnotonly improvepatientcare but might also aid in cost containment and compliance with meaningful use requirements [7,8]. As a result of the positive gains reported at other institutions, our department embraced CDS for computerized physician order entry (CPOE) of imaging studies. However, successful implementation of CDS into the CPOE for imaging studies has only been reported at institutions with “homegrown” CDS programs, which are programs developed by and for the institutions at which they were ultimately used, an approach that likely mitigated or eliminated many of the potential problems associated with CDSCPOE integration. The objective of this paper is to describe our experience at the University of Colorado attempting to integrate a third-party commercial CDS product into our health care system.

2015 RAD-AID Conference on International Radiology for Developing Countries: The Evolving Global Radiology Landscape

Abstract Radiology in low- and middle-income (developing) countries continues to make progress. Research and international outreach projects presented at the 2015 annual RAD-AID conference emphasize important global themes, including (1) recent slowing of emerging market growth that threatens to constrain the advance of radiology, (2) increasing global noncommunicable diseases (such as cancer and cardiovascular disease) needing radiology for detection and management, (3) strategic prioritization for pediatric radiology in global public health initiatives, (4) continuous expansion of global health curricula at radiology residencies and the RAD-AID Chapter Network’s participating institutions, and (5) technologic innovation for recently accelerated implementation of PACS in low-resource countries.

The University of Colorado Radiology Adult Dose-Risk Smartcard

The Department of Radiology at the University of Colorado School of Medicine in Denver developed the Adult Dose-Risk Smartcard shown in Figure 1 to provide a convenient, pocket-sized reference card communicating the effective doses and radiation risks of common adult radiologic examinations. The smartcard was distributed to University of Colorado radiologists, referring physicians, medical physicists, and attendees at the recent 1-day Colorado Radiation Safety Symposium: Risk and Dose Optimization in Radiology. The card is intended to facilitate radiation risk consultations and improve patient satisfaction by simplifying essential facts on radiation dose and risk to a level understandable by referring physicians and their patients. This allows patients to make more informed decisions about the relative risks of radiologic examinations compared with the medical risk caused by refusing a recommended imaging procedure. Estimates of effective doses for most adult procedures come from the published literature, many from the article “Effective Doses in Radiology and Nuclear Medicine: a Catalog” by Mettler et al [1]. Mammographic dose (and risk) estimates come from recent articles by Hendrick et al [2,3]. Most estimates of cancer risk from the low-dose radiation exposures in the smartcard are based on the latest report from the International Commission on Radiological Protection [4], whose radiation risk stimates are age averaged (for dults aged 18-65 years) and gender averaged, yielding an overall risk for fatal cancer induction of 4.1% (a 0.041 probability factor) per sievert or 0.0041% (a 0.000041 probability factor) per millisievert. Age-dependent estimates of mammographic risks specific to female patients are based on the National Academy of Sciences Biological Effects of Ionizing Radiation report [3,5]. Both International Commission on Radiological Protection [4] and Biological Effects of Ionizing Radiation [5] risk estimates for solid tumors assume a linear no-threshold relationship between radiation dose and cancer risk to extrapolate the high-dose, high-linear energy transfer exposures (eg, to atomic bomb survivors, in whom subsequent radiation-induced cancers have been documented) to the low-dose, low-linear energy transfer exposures from diagnostic radiology examinations, for which no direct cancer-causing effect has been documented in humans. There is good evidence from studies of atomic bomb survivors that organ doses 100 mSv result in a small, but statistically significant, increase in cancer risk. The risks stated on the University of Colorado smartcard assume a linear no-threshold model to extrapolate the dose-risk relationship down to the low doses used in diagnostic examinations. These risk estimates are conservative in terms of protecting patients and may overestimate rather than underestimate radiation risk from medical examinations. To put doses and risks in perspective, the smartcard permits the

Identification of Malpositioned Tubes and Lines in ICU Patients: An Automated Solution Utilizing the Electronic Medical Record

b s b q i A m i t R f I a t c c r S t c s DESCRIPTION OF THE PROBLEM Portable intensive care unit (ICU) chest radiography is the mainstay in confirming proper placement and evaluating continued position and function of support catheters, lines, and tubes [1]. However, portable radiographs are often suboptimal because of patient positioning, severe cardiopulmonary disease, or body habitus. Additionally, multiple devices, overlying leads and wires, and dressings or bed sheets can further obscure imaging findings. Direct communication in the PACS era between clinicians and reading radiologists is often very limited, and this lack of communication can lead to serious consequences. Pikwer et al [2] investigated the umber of malpositioned central enous catheters and their correlaion with radiographic findings. he investigators found an approxmate 3.3% incidence of malposiioned central venous catheters. uhm et al [3] followed a series of hest radiographs that were obained for confirmation of central enous catheter placement. This roup found an overall 1.82% rate f catheter misplacement, using ortable radiography for identificaion. However, the group also reorted a case that was not identified n chest radiography; this case reulted in a life-threatening compliation. Giantsou and Gunning [4] performed a retrospective analysis of patients after nasogastric tube placement. In their analysis, the verall incidence of incorrectly ositioned nasogastric tube placeent was 1% to 3%, with approxmately half of these cases occurring n mechanically ventilated patients. erious complications, particularly neumothorax, occurred in 66% of hese cases. Hence, the presence of malpositioned catheter represents significant clinical issue. The failre of a radiologist to accurately dentify an inappropriately posiioned catheter can result in a igher risk for significant patient orbidity. This undertaking was prompted y a case in which a malpositioned upport device was not identified y a junior resident on call. Subseuent use of this catheter resulted n significant patient morbidity. multidisciplinary morbidity and ortality conference was held and ncluded discussion by represenatives from the Department of adiology, the Department of Proessional Risk Management, and CU nursing staff. All parties greed that improved communicaion among ICU staff members, linicians, and radiologists could derease the number of interpretive erors related to tube and line position. everal individuals inquired whether he electronic medical record (EMR) ould be used as a tool to facilitate uch communication.

Ultrasound and Dual-Energy X-Ray Absorptiometry Report Transcription Error Rates and Strategies for Reduction

PURPOSE Radiologists play an essential role in patient care by providing accurate and timely results. An error-free radiology report is an expectation of both patients and referring physicians. Software is currently available that can eliminate measurement and side types of errors while saving radiologists and sonographers time. The objectives of this study were to evaluate the potential reduction in report errors, estimate the potential time savings associated with implementation, and conduct a cost-benefit analysis of implementing two software programs. METHODS Data on the number of measurement errors and side errors in ultrasound and dual-energy x-ray absorptiometry reports were collected, and the time required for data entry that the software would reduce was measured by report type. Generalized estimating equations regression was used to estimate error rates and data entry times and corresponding 95% confidence intervals by report type for radiologists and sonographers. Current wages and report volumes were then applied to the time savings to estimate the annual wage savings. Projected volume increases were applied to the annual estimates to generate a 5-year savings estimate. RESULTS Overall, measurement errors occurred in 6% to 28% of ultrasound reports, depending on the report type. Side errors were rare. It was estimated that over 5 years, the software could save