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I am excited to announce that Mayo Clinic has decided to permanently fund a 1-year fellowship position in Radiology Informatics. In the past, we had to compete with clinical fellows, which was a challenge when the fellow selection committee contained no informatics people. Now, that has changed, and we are excited to be able to select the person we feel best fits the profile of an informaticist. Mayo has traditionally been a unique organization, filling a spot between traditional academic sites and private practice. Our fellowship reflects that position, being heavily focused on practical project-based training, rather than didactic training. We have a broad range of skills in the informatics group, affording much latitude in the nature of the projects that we can entertain. I would encourage anyone thinking about a fellowship in informatics to seriously consider this career direction, and to submit an application for the Mayo program. Your application must be submitted by March 31 of the year preceding the appointment date.

Brad Erickson, MD, PhD
Radiology Informatics Fellowship Program Director

By C. Matthew Hawkins
Radiology Resident, UC Health – University of Cincinnati; @MattHawkinsMD

Extensive debate has transpired in the literature regarding the appropriateness, or lack thereof, of radiologists directly informing patients of the results of their imaging studies. Regardless of opinion, it has been tirelessly acknowledged that our current practice of rarely speaking to (or seeing) our patients needs some sort of remedy. There are, admittedly, legitimate legal concerns and collegial obstacles that have, to this point, prevented radiologists from seriously considering the practice of delivering results to patients [1, 2].  

Regardless – this question is likely a reflection of my egregious naivety, but – isn’t it time we somehow started communicating results to patients?  

This is not the platform to discuss the legal ramifications or moral/collegial responsibility of communicating results. I do concede that these issues present major dilemmas that must be solved prior to fully instituting a results-communication policy. But, even if we clear these hurdles, personally conveying results to patients as part of the current, RVU-driven workflow in a radiology department seems unrealistic. This is where IT can and must help. 

Perhaps patients could be asked how they would like their imaging results relayed to them when they schedule their imaging exam. They could elect to speak with the radiologist in person, have their results sent to them directly from the radiologist, or be old-fashioned and get the results from their referring clinician at a separate appointment.

Our work lists could be prioritized with stat/ER studies as the top priority followed by patients being seen in an outpatient clinic on the same day (these patients are unlikely to request a personal consultation with a radiologist since they are being seen by their referring clinician the same day) and patients who have requested a personal radiologist consult.  Prioritizing a work list this way would seem to provide an appropriate balance of service for referring clinicians and for patients. Consultation rooms, separate from reading rooms, with image-viewing capabilities would be necessary for face-to-face patient consults. After all, patients will want to see the images of their bodies, even if they’re normal. There would certainly be departmental design considerations required to make the process work, such as ensuring that the consult rooms are near the reading room. But, by sensibly prioritizing a work list, we can begin to see how relaying results to patients, in person, could realistically fit into a daily workflow.

Currently, patients make extra visits to their referring clinician’s office, often after extensive anxiety-provoking delays, so that results of their imaging studies can be conveyed – even for normal and unchanged studies. On the most rudimentary level, simply delivering “normal” and “stable” results to patients before they leave radiology departments would save the system significant cost and save patients enormous allotments of time. Plus, “normal” results do not take long to convey in person [1].

For patients who elect to have their results sent to them directly, rather than wait to speak to the radiologist in person, two possible communication methods come to mind. (Note: Sending a certified letter to patients, as we currently do in mammography, is an unacceptable option here. That was a great idea in 1980.) First, we could generate an electronic report on a secured web portal hosted by the department’s website. (Remember the multimedia reports I wrote about in my last post? This is where they come into play). A simple username and password is all it would require. And better yet, send them a text to notify them when their report is electronically available.

A second communication method for those truly wanting to maximize the potential of informatics would be to offer virtual video conferencing consults with patients. With remote screen control enabled, a radiologist and patient could engage in a video-chat conversation about the patient’s exam while viewing imaging findings, as the radiologist would control what images are displayed as well as cursor movement. Patients could electronically schedule these “appointments” from home, sometimes avoid unnecessary trips to physician offices, and simultaneously obtain a greater appreciation for the value provided by radiologists. (Not to peek too far down the rabbit hole, but imagine the second opinion consultation possibilities with a communication tool such as this…).

Obviously, new billing codes for clinical consultation would have to be established for a results notification process to work, particularly if the process temporarily extracts the radiologists from the traditional RVU-generating daily grind. Also, as mentioned previously, legal ramifications will have to be hashed out and the preferences of referring clinicians, regarding what results they would and would not want radiologists conveying to their patients, must be clarified. But, when the time comes, solutions for implementing a result-notification process must come from our IT community so that when we do it, we do it right.

1. Smith JN.  Gunderman RB.  Should we inform patients of radiology results?  Radiology.  May 2010.  255:317-321.
2. Berlin L.  Communicating results of all radiologic examinations directly to patients: Has the time come?  AJR.  Dec 2007.  189(6):1275-1282.

By Supriya Gupta, MD
Research Fellow, Imaging Informatics, Department of Abdominal Imaging, Massachusetts General Hospital, Harvard Medical School

The first lesson in a computer class teaches you that “data” are raw collections of facts and figures whereas “information” is meaningful data. Radiology departments are teeming with raw data in the form of text reports and images. More recently, increasing numbers of hospitals have geared a lot of their resources toward retrieving meaningful information for quality control, outcome analysis, clinical monitoring, and providing feedback for altering practice. While we are currently developing advanced data mining tools for information analysis and retrieval, the future holds a possibility of metamorphosing these tools into another realm. The foundation for the latter has been laid presently by implementing technology in healthcare systems and the growing emphasis on electronic health records. This in turn creates several opportunities for exploring and mobilizing these systems for enhanced visualization of data.

The “Now” and the “Need”

Relational queries and associative interactions between various report elements form the basis of the majority of the existing data mining technologies widely used in healthcare settings. Many of these use existing medical lexicons like SNO-MED, RadLex, and Natural Language Processing platforms to create a searchable database. Traditionally, informatics has been a zone of administrators, technologists, finance managers, and other people in the department who would like to know information about the real time operational statistics of the radiology department. How many cases are read in how much time, by whom, and where there any delays in the workflow and how can we get around these delays? While these functions form the backbone of the radiology workflow, their impact on the work style of the radiologist is minimal.

As more and more of these systems are now being geared into the clinics, it becomes imperative for a radiologist to not only familiarize themselves with these gadgets, but the innovators need to tailor these systems (or develop new applications) into a more user-friendly clinical use case format. There are numerous applications currently existing across various US hospitals which would gather the required data with a single mouse click, however, the clinicians, including the radiologists and the physicians, usually require some bit of training before they can start feeling comfortable with these systems. Hence, the need to evolve these systems into simple web- and windows-based formats which can be easily and quickly learned by the radiologists and physicians is increasingly growing.

Mark Twain once said, “You can’t depend on your eyes when your imagination is out of focus.” This holds more true for radiology than any other branch of medicine. Not only is finding the lesion important on an image for a radiologist, but he needs to create a visual replica of the patient scan mentally to actually understand the temporal association of that finding with the other anatomical organs in the body for providing an accurate impression. Not only that, he has to frequently go back into the medical records for previous reports to document if a similar lesion was present or not. This going back and forth can be very time consuming sometimes. One potential solution could be an integrated real-time data mining system. 

The “Future” and the “Possibility”

It would be potentially desirable by both physicians and patients to not have to read through the complicated text report of radiologist and search for the actual impression. The phrase “A picture is worth a thousand words (of radiology text report!)” can be extrapolated onto the data mining applications to create a visual representation of the radiology report findings so that the reader of the report does not have to read through the entire text. Since there may be numerous occasions where findings cannot be completely deciphered or questionable, the importance of a written report cannot be overruled. The visualization of the report can just provide a supplementary or an add-on feature which can be referred to in case of emergency or revisions. There would always be the text report available to fall back on for further details or any clarifications. Medical ontology in the dictated report can be analyzed and normalized to map to a human model or alternatively surface rendered three dimensional models can be built into the reports customized for each patient. These techniques might seem a little troublesome at first but they seem to hold a cost-effective solution in the long run. While acquiring and presenting the real DICOM data within the report would be the ideal solution, they may not be very easy to browse or might need some expertise to read. Mapping of that data onto a human model in an easy to understand format could provide an easier option just like the anatomy diagrams.

Even for the radiologist at the time of dictation, while he is writing the impression, it may be reasonable to employ tools to find the relevant imaging findings which could be highlighted and help him write the final impression. It has been found that many a times there is a discrepancy within the same report in terms of laterality of imaging findings (right vs. left) or important incidental findings might be missed out in the final impression. Real-time data mining technology can be extended to aid radiologists to avoid such situations. These can also be used for sending important findings alert to the referring physicians. Simple data mining solutions can be used to create an easy to navigate radiology record of a patient where the physician or the radiologist can easily select the exam/series he is interested in, from the huge list of exams and series in a given patient.

I believe the potential of imaging informatics and data mining technologies is infinite and can achieve wonders if we further integrate it with medical informatics as a part of every patient record. Various informatics-intensive imaging departments have diverted their resources for tapping into the vast potential of data mining of the radiology records and have created numerous in-house applications for research and development purposes. It would be interesting if these resources could be synchronized to achieve mutual benefits and feedback for quality control, outcome analysis, and development of guidelines.

By C. Matthew Hawkins
Radiology Resident, UC Health – University of Cincinnati; @MattHawkinsMD

The idea of creating multimedia radiology reports is certainly not new. [1] More recently, it has been shown to save time for referring clinicians and radiologists. [2] These well-done studies focused on embedding pertinent images, such as jpeg files, into our radiology reports. However, I think most would agree that since we’ve entered the era of smartphones and tablets with clinical applications, simply embedding jpegs into reports does not truly capitalize on the potential of today’s interactive multimedia applications.

Conversely, cramming reports full of new-age technological features does not necessarily make them beneficial for the referring clinicians, radiologists, or patients. New features must be tested with the opinions of our referring clinicians and patients entrenched in the development process.  

In light of impending increased tablet utilization by care providers and escalating on-line dependence and consumerism by patients, we could begin to prognosticate what multimedia features might be perceived to improve the value of our reports.

When a radiologist describes a finding and states the associated image number(s), a referring clinician could hover the mouse over the text description or tap a hyperlink within the report, which would immediately “pop-up” pertinent images on the screen. These images could be automatically retrieved by the radiology report application, rather than manually embedded, if the RIS, PACS, and reporting system are fully integrated. Would referring clinicians find it beneficial if these images could be further manipulated? Screen gestures to zoom and pan, annotation capabilities for their personal record, and teaching file storage may be appealing features for clinical colleagues. I could certainly envision a scenario where a junior level resident on the floor, during rounds, would view a radiology report, acquire the pertinent images via report-embedded hyperlinks, and show the staff physician a zoomed in view of a subtle fracture on his/her tablet or iPad. This resident could then forward this image onto the orthopedic team along with the consult request. An interactive multimedia reporting system makes this scenario feasible.

We could also use multimedia features to improve the perceived value of reports that are distributed to patients. Rather than simply receiving a paper with foreign words detailing our findings and impressions, New Age patients who are taking greater control of their healthcare decisions might prefer images with annotations to help identify described findings. The images in electronic patient-available reports could be saved by patients for their personal records and then transferred to the cloud, by patients themselves, for storage and future inter-facility sharing/transfer. Perhaps automatically generated hyperlinks within reports taking patients to websites with information about their diagnosis, or maybe even a list of physicians within the health system/ACO who care for patients with their diagnosis, would be an appealing feature for patients.

As appealing as these multimedia reporting features seem on the surface, our clinical colleagues and patients must be included in the process. Perhaps our clinical colleagues would always prefer to have access to the entire data set, rather than the radiologist-selected/annotated images. They might prefer a results notification feature as part of the image-viewing/reporting application. They may not, though.  

Patients might like pictures of the reporting radiologist and a brief biography or CV to accompany their report. Perhaps rather than receiving contact information for physicians within the ACO that treat their diagnosis, they would prefer to contact the radiologist directly for an in-person or virtual appointment to review their imaging study.

Before we spend significant dollars and human capital developing and trialing various technologically advanced reporting systems, we need to survey our target audience. In other words, develop our product around the ideas and wants of our patients and referring clinicians rather than trial a product full of features that we think are great ideas.

The future of radiology reporting is drenched with potential – this much we know. And, by proactively anticipating technological advances in healthcare, thinking about new ways to generate radiology reports with an unlimited scope and thoroughly understanding the needs of our clinicians and patients, we will optimize the perceived value of our reports.

1. Reiner B, Siegel E.  Radiology reporting:returning to our image-centric roots.  Am J Roentgenol 2006; 187:1151-5.
2. Iyer VR, etal.  Added Value of Selected Images Embedded into Radiology Reports to Referring Clinicians.  J Am Coll Radiol 2010; 7:205-210.

By Marc D. Kohli, MD
Director of Quality and Safety and Assistant Professor, Department of Radiology and Imaging Sciences, Indiana University School of Medicine

With the passage of the Healthcare Reform Bill, healthcare systems have been offered a new model for care delivery, the accountable care organization (ACO).  Anyone trying to understand what an ACO really means will likely be instantly confused (unless you’ve already read this JACR article). The term applies to a spectrum of different models that ultimately, as with most things, boil down to money.  The law allows hospital systems to adapt a new model for medicare patient payment ranging from incentive payments for quality care and low costs, to a full-risk model where the ACO is paid a risk-adjusted capitation for each patient.

In the full-risk model, fee-for-service goes away and radiology flips overnight from being a profit-center to a cost-center.  Indiana University Health, my healthcare system, is a statewide system that integrates services ranging from home health to primary care, neurosurgery, oncology, and a large transplantation service.  Due to our size and breadth, leadership has decided to take the necessary steps to transition to an ACO.  The full transformation impacts the entire system from creation of medical homes, to improving pharmacy services, to decreasing inappropriate imaging utilization by 10%, which is the #1 goal of the ambulatory task force. 

Luckily, our radiology practice has been asked to explore pathways to reduce inappropriate utilization.  I say luckily, because my relationship with one of the physicians leading the charge was forged through an unscheduled conversation in the physician’s lounge.  Through my informatics experience at SIIM and other meetings, I was able to steer the discussion away from a dreaded radiology benefit manager toward a decision support system (DSS).  In addition, our early involvement ensures radiology’s participation in building rules for the DSS, thus enabling our radiology practice to guide appropriate utilization rather than simply becoming a victim of irrational reductions.  As radiology becomes a cost center, if we don’t play a larger role in appropriate utilization, we’ll end up on the menu.

In summary, change in healthcare is a reality and informatics is central to improving the process.  I urge you to start talking with leadership at your own institution to reserve your seat at the table.

By Safwan S. Halabi, MD
Director, Imaging Informatics, Henry Ford Health System Department of Radiology

“See one. Do one. Teach one.” This age-old mantra among medical professionals succinctly describes the method of knowledge and skill transfer from the trainer to the trainee and vice versa. As a junior informatics professional, I have been asked on numerous occasions in regards to how I entered the field of imaging informatics and what experience and knowledge is required. The previously described “method” quickly came to mind to help the budding informaticist obtain the knowledge and skills necessary to thrive in this relatively new specialty.

“See One” / “Seek One”

Any mastery of a skill requires exposure to the one performing the skill.  It is the masters, mentors, and patrons who sacrifice their prestige, time, and funds to develop a new generation of professionals. All of the successful informatics professionals who I have encountered attest to the fact that their success is directly related to the mentors who not only exposed them to the field, but also provided the tools and networking necessary to develop their own identity as informaticists. 

Medical informatics professionals pride themselves with the knowledge and skills that allow them to act as liaisons between the IT, administrative, and clinical operations of a health system. However, to be able to navigate these treacherous and politically charged landscapes, it requires a guide or mentor to help understand the culture and personalities of the natives. A good mentor can equip the mentee with the necessary knowledge and tools, which in turn inculcates confidence and expertise. 

Therefore, my advice to those of you that want to become informatics professionals is to:
(1) “See One” by exposing yourself to the different  aspects of the field: shadow a Chief Medical Information Officer (CMIO); read the literature from, and attend the conferences of various informatics societies including SIIM, AMIA, and HIMSS; participate in the implementation of medical software/hardware or other IT workflow process; and,
(2) “Seek One” by finding a mentor who shares your goals and aspirations and is someone you can trust and get along with. It is also important that the mentor is able to connect you to other people in the field for networking and collaboration. SIIM has recently established a mentoring resource located here: http://www.siimweb.org/mentoring/. 

“Do One”

There are infinite opportunities to engage in Medical and Imaging Informatics endeavors due to the vast spectrum of topics that the field encompasses. Some of the major categories and learning tracks in Imaging Informatics can be found here: http://www.siim2011.org/learning_tracks.html. 

Many informatics professionals stumbled into the field while working on various projects in their departments like the implementation of a PACS, speech recognition system, quality, safety, and workflow improvement process, or work space design and ergonomics. Many of these individuals (including myself) experienced a deep sense of accomplishment with the successful implementation of a new piece of software/hardware or development of a more efficient and safer workflow process. As one of my mentors related to me, this “Do One” experience in informatics can be as important as fixing a fracture in the Emergency Department or controlling a patient’s high blood pressure. 

With the help of a mentor, consider starting your own project. Start simple and small. Look for the low hanging fruit in your unique environment. Is there an opportunity to eliminate a paper process and convert it to a digital process? Can communication between a medical provider and patient be improved? Is there a more efficient method to teach a new skill or knowledge to a medical student? Something as simple as reducing the number of mouse clicks to perform a task can significantly reduce injury of the person performing the task and may also deliver critical information in a more timely matter, which effectively improves patient care and safety. These are some of the basic questions that have lead to significant advances in the field of informatics. 

“Teach One”

Now that you have a few projects under your belt and are getting daily calls to help fix your colleagues’ notebook computer and smartphone, you are now ready to spread the gospel. Consider forming an informatics group of like-minded individuals at work or by joining social networking sites like Facebook, LinkedIn, and Google+, which have dedicated informatics groups and blogs. Start including students, residents, and fellows in your projects. Develop clinical user groups to get feedback on systems or workflows that you have implemented. Collaborate with other departments to share your knowledge and help guide their informatics endeavors. 

There is no turning back from the age of information. It is up to the informatics professional to manage and present this information in a way that benefits current and future generations. Are you up for the challenge?