Patient Attitudes About Viewing Their Radiology Images Online: Preintervention Survey.

BACKGROUND: Although patient data is available through electronic portals, little information exists about the benefits and/or challenges of providing patients with online access to their radiology images. OBJECTIVE: The aims of this quality improvement project were to understand patient attitudes toward being able to view their radiology images online and determine how information should be presented to ensure the images are helpful to the patients, rather than causing confusion and anxiety. METHODS: An online survey of consumers was conducted to evaluate attitudes toward online access to personal radiological images. RESULTS: A total of 105 responses were received from 686 community members (15.3%). Of 105 consumers, 94 (89.5%) reported a desire to have access to the radiology images within their online patient portal; 86.7% (91/105) believed it would help them better understand their medical conditions and 81.0% (85/105) said this would help them feel more in control of their care. Most respondents (74/105, 70.5%) said it would help them feel reassured that their doctor was doing the right thing, and 63.8% (67/105) said it would increase their level of trust in their doctor. Among surveyed patients, 78.1% (82/105) valued viewing their radiology images online, while 92.4% (97/105) valued their online radiology reports. Most patients (69/105, 65.7%) wished to discuss their results with their ordering clinician, 29.5% (31/105) wished to discuss with their interpreting radiologist, and 3.8% (4/105) wished to share their images on social media. The biggest potential concern among 23.8% (25/105) was that the images would be confusing. CONCLUSIONS: A large majority of surveyed patients desired the ability to view their radiology images online and anticipated many benefits and few risks. Health care organizations with electronic health records and online patient portals should consider augmenting their existing portals with this highly desired feature. To avoid the biggest patient concern, radiology reports should accompany images. Patients wanted to discuss their results with their ordering physician and their interpreting radiologist. Some even would like to share results on social media. Further research on the actual experience with such a tool will be needed.

Lung Cancer Screening, Version 3.2018, NCCN Clinical Practice Guidelines in Oncology.

Lung cancer is the leading cause of cancer-related mortality in the United States and worldwide. Early detection of lung cancer is an important opportunity for decreasing mortality. Data support using low-dose computed tomography (LDCT) of the chest to screen select patients who are at high risk for lung cancer. Lung screening is covered under the Affordable Care Act for individuals with high-risk factors. The Centers for Medicare & Medicaid Services (CMS) covers annual screening LDCT for appropriate Medicare beneficiaries at high risk for lung cancer if they also receive counseling and participate in shared decision-making before screening. The complete version of the NCCN Guidelines for Lung Cancer Screening provides recommendations for initial and subsequent LDCT screening and provides more detail about LDCT screening. This manuscript focuses on identifying patients at high risk for lung cancer who are candidates for LDCT of the chest and on evaluating initial screening findings.

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 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.

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.

Lung cancer screening, version 1.2015: featured updates to the NCCN guidelines.

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Lung Cancer Screening provide recommendations for selecting individuals for lung cancer screening, and for evaluation and follow-up of nodules found during screening, and are intended to assist with clinical and shared decision-making. These NCCN Guidelines Insights focus on the major updates to the 2015 NCCN Guidelines for Lung Cancer Screening, which include a revision to the recommendation from category 2B to 2A for one of the high-risk groups eligible for lung cancer screening. For low-dose CT of the lung, the recommended slice width was revised in the table on "Low-Dose Computed Tomography Acquisition, Storage, Interpretation, and Nodule Reporting."

Interventional radiology workflow management in the electronic medical record.

The electronic medical record (EMR) has significantly improved efficiency in many areas of radiology workflow. Following implementation of an electronic protocol selection process for cross-sectional imaging at the University of Colorado Hospital, the interventional radiology (IR) division desired to have a similar tool. Evaluation of the IR workflow demonstrated the need for a multilayered solution, which accounted for consultation, physician review, authorization and scheduling, pre-procedural nursing evaluation, physician rounding, and resource allocation and prioritization. This paper outlines the rationale for and components of this process.

Electronic workflow for imaging in clinical research.

In the transition from paper to electronic workflow, the University of Colorado Health System's implementation of a new electronic health record system (EHR) forced all clinical groups to reevaluate their practices including the infrastructure surrounding clinical trials. Radiological imaging is an important piece of many clinical trials and requires a high level of consistency and standardization. With EHR implementation, paper orders were manually transcribed into the EHR, digitizing an inefficient work flow. A team of schedulers, radiologists, technologists, research personnel, and EHR analysts worked together to optimize the EHR to accommodate the needs of research imaging protocols. The transition to electronic workflow posed several problems: (1) there needed to be effective communication throughout the imaging process from scheduling to radiologist interpretation. (2) The exam ordering process needed to be automated to allow scheduling of specific research studies on specific equipment. (3) The billing process needed to be controlled to accommodate radiologists already supported by grants. (4) There needed to be functionality allowing exams to finalize automatically skipping the PACS and interpretation process. (5) There needed to be a way to alert radiologists that a specialized research interpretation was needed on a given exam. These issues were resolved through the optimization of the "visit type," allowing a high-level control of an exam at the time of scheduling. Additionally, we added columns and fields to work queues displaying grant identification numbers. The build solutions we implemented reduced the mistakes made and increased imaging quality and compliance.

Brief report: airways abnormalities and rheumatoid arthritis-related autoantibodies in subjects without arthritis: early injury or initiating site of autoimmunity?

OBJECTIVE: To evaluate the presence of pulmonary abnormalities in rheumatoid arthritis (RA)-related autoantibody-positive subjects without inflammatory arthritis. METHODS: Forty-two subjects who did not have inflammatory arthritis but were positive for anti-cyclic citrullinated peptide antibodies and/or ≥2 rheumatoid factor isotypes (a profile that is 96% specific for RA), 15 autoantibody-negative controls, and 12 patients with established seropositive early RA (<1-year duration) underwent spirometry and high-resolution computed tomography (HRCT) lung imaging. RESULTS: The median age of autoantibody-positive subjects was 54 years, 52% were female, and 38% were ever-smokers; these characteristics were not significantly different from those of autoantibody-negative control subjects. No autoantibody-positive subject had inflammatory arthritis based on joint examination. HRCT revealed that 76% of autoantibody-positive subjects had airways abnormalities including bronchial wall thickening, bronchiectasis, centrilobular opacities, and air trapping, compared with 33% of autoantibody-negative controls (P = 0.005). The prevalence and type of lung abnormalities among autoantibody-positive subjects were similar to those among patients with early RA. In 2 autoantibody-positive subjects with airways disease, inflammatory arthritis classifiable as articular RA developed ∼13 months after the lung evaluation. CONCLUSION: Airways abnormalities that are consistent with inflammation are common in autoantibody-positive subjects without inflammatory arthritis and are similar to airways abnormalities seen in patients with early RA. These findings suggest that the lung may be an early site of autoimmune-related injury and potentially a site of generation of RA-related autoimmunity. Further studies are needed to define the mechanistic role of lung inflammation in the development of RA.

Understanding Patient Experiences, Opinions, and Actions Taken After Viewing Their Own Radiology Images Online: Web-Based Survey.

BACKGROUND: The ability for patients to directly view their radiology images through secure electronic portals is rare in the American health care system. We previously surveyed patients within our health system and found that a large majority wanted to view their own radiology images online, and we have since implemented this new feature. OBJECTIVE: We aim to understand patient experiences, opinions, and actions taken after viewing their own radiology images online. METHODS: We emailed a web-based survey to patients who recently viewed their radiology images via our electronic patient portal. RESULTS: We sent 1825 surveys to patients and received 299 responses (response rate 16.4%). Patients reported a favorable experience (258/299, 86.3% agree) viewing their radiology images online. Patients found value in reading their radiology reports (288/299, 96.3% agree) and viewing their images (267/299, 89.3% agree). Overall, patients felt that accessing and viewing their radiology images online increased their understanding of their medical condition (258/299, 82.9%), made them feel more in control and reassured (237/299, 79.2% and 220/299, 73.6%, respectively), and increased levels of trust (214/299, 71.6%). Only 6.4% (19/299) of the patients indicated concerns with finding errors, 6.4% (19/299) felt that viewing their images online made them worry more, and 7% (21/299) felt confused when viewing their images online. Of patients who viewed their images online, 45.2% (135/299) took no action with their images, 32.8% (98/299) saved a copy for their records, 25.4% (76/299) shared them with their doctor, and 14.7% (44/299) shared them with another doctor for a second opinion. A total of 9 patients (3%) shared their radiology images on Facebook, Instagram, or both, primarily to inform family and friends. Approximately 10.4% (31/299) of the patients had questions about their radiology images after viewing them online, with the majority (20/31, 65%) seeking out a doctor, and far fewer (5/31, 16%) choosing to ask a family member about their images. Finally, respondents viewed their images online using 1 or more devices, including computers, smartphones, tablets, or a combination of these devices. Approximately 26.7% (103/385) of the responses noted technical difficulties, with the highest incidence rate occurring with smartphones. CONCLUSIONS: We report the first known survey results from patients who viewed their own radiology images through a web-based portal. Patients reported high levels of satisfaction and increased levels of trust, autonomy, reassurance, and medical understanding. Only a small minority of patients expressed anxiety or confusion. We suggest that patient access to radiology images, such as patient access to radiology reports, is highly desired by patients and is operationally practical. Other health care institutions should consider offering patients access to their radiology images online in the pursuit of information transparency.

The Effect of Intrathoracic Lesion Location on Initial Tyrosine Kinase Inhibitor Response in Advanced Oncogene-Addicted Non-Small Cell Lung Cancer: A Comparison Between RECIST 1.1 and a Novel Method of Response Assessment (MAX).

INTRODUCTION: Different subtypes of non-small cell lung cancer (NSCLC) are associated with different patterns of metastatic spread. Anatomic location of lesions in the chest may influence patterns of cancer growth and the shrinkage to therapy. Consequently, lesion location could affect apparent response rates per RECIST. We sought to explore this and develop, as needed, treatment response assessments less affected by the location. METHODS: Cases of advanced oncogene-addicted NSCLC (EGFR, ALK, and ROS1) with pre- and on-therapy imaging during initial targeted therapy were identified. Lesions located in the lung parenchyma, pleural space or intra-thoracic lymph nodes were identified and analyzed separately from each other by RECIST 1.1 (unidimensional measurements) and by a novel MAX methodology (bidimensional measurements) which takes the axis with the greatest absolute percentage change on therapy in each location as the representative measurement. RESULTS: Three hundred three patients with 446 unidimensional measured lesions were included for RECIST analysis. Two hundred forty nine patients with 386 bidimensional measured lesions were included for MAX analysis, as well as the analysis comparing RECIST and MAX. Intrathoracic location significantly impacted percentage shrinkage and the response rate per RECIST. The response rates for pleural, intra-parenchymal and nodal lesions were 34.1%, 49.6%, and 68.3%, respectively (P = .0002). The MAX methodology both increased the apparent treatment effect and made it consistent between intrathoracic locations. For pleural, parenchymal and nodal lesions, the MAX calculated response rate were 83.7%, 72.2%, and 75.4%, respectively (P-value = .24). CONCLUSION: Intrathoracic lesion location affects RECIST-based treatment effectiveness estimations. The MAX methodology neutralizes location effect when examining impact of treatment and should be explored further.

Impact of a Hybrid Lung Cancer Screening Model on Patient Outcomes and Provider Behavior.

BACKGROUND: Lung cancer screening (LCS) implementation is complicated by the Centers for Medicare and Medicaid Services reimbursement requirements of shared decision-making and tobacco cessation counseling. LCS programs can utilize different structures to meet these requirements, but the impact of programmatic structure on provider behavior and screening outcomes is poorly described. PATIENTS AND METHODS: In a retrospective chart review of 624 patients in a hybrid structure, academic LCS program, we compared characteristics and outcomes of primary care provider (PCP)- and specialist-screened patients. We also assessed the impact of the availability of an LCS specialty clinic and best practice advisory (BPA) on PCP ordering patterns using electronic medical record generated reports. RESULTS: During the study period of July 1, 2014 through June 30, 2018, 48% of patients were specialist-screened and 52% were PCP-screened; there were no clinically relevant differences in patient characteristics or screening outcomes between these populations. PCPs demonstrate distinct practice patterns when offered the choice of specialist-driven or PCP-driven screening. Increased exposure to a LCS BPA is associated with increased PCP screening orders. The addition of a nurse navigator into the LCS program increased documentation of shared decision-making and tobacco cessation counseling to > 95% and virtually eliminated screening of ineligible patients. CONCLUSIONS: Systematic interventions including a BPA and nurse navigator are associated with increased screening and improved program quality, as evidenced by reduced screening of ineligible patients, increased lung cancer risk of the screened population, and improved compliance with LCS guidelines. Individual PCPs demonstrate clear preferences regarding LCS that should be considered in program design.

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.

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.

Dual energy subtraction digital radiography: technical considerations, clinical applications, and imaging pitfalls.

Emerging applications in digital radiography offer exciting advances in the evaluation of lung disease. Dual energy subtraction techniques have been recognized as a promising technique in the detection and characterization of pulmonary nodules. This essay will demonstrate a significantly expanded diagnostic role in the assessment of cardiothoracic disease with dual energy subtraction and digital radiography.

Transient Asymptomatic Pulmonary Opacities Occurring during Osimertinib Treatment.

INTRODUCTION: Osimertinib is an EGFR inhibitor licensed for the treatment of EGFR-mutant, T790M-positive NSCLC. Previously unreported, frequent transient asymptomatic pulmonary opacities were noted in patients during osimertinib therapy at the University of Colorado. METHODS: Computed tomography imaging and clinical notes on patients with NSCLC who had been treated with osimertinib at the University of Colorado were retrospectively reviewed. RESULTS: Transient asymptomatic pulmonary opacities developed in seven of 20 patients (35%) while they were receiving osimertinib. The radiological patterns seen included ground-glass opacities with or without nodular consolidation. The median time to development of the first lesion was 8.7 weeks (range 1.6-43 weeks), the median time to resolution during continued osimertinib was 6 weeks (range 1-11 weeks). CONCLUSIONS: Transient asymptomatic pulmonary opacities may be a previously unrecognized, benign feature associated with osimertinib therapy that may be mistaken for isolated pulmonary progression or the beginning of more severe pneumonitis. If new-onset pulmonary lesions, especially those associated with ground-glass appearances, are asymptomatic and localized and there is no evidence of disease progression elsewhere, it may be reasonable to continue treatment with osimertinib and monitor the lesions for resolution.

Evaluation of the cardiac surgery patient with MSCT.

Advances in MSCT have enabled assessment of cardiac function and anatomy, and ECG gating has allowed increasingly accurate depiction of coronary artery grafts and native coronary arteries. These capabilities now offer a comprehensive evaluation of the preoperative surgical patient. This essay outlines the important imaging issues and opportunities in the evaluation of the cardiac surgery patient.

Lung CT Screening Reporting and Data System Speed and Accuracy Are Increased With the Use of a Semiautomated Computer Application.

PURPOSE: The Lung CT Screening Reporting and Data System (Lung-RADS™) is an algorithm that can be used to classify lung nodules in patients with significant smoking histories. It is published in table format but can be implemented as a computer program. The aim of this study was to assess the efficiency and accuracy of the use of a computer program versus the table in categorizing lung nodules. METHODS: The Lung-RADS algorithm was implemented as a computer program. Through the use of a survey tool, respondents were asked to categorize 13 simulated lung nodules using the computer program and the Lung-RADS table as published. Data were gathered regarding time to completion, accuracy of each nodule's categorization, users' subjective categorization confidence, and users' perceived efficiency using each method. RESULTS: The use of a computer program to categorize lung nodules resulted in significantly increased interpretation speed (80.8 ± 37.7 vs 156 ± 105 seconds, P < .0001), lung nodule classification accuracy (99.6% vs 76.5%, P < .0001), and perceived confidence and efficiency compared with the use of the table. There were no significant differences in accuracy when comparing thoracic radiologists with the remainder of the group. CONCLUSIONS: Radiologists were both more efficient and more accurate in lung nodule categorization when using computerized decision support tools. The authors propose that other institutions use computerized implementations of Lung-RADS in the interests of both efficiency and patient outcomes through proper management. Furthermore, they suggest the ACR design future iterations of the Lung-RADS algorithm with computerized decision support in mind.