Peter B. Sachs

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.

Imaging study protocol selection in the electronic medical record.

WHAT WE SET OUT TO DO The Department of Radiology at the University of Colorado Hospital performs approximately 200 CT and MR studies per day. The imaging ordering and protocoling selection process had until recently been entirely paper based. Each order generated a paper request, which was then passed on to the radiologist in the appropriate subspecialty along with a section-specific protocol sheet. The scheduling office in our department distributed a large stack of these protocoling sheets twice daily to each section. Bassignani et al [1] described a “paperless” protocol selection process in 2010 that involved scanning documents into the PACS for review by a radiologist at the time of protocoling. Although this significantly decreased the manual transfer of paper, it was not a truly electronic process. The University of Colorado Hospital implemented an electronic medical record (EMR) in September 2011. With the deployment of the EMR, the order-entry, order-generation, and scheduling processes all became electronic. At the time of implementation, the expectation was that we would immediately be able to shift to electronic protocol selection of higher-level imaging studies (CT and MR), eliminating the voluminous amounts of paper and the related faxing of orders. A mechanism for this was embedded in our EMR. We envisioned the workflow as a simple progression from clinician order entry to radiologist protocol selection to authorization and scheduling of the examination to performance of the examination. WHAT WAS THE PROBLEM? Our actual workflow turned out to be quite complicated (Fig. 1). Although our EMR analysts had designed a very simple electronic protocol selection form triggered at order entry, this did not accommodate most aspects of this workflow. The simplified form that was created assuming a linear workflow failed for 10 reasons:

Process for Managing and Optimizing Radiology Work Flow in the Electronic Heath Record Environment

Electronic health record (EHR) implementation has dramatically impacted all facets of radiology workflow. Many departments find themselves unprepared for the multiple issues that surface following EHR deployment and the ongoing need for workflow optimization. This paper reviews the structure and processes utilized by the team, developed at the University of Colorado Hospital to evaluate, prioritize, and implement requests for workflow repairs and improvements within the EHR. The evolution of this team as the academic hospital formed a health system with two community hospital sites is also described. This structure may serve as a useful template for others considering EHR deployment or struggling to manage radiology workflow within an existing EHR environment.

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.

Radiographic Review of Current Therapeutic and Monitoring Devices in the Chest

Chest radiographs are obtained as a standard part of clinical care. Rapid advancements in medical technology have resulted in a myriad of new medical devices, and familiarity with their imaging appearance is a critical yet increasingly difficult endeavor. Many modern thoracic medical devices are new renditions of old designs and are often smaller than older versions. In addition, multiple device designs serving the same purpose may have varying morphologies and positions within the chest. The radiologist must be able to recognize and correctly identify the proper positioning of state-of-the-art medical devices and identify any potential complications that could impact patient care and management. To familiarize radiologists with the arsenal of newer thoracic medical devices, this review describes the indications, radiologic appearance, complications, and magnetic resonance imaging safety of each device. ©RSNA, 2018.

CT imaging of complications of aortic intramural hematoma: a pictorial essay

Aortic intramural hematoma (IMH) is a pathologic process with a clinical presentation identical to aortic dissection and associated with significant morbidity and mortality. Radiologists must be familiar with the imaging appearances of IMH as computed tomography (CT) plays a critical role in both diagnosis and patient management. The course of IMH is variable and the process may regress, remain stable, or progress in extent and therefore imaging findings associated with a negative prognosis must be recognized and included in the formal radiology report. Potentially life-threatening complications and findings associated with IMH include hemopericardium and cardiac tamponade, coexisting aortic dissection, ulcer-like projection, intramural blood pool, and extension of hematoma along the pulmonary or coronary arteries, which are identifiable with aortic protocol CT. The purpose of this pictorial review is to provide the reader with an image-based review of the diagnostic criteria, related complications, and associated critical prognostic features in patients presenting with aortic IMH.

CT and MR Protocol Standardization Across a Large Health System: Providing a Consistent Radiologist, Patient, and Referring Provider Experience

Building and maintaining a comprehensive yet simple set of standardized protocols for a cross-sectional image can be a daunting task. A single department may have difficulty preventing “protocol creep,” which almost inevitably occurs when an organized “playbook” of protocols does not exist and individual radiologists and technologists alter protocols at will and on a case-by-case basis. When multiple departments or groups function in a large health system, the lack of uniformity of protocols can increase exponentially. In 2012, the University of Colorado Hospital formed a large health system (UCHealth) and became a 5-hospital provider network. CT and MR imaging studies are conducted at multiple locations by different radiology groups. To facilitate consistency in ordering, acquisition, and appearance of a given study, regardless of location, we minimized the number of protocols across all scanners and sites of practice with a clinical indication-driven protocol selection and standardization process. Here we review the steps utilized to perform this process improvement task and insure its stability over time. Actions included creation of a standardized protocol template, which allowed for changes in electronic storage and management of protocols, designing a change request form, and formation of a governance structure. We utilized rapid improvement events (1 day for CT, 2 days for MR) and reduced 248 CT protocols into 97 standardized protocols and 168 MR protocols to 66. Additional steps are underway to further standardize output and reporting of imaging interpretation. This will result in an improved, consistent radiologist, patient, and provider experience across the system.

Launchpad for Onboarding New Faculty Into Academic Life

We developed a faculty professional development seminar series in order to facilitate the integration of our numerous new faculty into academics. The changing nature of the healthcare system, increasing clinical and administrative responsibility, and lack of access to senior mentors can hinder junior faculty productivity and possibly increase attrition. Given that no ready-made resources existed to address these issues we established a Professional Development Committee, developed a curriculum that covers relevant topics including promotion, mentorship, conflict management and feedback, and effective presentation of scientific data, and instituted changes iteratively based upon feedback. We used surveys from successive years of this seminar series to assess effectiveness, and our data demonstrate that our Professional Development Seminar Series was valued by its participants and that individual lectures improved from year to year. While it is too early to determine whether our efforts will lead to long-term changes in promotion success or faculty retention, our initial data are promising.