Matthew B. Morgan

The radiology digital dashboard: effects on report turnaround time.

As radiology departments transition to near-complete digital information management, work flows and their supporting informatics infrastructure are becoming increasingly complex. Digital dashboards can integrate separate computerized information systems and summarize key work flow metrics in real time to facilitate informed decision making. A PACS-integrated digital dashboard function designed to alert radiologists to their unsigned report queue status, coupled with an actionable link to the report signing application, resulted in a 24% reduction in the time between transcription and report finalization. The dashboard was well received by radiologists who reported high usage for signing reports. Further research is needed to identify and evaluate other potentially useful work flow metrics for inclusion in a radiology clinical dashboard.

Flying blind: using a digital dashboard to navigate a complex PACS environment.

Radiology workflows have become more distributed and complicated, and fewer tangible cues are available to the radiologist to help optimize task prioritization and selection. Additionally, faster scanners, more detailed exams, and increased demand for imaging services have precipitated a potential image overload for todays radiologists who are pressured to provide efficient, quality service in less time. Radiologists are faced with the task of operating within complex systems but are lacking tools to efficiently and effectively monitor these systems in real time. Dashboard technology can help address this deficiency in radiology and facilitate informed, optimized decisions about workflow. Possible areas of application include workflow consolidation, workload distribution, and urgency evaluation. Dashboards should be optimized, context-sensitive, customizable, and workflow-integrated. Further research is needed to identify the most important dashboard metrics, determine their optimal display, and validate their utility.

‘Wet Reads’ in the Age of PACS: Technical and Workflow Considerations for a Preliminary Report System

Communication between clinicians, technologists, and radi ologists has become more complex, with Picture Archiving and Communication Systems (PACS) now allowing the radiologist to be removed from the physical location of the patients and the site of imaging. With these changes, effective communication becomes an ongoing challenge. Efficient communication of study interpretations has also become a priority for radiologists as they struggle to maintain relevance and provide added value to patient care when clinicians have ready access to radiology images. The purpose of this paper is to share our experience in developing and implementing the Collaborative Notification System (CNS), a communication tool used to inform referring clinicians of urgent findings—a.k.a. “wet reads.” The system utilizes a system of web pages integrated into PACS for the sending and receiving of succinct messages to provide clinical information at the point of need. A second system of pager alerts provides notification of the need for such communication through a relatively unintrusive, one-way, acknowledged alert system. The CNS provides asynchronous, integrated communication for the reporting of urgent and emergent radiology findings in a complex, geographically distributed medical environment.

Informatics Leaders in Radiology: Who They Are and Why You Need Them

IT in health care has evolved rapidly over the past 20 years. The rise of the computer is at the core of these changes. Most agree that although these technologies have revolutionized the practice of medicine, they have additionally fostered a data revolution that is simultaneously useful and disruptive. The effective use and implementation of the right IT tools are critical to the success of the imaging profession. This article serves as a guideline to radiologists on how to build an effective IT division within an imaging enterprise from the perspective of leadership, management, and human resources. We address the process for building an IT team from the ground up and also provide recommendations for modifying an existing IT group to make it more effective. Paramount to this discussion is the concept of the imaging informatics professional and the advantage this type of training brings to a radiology department. In addition, we focus on the critical role of the physician informaticist as a liaison to bridge gaps among the IT, medical, and administrative functions in an organization.

Creation and Curation of the Society of Imaging Informatics in Medicine Hackathon Dataset

In order to support innovation, the Society of Imaging Informatics in Medicine (SIIM) elected to create a collaborative computing experience called a “hackathon.” The SIIM Hackathon has always consisted of two components, the event itself and the infrastructure and resources provided to the participants. In 2014, SIIM provided a collection of servers to participants during the annual meeting. After initial server setup, it was clear that clinical and imaging “test” data were also needed in order to create useful applications. We outline the goals, thought process, and execution behind the creation and maintenance of the clinical and imaging data used to create DICOM and FHIR Hackathon resources.

Toward a User-Driven Approach to Radiology Software Solutions: Putting the Wag Back in the Dog

The relationship between healthcare providers and the software industry is evolving. In many cases, industrys traditional, market-driven model is failing to meet the increasingly sophisticated and appropriately individualized needs of providers. Advances in both technology infrastructure and development methodologies have set the stage for the transition from a vendor-driven to a more user-driven process of solution engineering. To make this transition, providers must take an active role in the development process and vendors must provide flexible frameworks on which to build. Only then can the provider/vendor relationship mature from a purchaser/supplier to a codesigner/partner model, where true insight and innovation can occur.

Axillary lymph node FNA in women with breast cancer is a highly accurate procedure, so why are core biopsies being done?

Dear Dr. Bedrossian, Status of lymph nodes is the most important prognostic indicator for patients diagnosed with breast cancer. Assessment of axillary lymph nodes is therefore standard of care, and pre-surgical evaluation of axillary lymph nodes has become routine. The National Comprehensive Cancer Network (NCCN) Guidelines for Breast Cancer recommend sentinel lymph node biopsy for clinically negative lymph nodes. For clinically suspicious lymph nodes, the guidelines recommend sampling by either core needle biopsy or fine-needle aspiration (FNA). FNA can be performed by cytopathologists on palpable lymph nodes or by radiologists using ultrasound-guidance with or without a cytopathologist present for rapid on-site evaluation (ROSE) of the sample. In recent years at our institution, there has been a distinct switch in the type of procedure used for axillary lymph node sampling (Fig. 1). Prior to 2009, cytopathologists performed FNA on palpable axillary lymph nodes. Subsequently, radiologists performed ultrasound-guided FNA with a cytopathologist present for ROSE. In the last few years, the radiologists abandoned FNA entirely, preferring to take core needle biopsies only. A review of the literature shows the diagnostic accuracy of axillary lymph node FNA to be quite good, with sensitivity ranging from 65–99% and specificity from 80–100% (Table I). The results improve when the lymph nodes are clinically suspicious and when ultrasound is used. There are a number of variables that explain why accuracy ranges are reported, including whether the lymph nodes are clinically suspicious for involvement; the experience of the operator performing the biopsy; and the experience of the cytopathologist reading the slides, among others. But given the overall favorable results from the literature, we found it perplexing that core biopsy would be favored. In addition, a recent systematic review and meta-analysis found no significant difference in the accuracy of FNA and core needle biopsy (CNB). At our institution, radiologists are the first physicians to evaluate breast cancer patients, and they decide how to sample suspicious axillary lymph nodes. We hypothesized that radiologists believe FNA is less accurate than CNB at our institution. To address this, we undertook an institutional study to determine our own diagnostic accuracy of FNA of axillary lymph nodes and to compare our results against those reported at other institutions. Our study showed that FNA accuracy at our institution was consistent with (or even surpassed) previous published results of axillary lymph node FNA. Our study had two non-diagnostic cases (5%), a sensitivity of 96% and a specificity of 90%. There was one false-negative (2.6%), which had been called “less than optimal” during ROSE, and one false-positive, called lobular carcinoma during ROSE, but found on subsequent review to be histiocytes, a known mimic of lobular carcinoma (Fig. 2). Given these results, it was unlikely that suboptimal FNA performance was driving the switch to CNB. We then explored other reasons why CNB might be favored over FNA. *Correspondence to: Rachel E. Factor, M.D., Assistant Professor of Anatomic Pathology and Cytopathology, Huntsman Cancer Hospital, 1950 Circle of Hope, Room N3100, Salt Lake City, UT 84103, USA. Email: rachel.factor@path.utah.edu Received 18 June 2014; Revised 5 November 2014; Accepted 17 December 2014 DOI: 10.1002/dc.23251 Published online 28 January 2015 in Wiley Online Library (wileyonlinelibrary.com).

Abstract P3-07-07: Familial risk of breast density in extended Utah pedigrees

Background: Mammographic breast density (MBD) and family history are consistently associated with breast cancer risk, and breast density may account for a proportion of susceptibility to this disease. MBD has been shown to correlate in small cohort studies of twins and siblings. However, MBD has not been studied on a large scale in multi-generation families. We investigated the familial relative risk of MBD in the Utah population, as clustering of breast density in extended relatives may provide evidence for the role of genetics in breast density and inform screening recommendations. Methods: Using the Utah Population Database (UPDB), an extensive genealogical database linked to medical records) we identified 189,812 women ages 35-85 with pedigree information, who underwent digital mammography between 2005-2012, with no history of breast/ovarian cancer and no indication of tamoxifen/aromatase inhibitor use. Individuals with unusually frequent screening (>1/yr) or with inconsistent MBD assessments were not included. Subjects were categorized according to Breast Imaging-Reporting and Data System (BI-RADS®) composition classification at index mammogram available in radiology records of Intermountain Healthcare and University of Utah Healthcare systems, representing the majority of mammograms in Utah, as: (I) 0-25% fibroglandular densities (mostly fat); (II) 26-50% fibroglandular (scattered densities); (III) 51-75% fibroglandular (heterogeneously dense); or, (IV) >75% fibroglandular densities (extremely dense). Familial recurrence risks of MBD classification and breast cancer were estimated using Cox regression models in relatives (mothers, daughters, and sisters or 1st-degree; aunts, nieces, grandmothers, and granddaughters or 2nd-degree; first- and second-cousins) of probands classified as BI-RADS I (N=18,170) or BI-RADS IV (N=11,787), compared to those in the most common classifications, BI-RADS II (N=79,825) and III (N=80,030) combined. Women in the comparison group were randomly selected and matched 5:1 to probands on birth year. Results: Relatives of women with a history of extremely dense breasts (BI-RADS IV) were at increased relative risk (RR) of extremely dense breasts compared to women in BI-RADS II/III: 1st-degree, RR=2.3 (95%CI 2.0-2.7, P Conclusions: BI-RADS composition categories available from radiology records in the UPDB appear to be useful in assessing familial risk of MBD at the population level. Our results may inform screening guidelines in more distant as well as close relatives of women with a history of extremely dense breasts, whose families may be more susceptible to breast cancer. Citation Format: Karen Curtin, Leigh Neumayer, Matthew B Morgan, Matthew A Stein, Nicola J Camp, Geraldine P Mineau, Kerry G Rowe, Saundra S Buys. Familial risk of breast density in extended Utah pedigrees [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-07-07.

Adapting to the new realities of radiology resident education.

We read with interest the article titled “Cross-Sectional Examination Interpretation Discrepancies Between On-Call Diagnostic Radiology Residents and Subspecialty Faculty Radiologists: Analysis by Imaging Modality and Subspecialty” by Ruma et al [1] in the June 011 issue of JACR. We were leased to see that their analysis of 1,482 handwritten preliminary eports produced similar results to ur own analysis of 65,780 elecronic preliminary reports [2] and hat their breakdown by modality howed trends similar to ours. In particular, we agree with Ruma t al that the increased demand for 4-hour attending radiologist coverge may negatively affect radiology esident education by undermining he opportunity for autonomous ractice. In our experience, concerns bout resident education are given ittle weight by hospital administraors who are concerned (despite the vidence in the radiology literature) bout the medicolegal ramificaions of resident interpretations nd the inconvenience of discrepncies for emergency department taff members. Organized radiolgy has tried neither to measure the ffect of these changes nor to proose ways for residency programs to dapt to the new model of overight interpretation. If academic radiology is to coninue to provide residency training hat produces radiologists capable f functioning in high-stress clinial environments, we must conider alternative training methods hat permit graduated responsibilty across the 4 years of residency. e would be interested to know i

Workflow Testing and Workflow Engineering

When there is too much work and too few personnel, there are two main options: hire more staff or improve the efficiency of the existing employees. Generally, it is much cheaper and more satisfying to improve efficiency by identifying and removing workflow bottlenecks.