Kevin W. McEnery

Integration of radiologist peer review into clinical review workstation.

Professional peer review of random prior radiologist’s interpretations is mandated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The JCAHO expects documentation of 5% rate of random peer-review cases. Countless hours are spent in departments fulfilling these requirements. The integration of the peer-review process into the radiologist’s interpretation workflow was expected to increase the percentage of documented peer review, yet decrease the time and effort for this documentation radStation clinical review workstations are deployed at every reading station. When a requisition is barcoded, radStation retrieves the patient’s clinical information and automatically displays the prior comparison report. If the radiologist agrees with the prior report, a single click on a “quality assurance’ agree box documents the agreement. In the case of a discordance, an additional dialog box automatically appears and the radiologist enters the reason for disagreement and then submits the case as a discrepancy. The system holds the discordance for 3 to 5 working days, then notifies the original radiologist via E-mail that a prior interpretation has been submitted for peer review, lists the submitted discrepancy reason, and provides a link to display the discordant report. The peer-review database is separate from the existing radiology information system (RIS). At the end of every month, summary reports of all peer-review activity are generated automatically. Initial benchmarks of our deployed system anticipate documentation of long-term random peer-review rate at greater than 50% of interpreted cases. The system enhances the peer-review process by integrating it with the normal interpretation workflow. The time to complete peer review using radStation is less than 1 second per normal case and less than 60 seconds for a discordant case. The E-mail notification system is fully automent in the data collection. This system has completely replaced a manual paper-based system. The integration of peer review directly into the radiologist’s interpretation workstation greatly enhances the capability to easily exceed JCAHO standards. The overall increase in peer-review documentation should continue to improve the ability to document a consistent high quality of patient care.

Coordinating patient care within radiology and across the enterprise

For the practice of radiology, the transition to filmless imaging operations has resulted in a fundamental transition to more efficient clinical operations. In addition, the electronic delivery of diagnostic studies to the bedside has had a great impact on the care process throughout the health care enterprise. The radiology information system (RIS) has been at the core of the transition to filmless patient care. In a similar manner, the electronic medical record (EMR) is fundamentally and rapidly transforming the clinical enterprise into paperless/digital coordination of care. The widespread availability of EMR systems can be predicted to continue to increase the level of coordination of clinical care within the EMR framework. For the radiologist, readily available clinical information at the point of interpretation will continue to drive the evolution of the interpretation process, leading to improved patient outcomes. Regardless of practice size, efficient workflow processes are required to best leverage the functionality of IT systems. The radiologist should be aware of the scope of the RIS capabilities that allow for maximizing clinical benefit, and of the EMR system capabilities for improving = clinical imaging practice and care coordination across the enterprise. Radiology departments should be actively involved in forming practice patterns that allow efficient EMR-based clinical practice. This summary article is intended to assist radiologists in becoming active participants in the evolving role of both the RIS and EMR systems in coordinating efficient and effective delivery across the clinical enterprise.

Comparison of spiral computed tomography versus conventional computed tomography multiplanar reconstructions of a fracture displacement phantom.

PURPOSE.The capabilities of spiral computed tomography (CT) versus conventional CT to represent minimal fracture displacements on multiplanar reconstruction images in a phantom model were evaluated. MATERIALS AND METHODS.A displacement phantom was created from Teflon and was scanned with conventional and spiral CT, at slice collimations of 2 mm, 3 mm, and 5 mm. Three Z-axis interpolation algorithms (360_LI, 180_LI and 180_HI) were employed to process the spiral image data into planar images. Displacements of 5 mm or less were represented in the phantom, and the resultant multiplanar reconstructions were analyzed for the precision of displacement representation. Specifically, the edge profiles of the reconstructed images were measured and compared. RESULTS.Spiral CT reconstruction edge profiles were similar to those of conventional CT when minimal table increments (3 mm/sec or less), and an advanced interpolation algorithm (180_LI) was employed. Images obtained with 360_LI interpolation manifested the effect of widened slice profile even when employing minimal table speeds. CONCLUSIONS.With minimal table increment (3 mm/sec or less) and a high-order interpolation algorithm (180_LI), spiral-CT-derived reconstructions demonstrate similar edge profile resolution to reconstructions obtained from conventional CT.

Comparison of half-dose and full-dose gadolinium MR contrast on the enhancement of bone and soft tissue tumors

ObjectiveTo evaluate the effect of half-dose intravenous gadolinium contrast on the enhancement of bone and soft tissue tumors.Materials and methodsThis study is HIPAA compliant and informed consent was waived by the institutional review board. An institutional database search was performed over a 1-year period for patients with full- and half-dose MR examinations performed for musculoskeletal oncologic indications. Examination pairs that were identical with regard to field strength and presence or absence of fat saturation were included, resulting in 29 paired examinations. When multiple, the lesion that was best delineated and enhanced well on the first examination in the pair was chosen, yielding 17 bone and 12 soft tissue. Five musculoskeletal radiologists blinded to dosages were asked to assess for a difference in enhancement when comparing the lesion on both examinations and to rate the degree of difference on a three-point scale. They were also asked to identify the examination on which the lesion enhanced less (tallied as low dose). Results were analyzed with the exact binomial test.ResultsThe readers perceived an enhancement difference in 41% (59/145) of studies (p = 0.03) and the majority were rated as “mild” (66%, 39/59). The readers did not accurately identify the low-dose examinations (54% correctly identified, 32/59, p = 0.60).ConclusionsHalf-dose gadolinium enhancement of lesions could not be accurately distinguished from full-dose enhancement upon review of the same lesion imaged at both concentrations.

Giant Cell Tumor of Cervical Spine Presenting as Acute Asphyxia: Successful Surgical Resection After Down-staging With Denosumab.

Study Design. Case report and literature review. Objective. To describe treatment of a unique case of acute airway obstruction by a large C7 giant cell tumor (GCT) with preoperative denosumab followed by surgical resection, and review the literature on this rare entity. Summary of Background Data. Standard treatment for GCTs includes surgical resection or curettage and packing. Large lesions in the spine may require preoperative therapy with denosumab, a human monoclonal antibody to RANKL, to facilitate surgery. It is highly unusual for GCT arising in cervical spine to present with acute asphyxia (requiring tracheostomy). Methods. We report a patient with large C7 GCT that caused tracheal compression with almost complete airway obstruction requiring emergency intubation. Results. The tumor responded to subcutaneously administered denosumab with marked decrease in size and relief of symptoms. Increased tumor mineralization in response to therapy facilitated subsequent successful surgical tumor resection. The patient remains symptom-free 2 years after surgery without tumor recurrence. Conclusion. Denosumab can shrink the size of large GCTs, providing symptom relief before surgery and facilitate tumor resection. Level of Evidence: 5

Radiologist's clinical information review workstation interfaced with digital dictation system

Efficient access to information systems integrated into the radiologist’s interpretation workflow will result in a more informed radiologist, with an enhanced capability to render an accurate interpretation. We describe our implementation of radStation, a radiologist’s clinical information review workstation that combines a digital dictation station with a clinical information display. radStation uses client software distributed to the radiologist’s workstation and central server software, both running Windows NT (Microsoft, Redmond, WA). The client sytem has integrated digital dictation software. The bar-code microphone (Boomerang, Dictaphone Corp, Stratford, CT) also serves as a computer input device forwarding the procedure’s accession number to the server software. This initiates multiple quaries to available lagacy databases, including the radiology information system (RIS), laboratory information system, clinic notes, hospital discharge, and operative report system. The three-tier architecture then returns the clinical results to the radStation client for display. At the conclusion of the dictation, the digital voice file is transferred to the dictation server and the client notifies the RIS to update the examination status. The system is efficient in its information retrieval, with queries displayed in about 1 second. The radStation client requires less than 5 minutes of radiologist training in its operation, given that its control interface integrates with the well-learned dictation process. The telephone-based dictation system, which this new system replaced, remains available as a back-up system in the event of an unexpected digital dictation system failure. This system is well accepted and valued by the radiologists. The system interface is quickly mastered. The system does not interrupt dictation workflow with the display of all information initiated with examination bar-coding. This system’s features could become an accepted model as a standard tool for radiologists.

Integrated radiologist's workstation enabling the radiologist as an effective clinical consultant

Since February 2000, radiologists at the M. D. Anderson Cancer Center have accessed clinical information through an internally developed radiologists clinical interpretation workstation called RadStation. This project provides a fully integrated digital dictation workstation with clinical data review. RadStation enables the radiologist as an effective clinical consultant with access to pertinent sources of clinical information at the time of dictation. Data sources not only include prior radiology reports from the radiology information system (RIS) but access to pathology data, laboratory data, history and physicals, clinic notes, and operative reports. With integrated clinical information access, a radiologistss interpretation not only comments on morphologic findings but also can enable evaluation of study findings in the context of pertinent clinical presentation and history. Image access is enabled through the integration of an enterprise image archive (Stentor, San Francisco). Database integration is achieved by a combination of real time HL7 messaging and queries to SQL-based legacy databases. A three-tier system architecture accommodates expanding access to additional databases including real-time patient schedule as well as patient medications and allergies.

Design considerations for advanced, clinically integrated, radiologist digital dictation system

Radiologists require efficient access to clinical information in order to increase the clinical accuracy of their interpretations. Any system developed to access clinical information must do so efficiently while dozens of examinations await interpretation. radStation is a clinical display/report dictation system that has been designed not only to provide an effective interface to unrelated legacy databases but also to effectively integrate into the existing dictation workflow of radiologists. The three-tiered system architecture provides for efficient access to existing legacy databases and allows for future expansion with additional middle-tier (business rules) servers that are able to maintain robust interfaces to legacy databases (the database tier). However, the system architecture is of little concern to a practicing radiologist when experiencing robust system response. The system requires almost no training to master and is well-accepted by a very busy oncological radiology specialty practice.