Lessons From the Free-Text Epidemic: Opportunities to Optimize Deployment of Imaging Clinical Decision Support.

OBJECTIVE: The Protecting Access to Medicare Act of 2014 requires clinicians to consult Appropriate Use Criteria (AUC) when ordering advanced imaging procedures. Free-text order indications are available when there is no applicable structured indication but are unscored by the AUC. We determined the proportion of free-text indications among all advanced imaging orders and the proportion of free-text indications that could be mapped to a single structured indication. METHODS: All outpatient advanced diagnostic imaging orders placed in a large multisite health system were recorded after initial AUC deployment (November 20, 2017, to December 19, 2017). Clinicians were prompted upon order entry to select a structured indication or enter a free-text indication. We manually reviewed the two imaging examinations with the highest rate of free-text indications: enhanced CT abdomen/pelvis and unenhanced CT head. Regression analysis examined differences in patient-, imaging-, context-, and provider-level characteristics between scored and unscored examinations. RESULTS: Among all 39,533 orders for advanced imaging procedures, 59% (23,267 of 39,533) were unscored by the system. The regression model c-statistic (0.50-0.55) demonstrated poor model fit to evaluate for differences between scored and unscored examinations. Free-text indications were found in 71% (16,440 of 23,267) of unscored examinations and 42% (16,440 of 39,533) of all examinations. Manual review of all 1,693 CT abdomen/pelvis and 1,527 CT head examinations with free-text indications revealed that 3,132 free-text indications (97%) could be mapped to a single existing structured indication. DISCUSSION: Of all initially placed outpatient advanced imaging procedure orders, 42% included free-text indications and 97% of manually reviewed free-text indications could be mapped to a single structured indication.

PORTER: a Prototype System for Patient-Oriented Radiology Reporting.

To empower patients to participate in their medical care and decision-making, effective communication is critical. In radiology, the clinical report is the primary medium of communication. Although radiologists historically have authored reports with the referring provider as the intended reader, patients increasingly access the reports through portals to electronic health record systems. We developed a system named PORTER (Patient-Oriented Radiology Reporter) to augment radiology reports with lay-language definitions. Our IRB-approved, HIPAA-compliant study protocol analyzed 100 knee MRI reports from an academic medical center to identify the most commonly utilized terms. A glossary of 313 terms was constructed to include definitions of the terms and, where available, links to reference sources and public-domain images. Flesch-Kincaid readability scores were computed to assure that definitions were readable at or below 10th-grade reading level. The system provided an interactive web site to view outpatient knee MRI exams. After logging in with their exam ID number and date of birth, patients viewed their report annotated with definitions from the glossary. Applicable images were displayed when the user's mouse hovered over a glossary term. This patient-oriented system can help empower patients to better understand their radiology results.

Actionable findings and the role of IT support: report of the ACR Actionable Reporting Work Group.

The ACR formed the Actionable Reporting Work Group to address the potential role of IT in the communication of imaging findings, especially in cases that require nonroutine communication because of the urgency of the findings or their unexpected nature. These findings that require special communication with referring clinicians are classified as "actionable findings." The work group defines 3 categories of actionable findings that require, respectively, communication and clinical decision within minutes (category 1), hours (category 2), or days (category 3). Although the work group does not believe that there can be definitive lists of such findings, it developed lists in each category that would apply in most general hospital settings. For each category, the work group discusses ways in which IT can assist interpreting radiologists in successfully communicating to the relevant clinicians to ensure optimal patient care. IT systems can also help document the communication and facilitate auditing of the documentation. The work group recommends that vendors develop platforms that can be customized on the basis of local preferences and needs. Whatever system is used, it should be highly reliable and fit seamlessly into radiologists' workflow.

Radiologists' preferences for just-in-time learning.

BACKGROUND: Effective learning can occur at the point of care, when opportunities arise to acquire information and apply it to a clinical problem. To assess interest in point-of-care learning, we conducted a survey to explore radiologists' attitudes and preferences regarding the use of just-in-time learning (JITL) in radiology. MATERIALS AND METHODS: Following Institutional Review Board approval, we invited 104 current radiology residents and 86 radiologists in practice to participate in a 12-item Internet-based survey to assess their attitudes toward just-in-time learning. Voluntary participation in the survey was solicited by e-mail; respondents completed the survey on a web-based form. RESULTS: Seventy-nine physicians completed the questionnaire, including 47 radiology residents and 32 radiologists in practice; the overall response rate was 42%. Respondents generally expressed a strong interest for JITL: 96% indicated a willingness to try such a system, and 38% indicated that they definitely would use a JITL system. They expressed a preference for learning interventions of 5-10 min in length. CONCLUSIONS: Current and recent radiology trainees have expressed a strong interest in just-in-time learning. The information from this survey should be useful in pursuing the design of learning interventions and systems for delivering just-in-time learning to radiologists.