A major challenge for radiologists is obtaining meaningful clinical follow-up information for even a small percentage of cases encountered and dictated. Traditional methods, such as keeping medical ...record number follow-up lists, discussing cases with rounding clinical teams, and discussing cases at tumor boards, are effective at keeping radiologists informed of clinical outcomes but are time intensive and provide follow-up for a small subset of cases. To this end, the authors developed a picture archiving and communication system-accessible electronic health record (EHR)-integrated program called Correlate, which allows the user to easily enter free-text search queries regarding desired clinical follow-up information, with minimal interruption to the workflow. The program uses natural language processing (NLP) to process the query and parse relevant future clinical data from the EHR. Results are ordered in terms of clinical relevance, and the user is e-mailed a link to results when these are available for viewing. A customizable personal database of queries and results is also maintained for convenient future access. Correlate aids radiologists in efficiently obtaining useful clinical follow-up information that can improve patient care, help keep radiologists integrated with other specialties and referring physicians, and provide valuable experiential learning. The authors briefly review the history of automated clinical follow-up tools and discuss the design and function of the Correlate program, which uses NLP to perform intelligent prospective searches of the EHR.
RSNA, 2017.
Abstract
Electronic health records (EHRs) offer decision support in the form of alerts, which are often though not always interruptive. These alerts, though sometimes effective, can come at the cost ...of high cognitive burden and workflow disruption. Less well studied is the design of the EHR itself—the ordering provider’s “choice architecture”—which “nudges” users toward alternatives, sometimes unintentionally toward waste and misuse, but ideally intentionally toward better practice. We studied 3 different workflows at our institution where the existing choice architecture was potentially nudging providers toward erroneous decisions, waste, and misuse in the form of inappropriate laboratory work, incorrectly specified computerized tomographic imaging, and excessive benzodiazepine dosing for imaging-related sedation. We changed the architecture to nudge providers toward better practice and found that the 3 nudges were successful to varying degrees in reducing erroneous decision-making and mitigating waste and misuse.
Purpose
To create an algorithm able to accurately detect IVC filters on radiographs without human assistance, capable of being used to screen radiographs to identify patients needing IVC filter ...retrieval.
Methods
A primary dataset of 5225 images, 30% of which included IVC filters, was assembled and annotated. 85% of the data was used to train a Cascade R-CNN (Region Based Convolutional Neural Network) object detection network incorporating a pre-trained ResNet-50 backbone. The remaining 15% of the data, independently annotated by three radiologists, was used as a test set to assess performance. The algorithm was also assessed on an independently constructed 1424-image dataset, drawn from a different institution than the primary dataset.
Results
On the primary test set, the algorithm achieved a sensitivity of 96.2% (95% CI 92.7–98.1%) and a specificity of 98.9% (95% CI 97.4–99.5%). Results were similar on the external test set: sensitivity 97.9% (95% CI 96.2–98.9%), specificity 99.6 (95% CI 98.9–99.9%).
Conclusion
Fully automated detection of IVC filters on radiographs with high sensitivity and excellent specificity required for an automated screening system can be achieved using object detection neural networks. Further work will develop a system for identifying patients for IVC filter retrieval based on this algorithm.
Graphical abstract
The Appropriate Use Criteria Program, enacted by the Centers for Medicare & Medicaid Services in response to the Protecting Access to Medicare Act of 2014 (PAMA), aims to reduce inappropriate and ...unnecessary imaging by mandating use of clinical decision support (CDS) by all providers who order advanced imaging examinations (magnetic resonance imaging; computed tomography; and nuclear medicine studies, including positron emission tomography). Beginning 1 January 2020, documentation of an interaction with a certified CDS system using approved appropriate use criteria will be required on all Medicare claims for advanced imaging in all emergency department patients and outpatients as a prerequisite for payment. The Appropriate Use Criteria Program will initially cover 8 priority clinical areas, including several (such as headache and low back pain) commonly encountered by internal medicine providers. All providers and organizations that order and provide advanced imaging must understand program requirements and their options for compliance strategies. Substantial resources and planning will be needed to comply with PAMA regulations and avoid unintended negative consequences on workflow and payments. However, robust evidence supporting the desired outcome of reducing inappropriate use of advanced imaging is lacking.
Purpose To demonstrate the feasibility of contrast material-enhanced ulrasonographic (US) nephrostograms to assess ureteral patency after percutaneous nephrolithotomy (PCNL) in this proof-of-concept ...study. Materials and Methods For this HIPAA-compliant, institutional review board-approved prospective blinded pilot study, patients undergoing PCNL provided consent to undergo contrast-enhanced US and fluoroscopic nephrostograms on postoperative day 1. For contrast-enhanced US, 1.5 mL of Optison (GE Healthcare, Oslo, Norway) microbubble contrast agent solution (perflutren protein-type A microspheres) was injected via the nephrostomy tube. Unobstructed antegrade ureteral flow was defined by the presence of contrast material in the bladder. Contrast-enhanced US results were compared against those of fluoroscopic nephrostograms for concordance. Results Ten studies were performed in nine patients (four women, five men). Contrast-enhanced US demonstrated ureteral patency in eight studies and obstruction in two. One patient underwent two studies, one showing obstruction and the second showing patency. Concordance between US and fluoroscopic assessments of ureteral patency was evaluated by using a Clopper-Pearson exact binomial test. These results were perfectly concordant with fluoroscopic nephrostogram results, with a 95% confidence interval of 69.2% and 100%. No complications or adverse events related to contrast-enhanced US occurred. Conclusion Contrast-enhanced US nephrostograms are simple to perform and are capable of demonstrating both patency and obstruction of the ureter. The perfect concordance with fluoroscopic results across 10 studies demonstrated here is not sufficient to establish diagnostic accuracy of this technique, but motivates further, larger scale investigation. If subsequent larger studies confirm these preliminary results, contrast-enhanced US may provide a safer, more convenient way to evaluate ureteral patency than fluoroscopy.
RSNA, 2016 Online supplemental material is available for this article.
Ultrasound-guided percutaneous nephrolithotomy (PCNL) has become increasingly utilized. Patients with nondilated collecting systems represent a challenge: the target calix is often difficult to ...visualize. Here we report pilot study results for retrograde ultrasound contrast injection to aid in percutaneous renal access during ultrasound-guided PCNL.
From April to July 2016, consecutive patients over the age of 18 years with nondilated collecting systems on preoperative imaging who presented for PCNL were enrolled. B-mode ultrasound imaging was compared with contrast-enhanced mode with simultaneous retrograde injection of Optison™ via an ipsilateral ureteral catheter.
Five patients (four males and one female) with renal stones underwent PCNL with retrograde ultrasound contrast injection during the study period. Mean body mass index was 28.3 ± 5.6 kg/m
and mean stone size was 24.5 ± 12.0 mm. Under B-mode ultrasound, all patients demonstrated nondilated renal collecting systems that appeared as hyperechoic areas, where it was difficult to identify a target calix for puncture. Retrograde contrast injection facilitated delineation of all renal calices initially difficult to visualize under B-mode ultrasound. Renal puncture was then performed effectively in all cases with a mean puncture time of 55.4 ± 44.8 seconds. All PCNL procedures were completed without intraoperative complications and no adverse events related to ultrasound contrast injection occurred.
Retrograde ultrasound contrast injection as an aide for renal puncture during PCNL is a feasible technique. By improving visualization of the collecting system, it facilitates needle placement in challenging patients without hydronephrosis. Future larger scale studies comparing its use to standard ultrasound-guided technique will be required to validate this concept.
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